Treatment settings for adolescent psychiatric conditions

The intensive psychiatric treatment settings, including inpatient hospitalization, day programs and residential care, are valuable options for clinicians caring for adolescents with serious mental health problems. The availability of these setting may be limited by geographic, insurance, or financial restraints, but providers should stay informed about the treatment settings available in their area and be prepared to advocate for their adolescent patients' psychiatric needs. Although little evidence-based practice is available to guide clinicians taking care of adolescents in need of the most intensive psychiatric treatment settings, certain elements of care have proven most essential, including especially the successful engagement of families in treatment. Good outcomes for the most complicated adolescents follow from successful collaborations with families and the various providers that intersect in their multidisciplinary care.     

Evidence-based Treatments in the Field: A Brief Report on Provider Knowledge, Implementation, and Practice

This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments.     

The vaccines for children program: Policies, Satisfaction, and Vaccine Delivery

OBJECTIVES: Characterize the Vaccines for Children (VFC) programs in Minnesota and Pennsylvania, assess providers' satisfaction with each state's program, and examine changes in doses administered in the public sector since implementation of the VFC. METHODS: Primary care providers participating in the VFC in Minnesota and Pennsylvania were surveyed. Doses administered were based on data from the National Immunization Survey. Outcome measures included satisfaction, ease of use of VFC, doses of immunizations administered through public health departments, and overall immunization coverage for the two states. RESULTS: Most participating providers in each state (80% to 94%) reported overall satisfaction with the VFC. Pennsylvania physicians were less satisfied with quarterly ordering of immunizations than were Minnesota providers with monthly ordering (56% vs 80%, p<0.05). The most common recommendation was to reduce paperwork. Doses administered in the public sector declined in Minnesota from approximately 146,000 in 1994 to 65,400 in 1999, and in Pennsylvania from approximately 250,000 to 79,300 during the same period. CONCLUSIONS: The VFC appears to increase the numbers of poor and uninsured children who receive necessary childhood immunizations within their medical homes. Providers are generally satisfied with the program.     

Clinical trials as treatment option: Bioethics and health care disparities in substance dependency

Bioethicists have warned against the dangers of mixing research with treatment. They are concerned that research priorities may take precedence over individual patient needs and that research subjects tend to misunderstand the purpose of research or overestimate the direct medical benefits of participating in studies. Yet, other work has questioned whether clinical research can always be separated from therapeutic benefit for participants. Using in-depth interviews with participants in two phase III randomized U.S. clinical trials for methamphetamine dependency, we examine the treatment options available to participants, their experiences with participating in the trials, and potential problems of trial participation. We find that while participants have experience with four alternative treatment modalities – quitting alone, support groups, in-patient treatment facilities, and consulting primary care physicians – the randomized clinical trials compare favorably to alternatives because they provide access to evidence-based behavioral treatments, specialized medical professionals, non-judgmental staff, and the possibility of receiving an experimental drug. We conclude that while randomized clinical trials are imperfect substitutes for clinical care, they constitute a fragile and sporadic therapeutic niche in a country with fundamental problems in access to health care, a mixed punitive-therapeutic drug addiction policy, and a profit-driven pharmaceutical development and approval process.     

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.     

Oral Health Coverage Options for Pregnant Adults and Adolescents

Oral health care is a necessary and critical component of health care for pregnant women, but its importance is often overlooked by clinicians. Pregnant women who are low-income also find it particularly difficult to access care. This analytic essay summarizes oral health coverage for pregnant women under various types of health insurance coverage, including Medicaid, the Children’s Health Insurance Program, and coverage options available under the Affordable Care Act. We hope this information will help clinicians better understand the importance of oral health care during pregnancy and the range of coverage options that may be available to their patients.     

Minnesota plans and providers try collaboration to boost quality

What could possibly entice health plans and providers to agree on a common set of evidence-based protocols? Plans and providers in this groundbreaking Minnesota initiative explain how they work together to provide consistent care to more than 95% of the state's covered lives.     

Planning for the future of behavioral health services

Psychiatric and chemical dependency services are increasingly being delivered through managed care with greater emphasis on ambulatory and outpatient treatments. Inpatient facilities can preserve their involvement in behavioral health services by actively developing a managed care product line. This article describes the nature of change in behavioral services, what competitive behavioral health providers will look like in the future, and the actions hospital administrators should be taking now.     

Can goal-based advance planning guide medical care in the nursing home?

OBJECTIVE: To determine whether a goal-based system of advance planning, which allows patients to choose among five "pathways of care" (longevous, ameliorative/comprehensive, ameliorative/basic, palliative/comfort, or palliative/hospice), enables physicians to select treatment options in specified clinical situations. DESIGN: A pencil and paper test was administered in which clinicians were presented five common clinical scenarios and were asked which of four possible treatment options they would recommend, given a predetermined "pathway of care." SETTING: A 725-bed teaching nursing home and affiliated continuing care retirement community. MEASUREMENTS: The proportion of correct answers was measured for each clinician, for each clinical scenario, and for each pathway. RESULTS: Of the test answers, 78% coincided with the reference answers. The greatest rate of correct answers was found for the ameliorative/comprehensive pathway and the palliative/hospice pathway. CONCLUSION: Establishing pathways of care by asking nursing home residents to prioritize their goals of care may help clinicians narrow the range of appropriate options when facing an acute medical problem. Key Words: Advance planning; goals of care; treatment limitations     

Evidence-based health practice: knowing and using what works for older adults

Community-based health care agencies are facing demands for improved outcomes, cost-effective programming, and higher customer satisfaction. Implementing evidence-based health interventions and programs can help to address these challenges. This article provides an overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. The article concludes with a list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs.     

Gender and patient satisfaction with primary care: tuning in to women in quality measurement

This study analyzes the relationship between patient gender and satisfaction with primary care visits, using 1999 survey data on 1691 women and 760 men making primary care visits at multiple sites affiliated with a large academic health system designated as a National Center of Excellence in Women's Health (COE). The main findings are that in multivariate analyses controlling for patient and visit characteristics, different aspects of the content of primary care visits are important to women and men. Women's overall satisfaction with visits is more dependent than men's on informational content, continuity of care, and multidisciplinarity. Men's overall satisfaction is more dependent on the personal interest shown in them by providers. No differences in satisfaction are found between those seen in sites affiliated with the COE and other primary care sites within the health system that are not core sites of the COE. We conclude that quality improvement and research in women's primary care could benefit from gender analysis of patient satisfaction data and from more gender-sensitive patient satisfaction measures.     

Putting evidence-based clinical practice guidelines into practice: an academic pediatric center's experience

BACKGROUND: Clinical practice guidelines can provide a much-needed interface between research and practice, pointing the way to higher quality, evidence-based, and more cost-effective care. Cincinnati Children's Hospital Medical Center developed a formal process for the production of 29 evidence-based guidelines and companion tools. COMPONENTS OF DEVELOPMENT AND IMPLEMENTATION: Clinical practice guidelines and their companion documents are developed by interprofessional teams that are led by community physicians and that include hospital-based physicians, nurses, other allied health professionals, and patients or parents. An education coordinator develops an education plan that outlines specific clinical practice changes and expected outcomes to be monitored. Guideline evidence is embedded into companion documents and processes available at the point of care. Electronic order sets for treatments and medications have been developed using available guidelines as sources of evidence. All guideline-based order sets include an automatic order for use of the associated clinical pathway. It is important to create and maintain an evidence-based environment in an academic medical center. CONCLUSIONS: Keys to success include a rigorous methodology, tools that place the evidence in the hands of providers at the site of care, feedback on outcomes, and an environment that encourages evidence-based care.     

Access to care for low-income women: the impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.     

Are women and providers satisfied with antenatal care? Views on a standard and a simplified,evidence-based model of care in four developing countries

BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.     

Unintended effects of reimbursement schedules in mental health care

We evaluate the introduction of a reimbursement schedule for self-employed mental health care providers in the Netherlands in 2008. The reimbursement schedule follows a discontinuous discrete step function—once the provider has passed a treatment duration threshold the fee is flat until a next threshold is reached. We use administrative mental health care data of the total Dutch population from 2008 to 2010. We find an “efficiency” effect: on the flat part of the fee schedule providers reduce treatment duration by 2 to 7% compared to a control group. However, we also find unintended effects: providers treat patients longer to reach a next threshold and obtain a higher fee. The data shows gaps and bunches in the distribution function of treatment durations, just before and after a threshold. About 11 to 13% of treatments are shifted over a next threshold, resulting in a cost increase of approximately 7 to 9%.     

Evaluating behavioral health services in Minnesota's Medicaid population using the Experience of Care and Health Outcomes (ECHO) Survey

Performance data on Medicaid managed behavioral health care are for the most part unavailable. The purpose of the current study is to provide a benchmark of Medicaid enrollees' evaluations of access to, and quality of, behavioral health services and to examine the factors that influence these ratings. Eight hundred eighty-five Minnesota Medicaid managed care enrollees who received behavioral health services in 2000 completed the Experience of Care and Health Outcomes Survey, a multidimensional satisfaction survey that included measures of access to services, communication with clinicians, functional improvement, and the effect of treatment. Between 29 and 59 percent of the respondents gave the highest possible ratings to the behavioral health services they received. Access to services and functional improvements were rated less favorably than communication with clinicians and the effects of treatment. Ratings within certain domains varied by age, race, education, and region.     

Use of alternative medicine by children with cancer in Washington state.

BACKGROUND: Use of alternative medicine is widespread among adult cancer patients, but considerably less is known about the use of these therapies by pediatric cancer patients. Our objective was to investigate the distribution and patterns of alternative medicine use by children diagnosed with cancer in Washington State. METHODS: Pediatric cancer patients (< or =18 years) with first primary neoplasms were identified from the Cancer Surveillance System of western Washington. Telephone interviews were conducted with parents of 75 patients to obtain data on the prevalence and types of alternative medicine used, satisfaction with conventional and alternative medicine, motivations for use of alternative medicine, adverse effects, and costs. RESULTS: Seventy-three percent of patients used at least one alternative treatment or therapy. Twenty-one percent of patients consulted an alternative provider (e.g., acupuncturist, naturopathic doctor), and insurance companies covered 75% of these costs. Twenty-eight percent used high-dose dietary supplements such as vitamins C or E, and 35% used herbal preparations. Although use of alternative medicine was associated with parental dissatisfaction with their child's physician (P = 0.02), no patient used alternative medicine as a substitute for standard medical care. Most patients used alternative medicine to cope with disease symptoms or the side effects of the medical treatments. CONCLUSIONS: Pediatric oncology patients use alternative treatments as adjuncts to conventional care. Both researchers and health care providers should remain informed about the benefits and adverse effects of alternative therapies in order to discuss treatment options with patients and their families and to monitor treatment efficacy.     

Diagnosis and 10-year follow-up of a community-based hepatitis C cohort

OBJECTIVE: To determine the health care follow-up and treatment associated with physician-diagnosed hepatitis C (HCV) in a community-based population. STUDY DESIGN: We conducted a retrospective medical record review using records from all providers in Olmsted County, Minnesota. POPULATION: The study incorporated all Olmsted County residents with physician-diagnosed hepatitis C from 1990 through 1999. OUTCOMES MEASURED: We assessed demographic and health status information as well as health services use in subjects with physician-diagnosed HCV. RESULTS: Physicians diagnosed hepatitis C in 355 subjects (219 men [62%], 136 women [38%]), mean age 43 years, in the 10-year period studied. About half of diagnoses (45%, n = 159) were confirmed with polymerase chain reaction or liver biopsies. Identified risk factors included IV drug use (50%), multiple sex partners (36%), and blood transfusion (30%). Follow-up assessment with aspartate aminotransferase/amino alanine transferase (AST/ALT) tests occurred in about half (49%) of subjects, while 202 subjects (60%) were referred for gastrointestinal (GI) specialist evaluation and 49 patients (14% of all, 25% of those referred to a GI specialist) had specific treatment for hepatitis C. Although well over half of patients (60%) had possible contraindications to HCV treatment, including heavy alcohol use, few were referred for chemical dependency therapy. CONCLUSIONS: In this community, follow-up and treatment related to HCV were limited. Attention to prevention of disease-accelerating co- infections was only modest. Referral or documented recommendations for treatment of alcoholism or heavy chronic alcohol ingestion were minimal.     

Alcohol use and health outcomes in the oldest old

Given the increased use of marital- and family-based treatments as part of treatment for alcoholism and other drug disorders, providers are increasingly faced with the challenge of addressing intimate partner violence among their patients and their intimate partners. Yet, effective options for clinicians who confront this issue are extremely limited. While the typical response of providers is to refer these cases to some form of batterers' treatment, three fundamental concerns make this strategy problematic: (1) most of the agencies that provide batterers' treatment only accept individuals who are legally mandated to complete their programs; (2) among programs that do accept nonmandated patients, most substance-abusing patients do not accept such referrals or drop out early in the treatment process; and (3) available evidence suggests these programs may not be effective in reducing intimate partner violence. Given these very significant concerns with the current referral approach, coupled with the high incidence of IPV among individuals entering substance abuse treatment, providers need to develop strategies for addressing IPV that can be incorporated and integrated into their base intervention packages.