Quality Measures at the Interface of Behavioral Health and Primary Care

The development of quality measures has gained increasing attention as health care reimbursements transition from fee-for-service to value-based payment models. As behavioral health care moves towards integration of services with primary care, specific measures and payment incentives will be needed to successfully expand access. This study uses a keyword search to identify 730 quality indicators that are relevant to behavioral health and general medical health. Measures identified have been coded and grouped into domains based on a taxonomy developed by the authors. The analysis reveals that quality measures focusing on general medical conditions exceed those focused on behavioral health diagnoses for evidence-based treatments, patient safety, and outcomes. Furthermore, measures predominantly concentrate on care during or following hospitalizations, which represents a minority of behavioral health care and does not characterize the outpatient settings that are the focus of many models of integrated care. The authors offer recommendations for future steps to identify the quality measures that can best evaluate the evolving behavioral health care system.     

Superstitious conditioning as a model of delusion formation following chronic but not acute ketamine in humans

Background

Ketamine has previously been shown to induce delusion-like or referential beliefs, both acutely in healthy volunteers and naturalistically among nonintoxicated users of the drug. Delusions are theoretically underpinned by increased superstitious conditioning or the erroneous reinforcement of random events.

Materials and methods

Using a novel and objectively measured superstitious conditioning task, experiment 1 assessed healthy volunteers before and during placebo (n?=?16), low-dose (n?=?15), and high-dose ketamine (n?=?16) under randomized and double-blind conditions. Experiment 2 used the same task to compare ketamine users (n?=?18), polydrug controls (n?=?19), and nondrug-using controls (n?=?17).

Results

In experiment 1, ketamine produced dose-dependent psychotomimetic effects but did not cause changes in superstitious conditioning. Experiment 2 found increased levels of superstitious conditioning among ketamine users compared to polydrug and nondrug-using controls, respectively, as evidenced by both objective task responses and subjective beliefs following the task.

Conclusions

Results indicate that chronic but not acute exposure to ketamine may increase the propensity to adopt superstitious conditioning. These findings are discussed in terms of acute and chronic ketamine models of delusion-like belief formation in schizophrenia.     

Functional characteristics of the porcine colonic epithelium following transportation stress and Salmonella infection

OBJECTIVE: Stressful life events and infections contribute to gut disorders such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). We used a pig model to analyse whether this could be linked to altered mediator sensitivity of the epithelial lining. MATERIAL AND METHODS: Uninfected control pigs or pigs with subclinical Salmonella (S.) typhimurium DT 104 infection were killed either without (ConRest, InfRest) or with prior 8-h transportation (ConTrans, InfTrans). Short-circuit current (I(sc)), tissue conductance (G(t)) and release of mast cell mediators were monitored in isolated colonic epithelia mounted in Ussing chambers. Epithelia were exposed to histamine (100 microM, mucosally), substance P (SP; 1 microM, serosally), calcimycin A23187 (1 microM, serosally) and theophylline (10 mM, bilaterally). Transepithelial flux of histamine and colonic activities of histamine N-methyltransferase (HMT) and diamine oxidase (DAO) were determined. RESULTS: S. infection decreased baseline I(sc), G(t) and histamine fluxes, while transportation had no effect on these values. Mucosal histamine increased I(sc) only in ConTrans pigs. This was not associated with increased mucosal-to-serosal flux of histamine but with a 2-fold increased DAO activity. Serosal SP increased I(sc) only in transported animals, but the increase was six times higher in ConTrans versus InfTrans pigs. Effectiveness of SP was not dependent on the release of histamine or prostaglandin D2. A23187 and theophylline elicited increases in I(sc) that were not different between treatments. CONCLUSIONS: Transportation stress facilitates secretory responses of the colonic epithelium to SP and luminal histamine. This is suppressed by subclinical S. infection. Effects of S. infection on porcine colon resemble, in part, the known effects of an oral S. endotoxin application.     

Common genetic factors for depression and cardiovascular disease

There is increasing knowledge regarding the considerable comorbidity between depression and cardiovascular disease, which are two of the most common disorders in developed countries. The associated vulnerability is not unidirectional, as the presence of cardiovascular disease can also influence mood states. Although this may be the result of psychological factors, common biological mechanisms, including genetic ones, are thought to be responsible for this interaction; we can thus question whether variations in genes could be predisposing factors. Regarding the multiple interactions in the mechanisms between depression and cardiovascular system disorders, e.g., dysfunctions in the hypothalamic-pituitary-adrenocortical and sympathoadrenal axis and the response to stress, the importance of the serotonergic and immune systems, or the impact on the renin-angiotensin system, several candidate genes are being investigated. However, despite the interest in unraveling the potential susceptibility genes for both disorders, most available studies have so far dealt with the impact of polymorphisms in relation to either depression or cardiovascular disease. A few recent studies have now examined the effects of gene-gene or gene-environment interactions, and are investigating the impact of "depression-related" variants on cardiac response to stress. The first promising results were obtained with the serotonin transporter, and it may be hypothesized that this polymorphism interacts via the impact of the S allele on depression and via the effect of the L allele on platelet activation. However, the role played by various other candidate genes remains to be determined, especially regarding the question as to whether they are indicative of common pathophysiological mechanisms, or for identifying a subgroup of patients with somatic disorders that are more closely related to psychiatric symptoms.     

Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements

BACKGROUND: Integrity of the abdominal aortic aneurysm (AAA) neck is crucial for the long-term success of endovascular AAA repair (EVAR). However, suitable tools for reliable assessment of changes in small aortic volumes are lacking. The purpose of this study was to assess the intraobserver and interobserver variability of software-enhanced 64-row computed tomographic angiography (CTA) AAA neck volume measurements in patients after EVAR. METHODS: A total of 25 consecutive patients successfully treated by EVAR underwent 64-row follow-up CTA in 1.5-mm collimation. Manual CTA measurements were performed twice by three blinded and independent readers in random order with at least a 4-week interval between readings. Maximum and minimum transverse aortic neck diameters were measured twice on two different levels within the proximal neck. Volumetry of the proximal aortic neck was performed by using dedicated software. Variability was calculated as 1.96 SD of the mean arithmetic difference according to Bland and Altman. Two-sided and paired t tests were used to compare measurements. P values <.05 were considered to indicate statistical significance. RESULTS: Intraobserver agreement was excellent for dedicated aneurysmal neck volumetry, with mean differences of less than 1 mL (P > .05), whereas it was poor for transverse aortic neck diameter measurements (P < .05). However, interobserver variability was statistically significant for both neck volumetry (P < .005) and neck diameter measurements (P < .015). CONCLUSIONS: The reliability of dedicated AAA neck volumetry by using 64-row CTA is excellent for serial measurements by individual readers, but not between different readers. Therefore, studies should be performed with aortic neck volumetry by a single experienced reader.