Center for Health Care Evaluation

Palo Alto, CA, United States

Center for Health Care Evaluation

Palo Alto, CA, United States
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Maisel N.C.,Center for Health Care Evaluation | Karney B.R.,University of California at Los Angeles
Journal of Family Psychology | Year: 2012

Although stressful events and poor mental health predict worse intimate relationships in all segments of society, they may be especially detrimental for poorer couples who lack the financial resources that facilitate successful coping. To examine this hypothesis, associations among stress, mental health, and relationship satisfaction were examined in the Florida Family Formation study, a stratified random sample of more than 2000 Florida residents that included oversamples of low-income participants. As predicted, stressful life events and mental health problems accounted for more variance in relationship satisfaction among poorer than among more affluent individuals. These results suggest that models of relationship satisfaction addressing low-income populations may need to emphasize contextual and individual variables more than models developed in more affluent populations. © 2012 American Psychological Association.

Zulman D.M.,Center for Health Care Evaluation | Nazi K.M.,Stratton Medical Center | Turvey C.L.,University of Iowa | Wagner T.H.,Health Economics Resource Center | And 2 more authors.
Annals of Internal Medicine | Year: 2011

Background: Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers. Objective: To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet. Design: Web-based survey of a convenience sample. Setting: My HealtheVet Web site from 7 July through 4 October 2010. Participants: 18 471 users of My HealtheVet. Measurements: Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate. Results: Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person. Limitations: The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users. Conclusion: In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care. Primary Funding Source: Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.

Lemke S.P.,Center for Health Care Evaluation | Schaefer J.A.,Center for Health Care Evaluation
Psychiatric Services | Year: 2010

Objective: This study identified recent changes in the prevalence of psychiatric disorders among Department of Veterans Affairs (VA) nursing home residents. Methods: Psychiatric diagnoses in administrative databases were summarized for nursing home residents in 1998, 2002, and 2006. Census prevalence rates were compared with findings from earlier VA nursing home surveys. Prevalence rates were compared for age groups and birth cohorts of VA nursing home admissions in 1998 (N=27,734) and 2006 (N=32,543). Results: Among residents in the census samples, prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, depression prevalence increased sharply, alcohol use disorder prevalence declined, and drug use disorder prevalence increased. Among 1998 and 2006 admissions, dementia prevalence increased for most birth cohorts but declined for most age groups (35% to 32% overall). Depression prevalence increased for all age groups and birth cohorts (27% to 37% overall), as did posttraumatic stress disorder prevalence (5% to 12% overall). Serious mental illness prevalence increased among the oldest residents and birth cohorts (19% to 22% overall). Alcohol use disorder prevalence declined for all birth cohorts and most age groups (18% to 16% overall), but drug use disorder prevalence increased substantially for younger age groups (6% to 9% overall). Conclusions: Examining differences in prevalence between birth cohorts and age groups can clarify trends in nursing home resident characteristics and improve projections of their future needs.

Heinz A.J.,Center for Health Care Evaluation
Experimental and clinical psychopharmacology | Year: 2013

Delay discounting (DD), an index of impulsivity, reflects individuals' preference for smaller immediate rewards to larger delayed rewards. The current study examined (a) relations between DD and quantity, frequency, and severity of Cannabis use, as well as several other measures of co-occurring substance use and clinical severity, and (b) whether DD predicted Cannabis-cessation outcomes. Cannabis-dependent United States (U.S.) veterans (N = 72; 95% male) who were interested in making serious self-quit attempts were evaluated prior to their cessation attempts, during which they completed a computerized DD task, and were followed throughout six months postattempt. Results indicated that higher DD was significantly correlated with higher compulsive craving for Cannabis (ρ = .29, p < .05), younger age of first Cannabis use (r = -.32, p < .01), earlier commencement of regular Cannabis smoking (r = -.25, p < .05), and seeking professional help for a previous Cannabis quit attempt (ρ = .27, p < .05). DD did not significantly predict any Cannabis-cessation outcomes in the first week postattempt or during the 6-month follow-up. These results add to the literature on DD, which has focused on users of tobacco, alcohol, opioids, and cocaine, by demonstrating that DD is sensitive to developmental trajectories of Cannabis dependence, but does not reliably predict cessation outcomes. Results also suggest that DD may carry less relevance for Cannabis than for other substances of abuse. (c) 2013 APA, all rights reserved.

Harris A.H.,Center for Health Care Evaluation
Addiction science & clinical practice | Year: 2012

Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender. Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1-4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed. Having an AUDIT-C score of 9-12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men≤50 years, those with AUDIT-C scores≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1-4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR=1.24; 95% confidence interval [CI], 1.03-1.50). For men≥65 years with average comorbidity and education, those with AUDIT-C scores of 5-8 (adjusted prevalence, 7.9% versus 7.4%; OR=1.16; 95% CI, 1.02-1.31) and 9-12 (adjusted prevalence 11.1% versus 7.4%; OR=1.68; 95% CI, 1.30-2.17) were at significantly increased risk for trauma compared with men≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women. Men with severe alcohol misuse (AUDIT-C 9-12) demonstrate an increased risk of trauma. Men≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5-8 and 9-12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.

Del Re A.C.,Center for Health Care Evaluation
Addiction science & clinical practice | Year: 2013

As a quality improvement metric, the US Veterans Health Administration (VHA) monitors the proportion of patients with alcohol use disorders (AUD) who receive FDA approved medications for alcohol dependence (naltrexone, acamprosate, and disulfiram). Evidence supporting the off-label use of the antiepileptic medication topiramate to treat alcohol dependence may be as strong as these approved medications. However, little is known about the extent to which topiramate is used in clinical practice. The goal of this study was to describe and examine the overall use, facility-level variation in use, and patient -level predictors of topiramate prescription for patients with AUD in the VHA. Using national VHA administrative data in a retrospective cohort study, we examined time trends in topiramate use from fiscal years (FY) 2009-2012, and predictors of topiramate prescription in 375,777 patients identified with AUD (ICD-9-CM codes 303.9x or 305.0x) treated in 141 VHA facilities in FY 2011. Among VHA patients with AUD, rates of topiramate prescription have increased from 0.99% in FY 2009 to 1.95% in FY 2012, although substantial variation across facilities exists. Predictors of topiramate prescription were female sex, young age, alcohol dependence diagnoses, engagement in both mental health and addiction specialty care, and psychiatric comorbidity. Veterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Not including topiramate in the metric, which is prescribed more often than acamprosate and disulfiram combined, may underestimate the extent to which VHA patients at specific facilities and overall are receiving pharmacotherapy for AUD.

Cabriales J.A.,University of Texas at El Paso | Cooper T.V.,University of Texas at El Paso | Taylor T.,Center for Health Care Evaluation
Experimental and Clinical Psychopharmacology | Year: 2013

Illicit substance use has increased in Hispanics. Recent trends also warrant focus on prescription drug misuse, given its increased prevalence among college students. The aims of this study were to assess prescription drug misuse and illicit drug use in Hispanic students, as well as potential theoretically and empirically based risk and protective factors. Hispanic students (n = 435; 59% female) from a U.S. university located on the border with México completed a sociodemographic survey, licit, illicit, and prescription drug use frequency questionnaires, an attitudes and beliefs about prescription drugs survey, the Short Acculturation Scale for Hispanics, the Depression, Anxiety, and Stress Scales, the Collectivist Coping Styles Measure, and the Multidimensional Scale of Perceived Social Support. A hierarchical logistic regression assessed prescription drug misuse predictors including demographics, licit/illicit substance use, attitudes toward prescription drug use, acculturation, distress symptoms, coping style, perceived social support, and the interaction between distress symptoms and acculturation. A negative binomial regression assessed predictors of past 30-day illegal drug use (the same predictors as the previous model except illicit drug use). Results indicated that positive attitudes toward prescription drugs, higher anxiety, and lower depressive symptomatology increased the odds of prescription drug misuse. Past 30-day alcohol use, positive attitudes toward prescription drugs, and higher acculturation predicted past 30-day illicit drug use. Prescription drug misuse was differentially associated with distress symptoms, whereas the convergence model of acculturation was supported regarding illegal drug use. Inconsistent with hypotheses, protective factors were not significantly associated with substance use. © 2013 American Psychological Association.

Maisel N.C.,Center for Health Care Evaluation | Blodgett J.C.,Center for Health Care Evaluation | Wilbourne P.L.,Center for Health Care Evaluation | Humphreys K.,Center for Health Care Evaluation | And 3 more authors.
Addiction | Year: 2013

Aims: Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects. Methods: A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone. Results: Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo. Conclusions: In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively. © 2012.

Friedman S.A.,Center for Health Care Evaluation
Women's health issues : official publication of the Jacobs Institute of Women's Health | Year: 2011

The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period. We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. "New" patients in a given year had no outpatient use within the prior 3 years. Patients were "retained" if they continued to use VHA in subsequent years. Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years. The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services. Published by Elsevier Inc.

Boden M.T.,Center for Health Care Evaluation | Moos R.,Center for Health Care Evaluation | Moos R.,Stanford University
Schizophrenia Research | Year: 2013

Although integrated approaches are recommended and effective for treating patients with co-occurring substance use and psychotic disorders (SUD-PSY), many patients receive standard, nonintegrated substance use disorder (SUD) treatment. Research has yet to investigate how patients with co-occurring substance use and psychotic disorders respond to standard SUD treatment, an issue we address here. In a naturalistic follow-up of 236 male SUD-PSY patients receiving 12-step facilitation or cognitive-behavioral-oriented SUD treatment, we found that patients (1) demonstrated significant improvements in proximal outcomes (e.g., approach coping) from treatment intake to discharge, and in distal outcomes (e.g., psychiatric symptoms, substance use frequency) from treatment intake to 1- and 5-year follow-ups, and (2) tended to have similar outcomes whether they received 12-step facilitation or cognitive-behavioral SUD treatment. Patients who (3) were more involved in treatment, as reflected by more positive perceptions of and more satisfaction, tended to experience better proximal outcomes and engage in more continuing care, and those who (4) experienced better proximal outcomes tended to have better psychiatric and substance use outcomes in the years following treatment. Our results suggest that SUD-PSY patients can benefit from standard SUD treatments, even though it may not directly address their psychiatric disorders. © 2013.

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