Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD.

OBJECTIVE: This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD). METHODS: Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity. RESULTS: Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01). CONCLUSIONS: Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

A Bayesian Approach to Modeling Risk of Hospital Admissions Associated With Schizophrenia Accounting for Underdiagnosis of the Disorder in Administrative Records.

Schizophrenia is a debilitating serious mental illness characterized by a complex array of symptoms with varying severity and duration. Patients may seek treatment only intermittently, contributing to challenges diagnosing the disorder. A misdiagnosis may potentially bias and reduce study validity. Thus we developed a statistical model to assess the risk of 1-year hospitalization for patients diagnosed with schizophrenia, accounting for when schizophrenia is underreported in administrative databases. A retrospective study design identified patients seeking care during 2010 within an integrated health care system from the Health Maintenance Organization Research Network located in the southwestern United States. Bayesian analysis addressed the problem of underdiagnosed schizophrenia with a statistical measurement error model assuming varying rates of underreporting. Results were then compared to classical multivariable logistic regression. Assuming no underreporting, there was an 87% greater relative odds of hospitalization associated with schizophrenia, OR = 1.87, CI [1.08, 3.23]. Effect sizes and interval estimates representing the association between hospitalization and schizophrenia were reduced with the Bayesian approach accounting for underdiagnosis, suggesting that less severe patients may be underrepresented in studies of schizophrenia. The analytical approach has useful applications in other contexts where the identification of patients with a given condition may be underreported in administrative records.

Postdischarge Correlates of Health Literacy Among Medicaid Inpatients.

Health literacy may represent a target for intervention to improve hospital transitions. This study analyzed the association of health literacy with postdischarge utilization among Medicaid patients treated in an integrated health care system. Discharged inpatients covered by Medicaid (N = 112) participated in this observational study set in a single 600-bed hospital in a private, nonprofit, integrated health care system in the southwestern United States. Participants completed surveys within 15 days of discharge, self-reporting demographics, self-care behaviors, and 2 measures of health literacy (REALM-SF [Short Form of the Rapid Estimate of Adult Literacy in Medicine] and Chew [health literacy screen from Chew et al]). Electronic medical records data were incorporated to determine occurrence of 30-day/90-day postdischarge emergency visits and readmission. Half the respondents (54%) scored at the high-school grade equivalent on REALM-SF, while 46% scored adequate health literacy on the Chew. Forty percent (40%) experienced either emergency care or readmission within 90 days post discharge. Patients who were younger, female, or living with children had relatively better health literacy. Health literacy itself was not associated with readmission or postdischarge emergency care, although African American race was. Although Medicaid patients varied considerably on health literacy, this factor was not associated with adverse health care outcomes. Future work should better identify individuals requiring supportive transition services to reduce problems following hospital discharge.

Design and challenges for a randomized, multi-site clinical trial comparing the use of service dogs and emotional support dogs in Veterans with post-traumatic stress disorder (PTSD).

Posttraumatic stress disorder (PTSD) is a leading cause of impairments in quality of life and functioning among Veterans. Service dogs have been promoted as an effective adjunctive intervention for PTSD, however published research is limited and design and implementation flaws in published studies limit validated conclusions. This paper describes the rationale for the study design, a detailed methodological description, and implementation challenges of a multisite randomized clinical trial examining the impact of service dogs on the on the functioning and quality of life of Veterans with PTSD. Trial design considerations prioritized participant and intervention (dog) safety, selection of an intervention comparison group that would optimize enrollment in all treatment arms, pragmatic methods to ensure healthy well-trained dogs, and the selection of outcomes for achieving scientific and clinical validity in a Veteran PTSD population. Since there is no blueprint for conducting a randomized clinical trial examining the impact of dogs on PTSD of this size and scope, it is our primary intent that the successful completion of this trial will set a benchmark for future trial design and scientific rigor, as well as guiding researchers aiming to better understand the role that dogs can have in the management of Veterans experiencing mental health conditions such as PTSD.

Analysis of Glycemic Control of a Pharmacist-Led Medication Management Program in Patients with Type 2 Diabetes.

BACKGROUND: An integrated health care system with its own regional health plan located in Texas implemented a pharmacist-led diabetes medication management program (MMP) to treat type 2 diabetic patients (baseline A1c > 7.5%). The MMP formed collaborative practice agreements with the system's physicians to allow ambulatory care pharmacists to modify and adjust diabetic drug regimens when appropriate. Enrolled MMP patients received personalized visits with ambulatory care pharmacists and a copay waiver on diabetes medications. OBJECTIVE: To study the outcomes of an outpatient, pharmacist-led MMP, along with a copay waiver on diabetes drugs, in treating adults with type 2 diabetes mellitus over a 2-year period compared with standard care practice. METHODS: This retrospective study employed a quasi-experimental design and used medical claims, pharmacy claims, eligibility data, and electronic medical records. Patients aged 18 to 62 years, who were diagnosed with type 2 diabetes mellitus, and had at least 1 diabetes-related pharmacy claim in the year before the MMP, as well as continuous enrollment in the health plan, were included. Patients enrolled in the pharmacist-led MMP for at least 2 years (n =75) were matched to standard care patients (n =75) on age, gender, baseline A1c, insulin use, and physical comorbidity. The primary outcome was the 2-year change in A1c. Secondary outcomes included inpatient costs, outpatient costs, and pharmacy costs from the baseline period (year before enrollment) compared with the follow-up period (second year of enrollment). RESULTS: After matching MMP patients (n = 75) to control patients (n = 75), the baseline A1c (9.30 and 9.26), the mean age (53.0 and 53.3, respectively), the Selim Physical Score (3.32 and 3.26, respectively), and the use of insulin (56.0% and 56.0%, respectively) were similar in both groups. MMP patients had a greater mean reduction in A1c compared with standard care patients (-1.24 vs. -0.59, P = 0.009) from baseline to after 2 years. After 2 years, the A1c for MMP patients was significantly lower compared with control patients (8.06 vs.8.67, respectively, P = 0.014). There was also a difference in A1c after 1 year for MMP patients versus control patients (8.18 and 8.69, respectively, P = 0.012). CONCLUSIONS: A pharmacist-led diabetes MMP, combined with a diabetes drug copay waiver, was effective in significantly reducing A1c over a 2-year period for type 2 diabetic patients in this regional health plan.

Primary care-mental health integration and treatment retention among Iraq and Afghanistan war veterans.

Despite the high prevalence of posttraumatic stress disorder (PTSD) and medical comorbidity among veterans from Iraq/Afghanistan (OEF/OIF), keeping these patients engaged in health care is challenging. Primary Care-Mental Health Integration (PC-MHI), an initiative in the Veterans Health Administration (VA), sought to improve access to mental health care from within primary care. This study examined the lag between first PC-MHI visit and next mental/medical care visit, if any, and the relationship of PC-MHI with short-term (subsequent year) and long-term (4 years later) use of VA. We identified 2,470 OEF/OIF veterans receiving care during fiscal year 2006 (FY06) in a regional VA health care system. Unconditional survival analysis modeled time to next mental/medical visit and logistic regression modeled short- and long-term care as a function of PC-MHI, demographics, and clinical covariates. Of 181 patients in the PC-MHI program, 60%/18% returned for mental/medical care within 1 month, and 82%/74% within 1 year. Sixty-one percent (1,503) were still using the VA in FY09. Short-term mental care was related to prior-year PC-MHI. Consistent correlates of short- and long-term mental/medical care included physical comorbidity and Priority 1 status. Most patients attended mental health appointments subsequent to PC-MHI, and PC-MHI was correlated with mental health treatment retention in adjusted models for our cohort. Need for treatment, notably VA Priority 1 status and physical comorbidity, were the primary correlates of care-seeking. Developing innovative approaches to engaging new veterans in care remains imperative as multiple options will be necessary to meet the needs of these complex patients.