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Biomedical subjects

K B Wells

Publications and source records attributed to K B Wells.

At least 37 records · Page 2Linked to original sources
PubMed2000

Community effects on access to behavioral health care.

OBJECTIVE: To explore the effects of community-level factors on access to any behavioral health care and specialty behavioral health care. DATA: Healthcare for Communities household survey data, merged to supplemental data from the 1990 Census Area Resource File, 1995 U.S. Census Bureau Small Area Estimates, and 1994 HMO enrollment data. STUDY DESIGN: We use a random intercept model to estimate the influences of community-level factors on access to any outpatient care, any behavioral health care conditional on having received outpatient care, and any specialty behavioral health care conditional on having received behavioral health care. DATA COLLECTION: HCC data were collected in 1997 from about 10,000 households nationwide but clustered in 60 sites. PRINCIPAL FINDINGS: Individuals in areas with greater HMO presence have better overall access to care, which in turn affects access to behavioral health care; individuals in poorer communities have less access to specialty care compared to individuals in wealthier communities. CONCLUSIONS: Our findings of lower access to specialty care among those in poor communities raises concerns about the appropriateness and quality of the behavioral health care they are receiving. More generally, the findings suggest the importance of considering the current status and expected evolution of HMO penetration and the income level in a community when devising health care policy.

Behavioral Medicine↗
PubMed1999

Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices.

BACKGROUND: Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions. METHODS: Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with self-report. Quality of life was assessed by the 12-Item Short-Form Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions. RESULTS: Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P<.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P<.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility. CONCLUSIONS: Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority.

Adolescent↗
PubMed1999

The design of Partners in Care: evaluating the cost-effectiveness of improving care for depression in primary care.

This paper describes a study design that blends health services and clinical research approaches to examine the cost-effectiveness of treatments and of quality improvement for depression in primary care, managed care practices. Six managed care organizations in Los Angeles (Calif.), San Antonio (Tex.), San Luis Valley (Colo.), Twin Cities (Minn.), and Columbia (Md.) participated. Primary care clinics were randomized to one of two quality improvement interventions or care as usual. Interventions included patient and provider education, nurse-assisted patient assessment, and resources to support appropriate medication management or access to cognitive behavioral therapy. Practices implemented the interventions with study support. Providers and patients selected treatment. Patients with depressive symptoms regardless of comorbidities were eligible. Over 27,000 primary care patients visiting the practices of 181 primary care clinicians were screened for depression, 14% were potentially eligible, and 1356 enrolled into the 2-year longitudinal study. Enrollees were similar to eligibles, but usual care clinic patients tended to be less severely depressed than intervention clinic patients, partly due to clinic staff enthusiasm. The result of the study showed that studying treatment effects and quality improvement in nonacademic settings is feasible, but requires relaxation of design features of experiments that protect internal validity. The trade-off between certainty of causal inference and generalizability to usual care conditions is discussed. The strengths and limitations of this study design are compared to those of clinical trials and recent clinical effectiveness studies.

Adolescent↗
PubMed1999

Treating depression in staff-model versus network-model managed care organizations.

OBJECTIVE: To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers' depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Chi-Square Distribution↗
PubMed1999

What outcomes matter to patients?

OBJECTIVE: This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status. DESIGN: Cross-sectional data from quasi-experimental, prospective study. SETTING: Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado. PATIENTS: Consecutive adult outpatients (n = 16,689) visiting primary care providers. MEASUREMENTS AND MAIN RESULTS: Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions. CONCLUSIONS: Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.

Adolescent↗
PubMed1999

Relationship between age and patients' current health state preferences.

This article explores age differences in preferences for current health states, which is one way to measure trade-offs between "quantity of life" and the "quality" of those health states. Data are from 17,707 adult outpatients visiting 46 primary care, managed care practices. Patient preferences (utility) for their current health were assessed by standard gamble and time trade-off methods. Although older primary care patients' utility measurements for their current health were lower than other patient groups, most of the difference in value measurements was attributable to differences in health. Health providers should take care to assess individual preferences from all patients regardless of age.

Adolescent↗
PubMed1999

Treatment research at the crossroads: the scientific interface of clinical trials and effectiveness research.

OBJECTIVE: Policy and clinical management decisions depend on data on the health and cost impacts of psychiatric treatments under usual care, i.e., effectiveness. Clinical trials, however, provide information on treatment efficacy under best-practice conditions. An understanding of the design, analysis, and conventions of both efficacy and effectiveness studies can lead to research that better informs clinical and societal questions. METHOD: This paper contrasts the strengths and limitations of clinical trials and effectiveness studies for addressing policy and clinical decisions. These research approaches are assessed in terms of outcomes, treatments, service delivery context, implementation conventions, and validity. RESULTS: Clinical trials and effectiveness research share problems of internal and external validity despite more attention to internal validity in clinical trials (e.g., randomization, blinding, standardized protocols) and to external validity in effectiveness studies (e.g., community-based treatments, representative samples). CONCLUSIONS: To develop research at the interface of clinical trials and effectiveness studies, research goals must be redefined, and methods, such as cost-utility and econometric analyses, must be shared and developed. Development of hybrid designs that combine features of efficacy and effectiveness research will require separation of conventions such as frequency of follow-up, intensity of measurement, and sample size from the central scientific issues of aims and validity.

Clinical Protocols↗
PubMed1999

Termination of social security benefits among Los Angeles recipients disabled by substance abuse.

OBJECTIVES: Although a 1996 federal law terminated Social Security disability benefits to individuals disabled primarily by drug addiction and alcoholism, many were expected to successfully appeal for recertification based on mental illness. This study examined appeal and recertification in Los Angeles County. METHODS: Data for 2,001 persons receiving Social Security disability benefits in 1996 because of substance abuse disability were obtained from the referral and monitoring agency, where each person had completed the Addiction Severity Index (ASI) during an initial visit in the past two years. Administrative data were obtained from the Social Security Administration. Severity of psychiatric symptoms--low, medium, or high--was based on the composite score on the ASI psychiatric subscale. Logistic regression analyses examined the relationship between severity and appeal and recertification status. RESULTS: Fifty-one percent of the subjects scored in the medium- or high-severity range. Appeals were made by 80 percent of the 506 recipients with high scores, 72 percent of the 510 recipients with medium scores, and 74 percent of the 985 recipients with low scores. Recertification rates were 60 percent, 45 percent, and 47 percent, respectively. Compared with recipients who had low scores, those with high scores were more likely to appeal and to be recertified. However, benefits were terminated for 51 percent of recipients with high scores, including all those who did not appeal. CONCLUSIONS: Many recipients of Social Security disability benefits with comorbid psychiatric problems lost benefits either because they did not appeal or because their appeal was denied.

Comorbidity↗
PubMed1999

The design of Healthcare for Communities: a study of health care delivery for alcohol, drug abuse, and mental health conditions.

There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

Community Mental Health Services↗
PubMed1998

Medication management of depression in the United States and Ontario.

OBJECTIVE: To compare rates of contact for mental problems and receipt of appropriate antidepressant medication management for persons in the general population with major depression in the United States and Ontario, Canada. DESIGN: Survey using the U.S. National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Survey. PARTICIPANTS: All persons with major depression as described in DSM-III-R in the previous 12 months, from a multistage random sample of persons aged 21 to 54 years living in households in the United States (n = 574) and Ontario (n = 250) in 1990. MEASUREMENTS AND MAIN RESULTS: Self-reported contact with general medical or mental health specialty providers for mental problems and appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any provider within the previous 12 months, were the main outcome measures. The proportion of depressed persons receiving appropriate management was lower in the United States than in Ontario (7.3% vs 14.9% in Ontario, adjusted odds ratio [AOR] 95% CI 0.4; 95% confidence interval [CI] 0.2, 0.8). This difference was largely the result of fewer Americans than Canadians having any mental health care from general medical physicians (9.6% in the United States vs 25.8% in Ontario; AOR 0.3; 95% CI 0.1, 0.5) rather than from specialty providers (20.8% in the United States vs 28.9% in Ontario; AOR 0.7; 95% CI 0.4, 1.1). These between-country differences were much greater for the poor than for those with higher incomes. The Ontario-United States AOR of making contact with either type of clinical provider was 7.5 (95% CI 2.7, 20.7) for lowest-income persons but 2.1 (95% CI 0.3, 5.6) for highest-income persons. The proportions of depressed recipients of any mental health care who received appropriate management were similar between countries (23.9% in the United States vs 27.7% in Ontario; AOR 0.8; 95% CI 0.3, 1.7). CONCLUSIONS: Most persons with depression in the United States and Ontario do not receive appropriate medication management. The rate of appropriate medication management in the United States relative to Ontario is lower largely because there is less contact with general medical physicians for mental problems, especially for the poor. Economic barriers, rather than knowledge and attitudinal factors, appear to explain this difference.

Adult↗
PubMed1998

Empirically defined health states for depression from the SF-12.

OBJECTIVE: To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression. DATA SOURCES: From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients. METHODOLOGY: We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis. PRINCIPAL FINDINGS: We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time. CONCLUSIONS: Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Chi-Square Distribution↗
PubMed1997

Course of depression in patients with comorbid anxiety disorders.

This study examined the extent to which the presence of comorbid anxiety disorder affected the course of depression. 650 depressed outpatients visiting general medical clinicians and mental health specialists were followed for 1 or 2 years. All types of anxiety increased the probability of a new depressive episode among patients with subthreshold depression. Co-occurring panic and phobia decreased the likelihood of remission. The initial number of depressive symptoms was greatest among depressed patients with comorbid anxiety and this relatively higher level persisted over two years. The findings emphasize the poor clinical prognosis associated with comorbid anxiety disorder.

Adult↗
PubMed1997

Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans.

OBJECTIVE: Although posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic condition, the relationship between PTSD and functioning and quality of life remains incompletely understood. METHOD: The authors undertook an archival analysis of data from the National Vietnam Veterans Readjustment Study. The study subjects consisted of the nationally representative sample of male Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. The authors estimated PTSD at the time of the interview with the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. They examined the following outcomes: diminished well-being, physical limitations, bed day in the past 2 weeks, compromised physical health status, currently not working, and perpetration of violence. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions. RESULTS: The risks of poorer outcome were significantly higher in subjects with PTSD than in subjects without PTSD in five of the six domains. For the outcome domains of physical limitations, not working, compromised physical health, and diminished well-being, these significantly higher risks persisted even in the most conservative logistic models that removed the shared effects of comorbid psychiatric and other medical disorders. CONCLUSIONS: The suffering associated with combat related-PTSD extends beyond the signs and symptoms of the disorder to broader areas of functional and social morbidity. The significantly higher risk of impaired functioning and diminished quality of life uniquely attributable to PTSD suggests that PTSD may well be the core problem in this group of difficult to treat and multiply afflicted patients.

Combat Disorders↗
PubMed1997

Measuring health outcomes for depression.

In this article, we describe the clinical and health-related quality of life outcome measures for depressed patients in the Medical Outcomes Study, a 4-year longitudinal study that started in 1986. We prioritize the measures in terms of importance, consider how they can be improved in future studies, and discuss how they should be used in more applied evaluations, such as studies by managed care companies and group practices. We emphasize the importance of identifying appropriate evaluation questions and selecting study designs and patient populations that permit meaningful answers about evaluating outcomes of care for depression. Although the outcome measures described here may be a useful starting point, they will need to be combined with carefully constructed measures of process of care as well, so that links between the two can be maximized.

Depressive Disorder↗
PubMed1997

Caring for depression in primary care: defining and illustrating the policy context.

Depression is a socially important condition that is often undertreated. This article reviews data from the Medical Outcomes Study illustrating the policy importance of depression, highlighting style of treatment under prepaid managed or fee-for-service care and strategies to improve the cost-effectiveness and efficiency of care.

Comorbidity↗
PubMed1996

Prevalence of comorbid anxiety disorders in primary care outpatients.

OBJECTIVE: To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions. DESIGN: Observational study. SETTING: Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes. PATIENTS: Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression. MEASURES: Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed). METHODS: Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers. RESULTS: Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%). CONCLUSION: Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.

Adult↗
PubMed1996

Mental health problems among homeless mothers: relationship to service use and child mental health problems.

BACKGROUND: The purpose of this study was to describe the prevalence of psychological distress and probable lifetime mental disorders among homeless mothers, their use of services, and the relationship between maternal and child mental health problems. METHOD: The study involved a cross-sectional assessment of 110 mothers and 157 children living in homeless shelters in Los Angeles County. RESULTS: The majority (72%) of sheltered homeless mothers reported high current psychological distress or symptoms of a probable lifetime major mental illness or substance abuse. However, few mothers (15%) in need of services received mental health care, and the main point of contact for those with a mental health problem was the general medical sector. Mothers with a probable mental disorder were also significantly more likely to have children with either depression or behavior problems. CONCLUSIONS: Homeless mothers have a high level of unmet need for mental health services. The relationship between maternal and child problems underscores the need for homeless family interventions that promote access to psychiatric care for both generations.

Adult↗