Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis.

BACKGROUND: Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. OBJECTIVE: Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. METHODS: Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. RESULTS: The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. CONCLUSIONS: Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.

Revising ruling discourses: The griefwork evidence-to-practice gap and the mental health workforce.

Elisabeth Kübler-Ross' pioneering work focused on dying, yet some clinicians persist in prescribing it as a path through grief. We surveyed 964 mental health clinicians who completed a five-section mixed methods survey: two sections assessed knowledge with multiple choice questions and a case study to assess clinicians' knowledge-base and approach to grief/loss in practice. Analysis of four items related to Kübler-Ross' model and 66/962 case studies indicates ongoing use of "stages" and Kübler-Ross' model. Only 330 (34.2%) of the clinicians were deemed knowledgeable; 462 (47.9%) were questionable; and 172 (17.9%) were misinformed, continuing to use Kübler-Ross' stage theory for grief.

Addressing racial inequality and its effects on vaccination rate: A trial comparing a pharmacist and peer educational program (MOTIVATE) in diverse older adults.

BACKGROUND: The mortality, morbidity, health care utilization, and cost attributable to vaccine-preventable diseases are substantial for those aged 50 years and older. Although vaccination is the most cost-effective strategy to prevent common infectious diseases in older adults, vaccination rates remain below US Centers for Disease Control and Prevention benchmarks, especially among racial minorities. Historical mistrust, structural racism within the US medical system, and misinformation contributed to lower immunization rates among minorities, especially Black Americans. To address the critical need to increase knowledge and trust in vaccination, 2 community-based educational interventions were tested: a pharmacist-led didactic session (PHARM) and a peer-led educational workshop (PEER). OBJECTIVE: To determine and compare the effectiveness and costs of PEER and PHARM community-based education models in improving knowledge and trust in vaccinations. METHODS: The Motivating Older adults to Trust Information about Vaccines And Their Effects (MOTIVATE) study was a cluster-randomized trial conducted in the greater Delaware Valley Region sites from 2017 to 2020. The included sites (7 senior centers, 3 housing units, 1 church, and 1 neighborhood family center) predominantly served Black communities. Participants were randomized to either PHARM or PEER sessions covering influenza, pneumococcal disease, herpes zoster, and beliefs related to vaccines. Peer leaders facilitated smaller workshops (5-10 participants), whereas pharmacists conducted larger didactic lectures with 15-43 participants. Outcomes were captured through a self-administered survey at baseline, postprogram, and 1 month after the program. Intervention costs were measured in 2017 US dollars. RESULTS: 287 participants were included. Their mean age was 74.5 years (SD = 8.94), 80.5% were women, 64.2% were Black, and 48.1% completed some college. Knowledge scores within groups for all 3 diseases significantly increased postprogram for both PEER and PHARM and were sustained at 1 month. Between-group knowledge differences were significant only for influenza (PEER participants had significantly larger improvement vs PHARM). Vaccination trust significantly increased in both groups. Total program costs were $11,411 for PEER and $5,104 for PHARM. CONCLUSIONS: Both interventions significantly improved knowledge and trust toward vaccination and retained their effect 1 month after the program. The 2 effective community-based education models should be expanded to ensure timely and trusted information is available to educate older adults about vaccine-preventable diseases. Further research is encouraged to assess the long-term cost-effectiveness of these models' utilization on a larger scale. DISCLOSURES: Dr Schafer is an employee of Merck; however, at the time of the project, he was a professor at Thomas Jefferson University. The other authors have no conflicts of interest to disclose. This study was supported in part by a research grant from the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. The opinions expressed in this article are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. The sponsor played no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the article. Study Registration Number: NCT03239665.

Racial and ethnic disparities in depression care in community-dwelling elderly in the United States.

OBJECTIVES: We investigated racial/ethnic disparities in the diagnosis and treatment of depression among community-dwelling elderly. METHODS: We performed a secondary analysis of Medicare Current Beneficiary Survey data (n = 33,708) for 2001 through 2005. We estimated logistic regression models to assess the association of race/ethnicity with the probability of being diagnosed and treated for depression with either antidepressant medication or psychotherapy. RESULTS: Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted for a range of covariates including a 2-item depression screener, we found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66). CONCLUSIONS: Among elderly Medicare beneficiaries, significant racial/ethnic differences exist in the diagnosis and treatment of depression. Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.

The impact of electronic health record functions on patterns of depression treatment in primary care.

BACKGROUND: Many individuals with depression are not being linked to treatment by their primary care providers. Electronic health records (EHRs) are common in medicine, but their impact on depression treatment is mixed. Because EHRs are diverse, differences may be attributable to differences in functionality. This study examines the relationship between EHR functions, and patterns of depression treatment in primary care. METHODS: secondary analyses from the 2013-2016 National Ambulatory Medical Care Survey examined adult primary care patients with new or acute depression (n = 5,368). Bivariate comparisons examined patterns of depression treatment by general EHR use, and logistic regression examined the impact of individual EHR functions on treatment receipt. RESULTS: Half the sample (57%; N = 3,034) was linked to depression treatment. Of this, 98.5% (n = 2,985) were prescribed antidepressants, while 4.3% (n = 130) were linked to mental health. EHR use did not impact mental health linkages, but EHR functions did affect antidepressant prescribing. Medication reconciliation decreased the odds of receiving an antidepressant (OR = .60, p < .05), while contraindication warnings increased the likelihood of an antidepressant prescription (OR = 1.91, p < .001). CONCLUSIONS: EHR systems did not impact mental health linkages but improved rates of antidepressant prescribing. Optimizing the use of contraindication warnings may be a key mechanism to encourage antidepressant treatment.

Antidepressant treatment and adherence to antiretroviral medications among privately insured persons with HIV/AIDS.

In order to examine relationships between depression treatments (antidepressant and/or psychotherapy utilization) and adherence to antiretroviral therapy (ART), we conducted a retrospective analysis of medical and pharmacy insurance claims for privately insured persons living with HIV/AIDS (PLWHA) diagnosed with depression (n = 1,150). Participants were enrolled in 80 insurance plans from all 50 states. Adherence was suboptimal. Depression treatment initiators were significantly more likely to be adherent to ART than the untreated. We did not observe an association between psychotherapy utilization and ART adherence, yet given the limitations of the data (e.g., there is no information on types of psychological treatment and its targets), the lack of association should not be interpreted as lack of efficacy.

Use of Medicaid data to explore community characteristics associated with HIV prevalence among beneficiaries with schizophrenia.

OBJECTIVES: People with severe mental illness (SMI) may be at increased risk for several adverse health conditions, including HIV/AIDS. This disproportionate disease burden has been studied primarily at the individual rather than community level, in part due to the rarity of data sources linking individual information on medical and mental health characteristics with community-level data. We demonstrated the potential of Medicaid data to address this gap. METHODS: We analyzed data on Medicaid beneficiaries with schizophrenia from eight states that account for 66% of cumulative AIDS cases nationally. RESULTS: Across 44 metropolitan statistical areas (MSAs), the treated prevalence of HIV among adult Medicaid beneficiaries diagnosed with schizophrenia was 1.56% (standard deviation = 1.31%). To explore possible causes of variation, we linked claims files with a range of MSA social and contextual variables including local AIDS prevalence rates, area-based economic measures, crime rates, substance abuse treatment resources, and estimates of injection drug users (IDUs) and HIV infection among IDUs, which strongly predicted community infection rates among people with schizophrenia. CONCLUSIONS: Effective strategies for HIV prevention among people with SMI may include targeting prevention efforts to areas where risk is greatest; examining social network links between IDU and SMI groups; and implementing harm reduction, drug treatment, and other interventions to reduce HIV spread among IDUs. Our findings also suggest the need for research on HIV among people with SMI that examines geographical variation and demonstrates the potential use of health-care claims data to provide epidemiologic insights into small-area variations and trends in physical health among those with SMI.

Illuminating Racial Inequity in Diabetes Control: Differences Based on Gender and Geography.

The objective of this study is to describe racial differences in type 2 diabetes mellitus "diabetes" control among the adults in the USA, and to examine attributes that may exacerbate racial differences. Secondary analyses of data from the National Ambulatory Medical Care Survey (NAMCS) collected in years 2012-2014 in the USA. Study sample was limited to White or African American patients aged 25 or older and living with diabetes (n = 4106). Outcome measure, poor diabetes control, was based on lab values for HbA1c (> 7%). Covariates include demographics, insurance, comorbid conditions, and continuity of care and location (urban vs. rural). Overall, African Americans have 33% higher odds of poor diabetes control compared with Whites. Adjusted probability of poor diabetes control was 48% overall, 65% for African American women and 69% for African Americans living in rural areas. African Americans continue to have poorer diabetes control compared to Whites. This difference is exacerbated for African American women, and for all African Americans living in rural areas. Policy should include concentrated screening and treatment resources for African Americans in rural settings.

A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs.

OBJECTIVE: This article employs a best-worst scaling (BWS) experiment to identify the claims-based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States. DATA SOURCES: Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18). STUDY DESIGN: Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims-based outcomes as most and least important for program evaluation. DATA ANALYSIS: Stratified by respondent group, best-worst scores were calculated to identify the relative importance of the claims-based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs. PRINCIPAL FINDINGS: Safety indicators (eg, antipsychotic co-pharmacy, cross-class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized "antipsychotic treatment reduction" and "increased psychosocial treatment." Caseworkers, prescribers, and caregivers prioritized "increased follow-up after treatment initiation." Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow-up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64). CONCLUSIONS: The BWS experiment supported rank ordering of candidate claims-based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.

Prevalence of diagnosed HIV disease among medicaid beneficiaries with schizophrenia in U.S. metropolitan areas.

Numerous reports suggest HIV may be elevated among those with severe mental illnesses such as schizophrenia or bipolar illness, but this has been studied in only a limited number of sites. Medicaid claim's files from 2002 to 2003 were examined for metropolitan statistical areas (MSAs) in 8 states, focusing on schizophrenia. Across 102 MSAs, 1.81% of beneficiaries with schizophrenia had received diagnoses of HIV/AIDS. MSA rates ranged widely, from 5.2% in Newark, NJ, to no cases in 16 of the MSAs.

Predictors of maternal depression in the first year postpartum: marital status and mediating role of relationship quality.

Existing literature has documented the associations between marital status and maternal depression within the first year postpartum. Using data that is representative of urban non-marital births in the United States with a large over-sample of non-marital births, we investigate the association of maternal depression with not only marital status but also relationship quality with the father of the baby. Quality is independently associated with maternal depression after controlling for marital status and other variables that have been documented as risk factors for maternal depression. In addition, relationship quality explains away the associations between marital status and maternal depression. After controlling for relationship quality, single women were no more likely to be depressed compared to married or cohabiting women.

Housing Plus Services, IADL Impairment, and Healthcare Expenditures: Evidence From the Medicare Current Beneficiaries Survey.

BACKGROUND AND OBJECTIVES: Despite enthusiasm for the potential cost savings of embedding supportive services in senior housing, few population health studies have empirically examined such associations. We investigated the extent to which associations between housing plus services in senior housing and healthcare expenditures depend upon residents' instrumental activities of daily living (IADL) impairment and the level of services available. RESEARCH DESIGN AND METHODS: We used data from 2,601 participants aged 65 or older in the 2001-2013 Medicare Current Beneficiary Survey, who reported living in senior or retirement housing. Based on survey self-reports, we created a measure of housing with different levels of services, including the categories of housing without services, housing plus services (i.e., assistance with IADLs, but not with medications), and housing plus enhanced services (i.e., assistance with IADLs including medications). Administrative and survey data were used to create measures of healthcare expenditures paid by all sources. We estimated generalized linear models based on pooled data from participants across the 13 years of data collection. RESULTS: Residents with IADL impairment-who lived in housing plus enhanced services-had lower total healthcare expenditures than their counterparts in housing without services and housing plus services. Upon examining component healthcare costs, this pattern of results was similar for inpatient/subacute care, as well as ambulatory care, but not for home health care. DISCUSSION AND IMPLICATIONS: Findings indicate the importance of studies on the cost savings of housing-based service programs to consider resident IADL status and the types of services available.

Is College Completion Associated with Better Cognition in Later Life for People Who Are the Least, or Most, Likely to Obtain a Bachelor's Degree?

OBJECTIVES: Drawing on insights from theorizing on cumulative dis/advantage (CDA), we aimed to advance understanding of educational attainment as a protective factor for later-life cognition by examining whether associations between obtaining a bachelor's degree and later-life cognition differ according to individuals' likelihood of completing college based on characteristics in adolescence. METHODS: We conducted a propensity score analysis with data from the Wisconsin Longitudinal Study (WLS). Measures to predict college completion were assessed prospectively in adolescence, and a global measure of later-life cognition was based on cognitive assessments at age 65. RESULTS: College completion by age 25 (vs high school only) was associated with better later-life cognition for both men and women. Among men specifically, associations were stronger for those who were less likely as adolescents to complete college. DISCUSSION: Results indicate the utility of a CDA perspective for investigating the implications of interconnected early life risk and protective factors for later-life cognition, as well as ways in which college education can both contribute to, as well as mitigate, processes of CDA.

Comparison of safety and utilization outcomes in inpatient versus outpatient laparoscopic sleeve gastrectomy: a retrospective, cohort study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common type of bariatric surgery performed in the United States and may be performed on an outpatient basis. Limited literature exists comparing outcomes of outpatient and inpatient LSG, and study results are conflicting. OBJECTIVES: To compare safety and utilization outcomes of outpatient versus inpatient LSG. SETTINGS: Retrospective, multihospital database study (Optum Pan-Therapeutics Database). METHODS: Patients 18 years of age and older who underwent LSG between October 1, 2015, and December 31, 2018, were identified from the Optum Pan-Therapeutics Database and classified as having undergone outpatient or inpatient surgery. Nearest neighbor propensity score matching and generalized estimating equations accounting for procedural physician-level clustering were used to compare the following outcomes between outpatient and inpatient LSG: all-cause 30-day patient morbidity, hospital readmission, readmission length of stay, bariatric reoperation. and mortality. RESULTS: We identified 22,945 patients (outpatient: 1542; inpatient: 21,403) meeting the study inclusion criteria. After propensity score matching, the inpatient and outpatient groups contained 1542 and 13,903 patients, respectively. Bariatric reoperation (n = 13) and mortality (n = 5) were rare events occurring in <.1% of all cases. Compared with the inpatient group, the outpatient group had a statistically significant lower readmission length of stay (4.63 versus 3.23 days; P = .0057). Otherwise, there was no significant association between procedure setting and 30-day overall morbidity (4.8% versus 5.3%; P = .5775) or hospital readmission (2.6% versus 2.1%; P = .1841). CONCLUSIONS: Safety and utilization outcomes were similar between outpatient and inpatient LSG, and outpatient LSG was associated with shorter hospital readmission length of stay.

Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children.

BACKGROUND: Prior authorization of prescription medications is a policy tool that can potentially impact care quality and patient safety. OBJECTIVE: To examine the effectiveness of a mandatory peer-review program in reducing antipsychotic prescriptions among Medicaid-insured children, accounting for secular trends that affected antipsychotic prescribing nationally. DATA SOURCE: Medicaid Analytical eXtracts (MAX) with administrative claims for health services provided between January 2006 and December 2011. STUDY DESIGN: This retrospective, observational study examined prescription claims records from Washington State (Washington) and compared them to a synthetic control drawing from 20 potential donor states that had not implemented any antipsychotic prior authorization program or mandatory peer review for Medicaid-insured children during the study period. This method provided a means to control for secular trends by simulating the antipsychotic use trajectory that the program state would have been expected to experience in the absence of the policy implementation. PRINCIPAL FINDINGS: Before the policy implementation, antipsychotic use prevalence closely tracked those of the synthetic control (6.17 per 1000 in Washington vs. 6.21 in the synthetic control group). Within two years after the policy was implemented, prevalence decreased to 4.04 in Washington and remained stable in the synthetic control group (6.47), corresponding to an approximately 38% decline. CONCLUSION: Prior authorization program designs and implementations vary widely. This mandatory peer-review program, with an authorization window and two-stage rollout, was effective in moving population level statistics toward safe and judicious use of antipsychotic medications in children.

Antipsychotic Use Among Youth in Foster Care Enrolled in a Specialized Managed Care Organization Intervention.

OBJECTIVE: Little is known about whether interventions implemented by specialized Medicaid managed care organizations (MMCOs) contributed to recent stabilization of antipsychotic prescribing to youths in foster care. This study examined a multimodal antipsychotic intervention implemented by a specialized MMCO for youths in foster care with routine mental health screening, health passports, elective psychiatric consultation line, and retrospective drug utilization reviews to determine whether this multimodal intervention significantly reduced antipsychotic dispensing for youths with conditions without US Food and Drug Administration (FDA)-approved indications. METHOD: Employing a difference-in-differences design, intervention effectiveness for youths in foster care (age 6-17 years) compared with adopted youthss was examined. Analyses were stratified by FDA-indicated conditions, other externalizing conditions, and other internalizing conditions. Outcomes included predicted annual probabilities of any antipsychotic dispensed, antipsychotic dispensed for ≥90 consecutive days, and glucose and lipid testing. RESULTS: Intervention-enrolled youths with FDA-indicated conditions, relative to comparison youths, experienced a 0.6% reduction in any antipsychotic dispensed and 3.1% increase for ≥90 consecutive days dispensed in the 2 years following implementation, both nonsignificant differences. Youths with other externalizing disorders experienced significant reductions, relative to comparison youths, in any antipsychotic dispensed (-6.3%, p < .001) and in ≥90 consecutive days dispensed (-5.5%, p < .001). Youths with other internalizing disorders experienced a significant reduction, relative to comparison youths, in any antipsychotic dispensed (-7.6%, p < .001) and in ≥90 consecutive days dispensed (-5.1%, p < .001). Glucose and lipid testing increased at statistically comparable rates for both groups. CONCLUSION: MMCO implementation significantly reduced antipsychotic medications without FDA-indicated conditions prescribed to youths, while not significantly affecting antipsychotic medications prescribed to youths with FDA-indicated conditions.

Substance abuse and hospitalization for mood disorder among Medicaid beneficiaries.

OBJECTIVES: We compared the influence of substance abuse with that of other comorbidities (e.g., anxiety, HIV) among people with mood disorder (N=129,524) to explore risk factors for psychiatric hospitalization and early readmission within 3 months of discharge. METHODS: After linking Medicaid claims data in 5 states (California, Florida, New Jersey, New York, and Texas) to community-level information, we used logistic and Cox regression to examine hospitalization risk factors. RESULTS: Twenty-four percent of beneficiaries with mood disorder were hospitalized. Of these, 24% were rehospitalized after discharge. Those with comorbid substance abuse accounted for 36% of all baseline hospitalizations and half of all readmissions. CONCLUSIONS: Results highlight the need for increased and sustained funding for the treatment of comorbid substance abuse and mood disorder, and for enhanced partnership between mental health and substance abuse professionals.

Psychiatric diagnosis and antiretroviral adherence among adolescent Medicaid beneficiaries diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome.

Research on adults with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has suggested that psychiatric and substance abuse comorbidities are prevalent in this population, and that these may sometimes be associated with use of antiretroviral therapy (ART) and adherence. For adolescents with HIV/AIDS, much less is known about patterns of mental health comorbidity, and even fewer data are available that compare them to socioeconomically comparable youth without HIV/AIDS. Using medical and pharmacy data from 1999 to 2000 Medicaid claims (Medicaid Analytic Extract) from 4 states for beneficiaries aged 12 to 17 years, we identified 833 youth under care for HIV/AIDS meeting study criteria within the HIV/AIDS group, receipt of ART was less likely for youth who had diagnoses of substance abuse, conduct disorders, or emotional disorders than for others. Once ART was initiated, adherence did not significantly differ between adolescents living with a psychiatric condition, and those who were not, with the exception of an association between conduct disorder and lower adherence. Among those with HIV/AIDS, ART use and adherence were more common among youth with higher rates of service use, regardless of psychiatric status. Associations between race and adherence varied by gender: compared with their white counterparts, minority girls had lower, and minority boys had higher adherence.

Long-term adherence to evidence based secondary prevention therapies after acute myocardial infarction.

BACKGROUND: After acute myocardial infarction (AMI), treatment with beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) is widely recognized as crucial to reduce risk of a subsequent AMI. However, many patients fail to consistently remain on these treatments over time, and long-term adherence has not been well described. OBJECTIVE: To examine the duration of treatment with beta-blockers and ACEI within the 24 months after an AMI. DESIGN: A retrospective, observational study using medical and pharmacy claims from a large health plan operating in the Northeastern United States. SUBJECTS: Enrollees with an inpatient claim for AMI who initiated beta-blocker (N = 499) or ACEI (N = 526) therapy. MEASUREMENT: Time from initiation to discontinuation was measured with pharmacy refill records. Associations between therapy discontinuation and potential predictors were estimated using a Cox proportional hazards model. RESULTS: ACEI discontinuation rates were high: 7% stopped within 1 month, 22% at 6 months, 32% at 1 year and 50% at 2 years. Overall discontinuation rates for beta-blockers were similar, but predictors of discontinuation differed for the two treatment types. For beta-blockers, the risk of discontinuation was highest among males and those from low-income neighborhoods; patients with comorbid hypertension and peripheral vascular disease were less likely to discontinue therapy. These factors were not associated with ACEI discontinuation. CONCLUSION: Many patients initiating evidence-based secondary prevention therapies after an AMI fail to consistently remain on these treatments. Adherence is a priority area for development of better-quality measures and quality-improvement interventions. Barriers to beta-blocker adherence for low-income populations need particular attention.

Incarceration rates of persons with first-admission psychosis.

OBJECTIVE: This prospective study examined jail stay in a cohort of persons with schizophrenia and other psychotic disorders who experienced their first hospital admission and who were participating in the Suffolk County Mental Health Project. Demographic and clinical risk factors for jail placement were investigated over a four-year period after hospital discharge. METHODS: The sample included 538 first-admission respondents diagnosed as meeting DSM-IV criteria for having schizophrenia, psychotic mood disorder, or other psychotic disorders. Initial interviews occurred in the hospital; face-to-face follow-ups occurred at the six-, 24-, and 48-month points, and telephone contact was maintained every three to six months. Multivariate logistic regression analysis was used to examine the demographic and clinical risk factors. RESULTS: Forty-seven respondents (9%) were incarcerated over the follow-up period. Among them, 20 were incarcerated multiple times. The prevalence, incidence, reasons for incarceration, and time served did not vary significantly by diagnosis. The most significant predictors of jail stay and time to incarceration during the follow-up were being male or black and having been incarcerated before admission. Predictive effects of other risk factors (for example, symptom severity or substance abuse) were smaller or statistically insignificant. CONCLUSIONS: The results suggest a need for mental health care professionals to routinely evaluate, document, and collaboratively address incarceration history, especially when working with black males, in an effort to avert future incarceration.