The relationship between a worksite wellness clinic and hospital emergency department visits.

OBJECTIVE: To assess the relationship between the provision of episodic medical care at the worksite and nonadmission emergency department (ED) visits. METHODS: A historical cohort design was used to study the differences of nonadmission ED visits among insurance plan participants employed at two acute care hospitals, one with a worksite wellness clinic and one without over an 8-year period. RESULTS: A significant reduction in the risk of an insurance plan member visiting the ED in the time period after the clinic was opened among plan members with access to a worksite wellness clinic was observed. No significant reduction was noted in ED visits for insurance plan members without access to a worksite clinic. CONCLUSIONS: A wellness clinic rendering episodic medical care is associated with significant reductions in ED visits and insured employees who use an ED.

Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial.

BACKGROUND: Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN: We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION: Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.

Adapting hypertension self-management interventions to enhance their sustained effectiveness among urban African Americans.

African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions' cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.

Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members.

INTRODUCTION: We aimed to inform the design of behavioral interventions by identifying patients' and their family members' perceived facilitators and barriers to hypertension self-management. MATERIALS AND METHODS: We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients' hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants' perceptions regarding patient, family, clinic, and community-level factors influencing patients' effective hypertension self-management. RESULTS: Patient participants identified several facilitators (including family members' support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients' doctor's visits and discussions with patients' doctors outside of visits) and barriers (including their own limited health knowledge and patients' lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients' hypertension self-management. CONCLUSION: African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients' hypertension self-management. Patients' and their family members' views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.

Chronic care improvement in primary care: evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.

OBJECTIVE: To examine the effects of an intervention comprising (1) a practice-based care coordination program, (2) augmented by pay for performance (P4P) for meeting quality targets, and (3) complemented by a third-party disease management on quality of care and resource use for older adults with diabetes. DATA SOURCES/STUDY SETTING: Claims files of a managed care organization (MCO) for 20,943 adults aged 65 and older with diabetes receiving care in Alabama, Tennessee, or Texas, from January 2004 to March 2007. STUDY DESIGN: A quasi-experimental, longitudinal study in which pre- and postdata from 1,587 patients in nine intervention primary care practices were evaluated against 19,356 patients in MCO comparison practices (>900). Five incentivized quality measures, two nonincentivized measures, and two resource-use measures were investigated. We examined trends and changes in trends from baseline to follow-up, contrasting intervention and comparison group member results. PRINCIPAL FINDINGS: Quality of care generally improved for both groups during the study period. Only slight differences were seen between the intervention and comparison group trends and changes in trends over time. CONCLUSIONS: This study did not generate evidence supporting a beneficial effect of an on-site care coordination intervention augmented by P4P and complemented by third-party disease management on diabetes quality or resource use.

Examining the effectiveness of hydroxyurea in people with sickle cell disease.

This study investigated hydroxyurea use in people with sickle cell disease (SCD) outside of a research setting. Pharmacy data, outpatient visits, hospital admissions, and length of stay were assessed for all patients with SCD enrolled in a Medicaid managed care organization in Maryland. Three hundred and ninety (390) people with SCD were covered between the years 2001-2005. A large majority (85.9%) never had a claim for a hydroxyurea refill. Hydroxyurea users had higher admission rates than non-hydroxyurea users (5 vs. 1.5, p=.004). Patients who were in the highest tertile of refills of hydroxyurea had significantly fewer hospital admissions than patients in the lowest tertile (2.44 vs. 7.57, p=.043). Patients with the lowest hydroxyurea refill usage had significantly higher mean costs per month enrolled than those with the highest number ($4,553 vs. $2,017, p=.031). Hydroxyurea was underutilized in this patient population. Patients with more regular refills of hydroxyurea had fewer admissions to the hospital and markedly decreased costs.

Evaluating a palliative care case management program for cancer patients: the Omega Life Program.

PURPOSE: This study evaluated a cancer case management pilot program focusing on palliative care, the Omega Life Program (OLP), by assessing whether the program was associated with reduced hospital utilization. METHODS: A retrospective observational study of patients with cancer who enrolled in the OLP (intervention) compared to those who chose not to enroll (comparison) from January 1, 2005 to February 28, 2007. Patients were included in the primary analyses if they died by the end of the study period and were enrolled in the program at least 1 week before death. Patients were followed from the time of referral until death. Outcomes included whether or not the patients had any admissions during this period and, for patients with at least one admission, the total number of inpatient hospital admissions, inpatient days, and hospital costs. RESULTS: Approximately 75% of eligible patients enrolled in the OLP; 60% were older than 50 and 60% were female. Of included patients in the intervention group (n = 69), 59% had no admissions compared to 15% of patients in the comparison group (n = 20). However, among patients who had at least one admission, the mean number of hospital admissions, inpatient days, and hospitals costs were not significantly different between the groups. CONCLUSIONS: In this pilot study, patients in the OLP had significantly reduced odds of having any hospital admissions compared to those in usual care. This type of program may improve outcomes for patients, but further research is needed to evaluate outcomes using larger samples and more rigorous study designs.

Pedophilia.

This article addresses the risk factors associated with the psychiatric disorder pedophilia, its treatment, and treatment outcomes. It addresses physician responsibilities associated with case identification of victims and possible roles in the medical management of pedophilia. The essential feature of pedophilia is that an individual is sexually attracted exclusively or in part to prepubescent children. While pedophilia may be limited to fantasies and impulses, pedophilic behaviors are the primary concern of both the mental health and criminal justice systems. Remote risk factors for development of pedophilia often include the individual having been sexually abused as a child. Proximate risk factors for its behavioral expression are prevalence of comorbid psychiatric disorders and substance abuse disorders. Current treatment goals focus on stopping the behavior and achieving long-term behavioral control in the community. Common treatment methods are cognitive-behavioral, group therapy, and, when appropriate, medications such as androgen-lowering agents that can act as sexual appetite suppressants. Meta-analyses have established that treatment is more effective than nontreatment in preventing recidivism of sexual offenders in general, a finding that has a high probability of application to individuals with pedophilia. Pedophilia is a chronic psychiatric disorder, but it is treatable in terms of developing strategies for preventing behavioral expression. Ultimately, reducing the prevalence of pedophilic behavior requires further collaboration between the criminal justice system and the health care communities.

Alexithymia in patients attending a sexual disorders clinic.

We measured alexithymic traits with the Toronto Alexithymia Scale (TAS; Bagby, Taylor, & Parker, 1988) in 170 individuals attending a sexual disorders clinic. We diagnosed 114 of the subjects with a sexual dysfunction and 56 with paraphilic disorders. We determined that 20.2% of the dysfunctional group and 26.8% of the paraphilic were alexithymic when the TAS was measured categorically. When we considered the TAS as a dimensional variable, the subset with paraphilias had significantly higher scores on the TAS only when depressed mood, as measured by the Brief Symptom Inventory (Derogatis, 1993), was covaried. These data suggest that alexithymia in both sexually dysfunctional and paraphilic individuals is related to depressed mood, although the effect is more pronounced in paraphilics.

Erectile dysfunction and depression: category or dimension?

Depression, as a risk factor for erectile dysfunction (ED), has received minimal systematic attention. One-hundred twenty men with ED evaluated in a sexual behaviors clinic were studied. The categorical Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) diagnosis of a depressive disorder was found in only 14 subjects (14.7%). Dimensional quantification of depression was measured with the Brief Symptom Inventory (BSI). The BSI data revealed clinically significant elevations of depression and other dysphoric affects. The presence of a comorbid medical diagnosis did not affect the rates of categorical diagnosis of depression or the dimensional levels. The five factors of personality in the NEO-PI were within normal range. The data demonstrates that men with ED are affectively distressed but infrequently meet criteria for categorical DSM-IV depression.

A model for managed behavioral health care in an academic department of psychiatry.

In response to the effects of the managed care environment on patient flow and care, the department of psychiatry and behavioral sciences of the Johns Hopkins School of Medicine developed and has been managing a capitated behavioral health care program. The program is responsible for providing mental health and substance abuse services for 22,000 members of the TRICARE Uniformed Services Family Health Plan (USFHP), directed by the U.S. Department of Defense. The integration of primary care and behavioral health care is a major feature of the USFHP/TRICARE program. The authors describe the transition from a carve-out for-profit managed care organization to the integrated program managed by the department. During the first two years of the program, access to services increased and use of inpatient services decreased without the need to deny service use. To supplement previous reports of the involvement of academic psychiatry departments in behavioral health care, the authors supply utilization and financial data that may serve as benchmarks for similar efforts by other departments.