Behavioral Health Disorders and the Quality of Diabetes Care: A Dissertation

Both diabetes and behavioral health disorders (mental and substance use disorders) are significant health issues in the United States. While previous studies have shown worse health outcomes in people with diabetes and co-occurring behavioral health disorders (BHDs) than those with diabetes alone, it is unclear whether the quality of diabetes care was poorer in the presence of co-occurring BHDs. Although previous research has observed a trend of positive outcomes in people with comprehensive diabetes care, there is a lack of evidence about whether that mode of care delivery can improve outcomes in people with co-occurring BHDs. Therefore, further studies are necessary. Using a combined dataset from Medicare and Medicaid claims for Massachusetts residents, this study compared the quality of diabetes care (e.g., having at least 1 hemoglobin A1c test) and diabetes outcomes (e.g., eye complications) among Medicare and Medicaid beneficiaries with diabetes and co-occurring BHDs to those with diabetes alone in Massachusetts in 2005. The results showed a mixed picture on the relationships between BHDs and diabetes outcomes. While substance use disorders had adverse impact on adherence to quality measures (e.g., 20% less likely to attain full adherence, p0.05). Findings from this dissertation research suggest that disparities exist in the quality of diabetes care and health outcomes between people with substance use disorders and those without. The mode of care delivery needs to be further examined so that interventions can be designed to improve the outcomes of people with diabetes

Behavioral Health Service Use and Expenditures in Massachusetts Medicare and Medicaid Members Aged 55 and Over, 2005

Summary: This report describes behavioral health service use and expenditures for Massachusetts Medicare and Medicaid (MassHealth) members aged 55 and over with behavioral health disorders (BHDs) in calendar year 2005. With an expected increase in the number of elders with BHDs, a better and more comprehensive understanding of behavioral health service delivery is essential in order to identify opportunities for systematic changes that can improve behavioral health services for elders. However, older adults have not been the main focus of previous studies on behavioral health services and expenditures. Furthermore, although existing studies have examined behavioral health services and expenditures in broad geographic areas and at the national level, few studies have taken into account variations among health insurance coverage, particularly Medicare and Medicaid which are important resources for elders and for people with disabilities

Twelve-Month Diagnosed Prevalence of Mental Illness, Substance Use Disorders, and Medical Comorbidity in Massachusetts Medicare and Medicaid Members Aged 55 and Over, 2005

This report describes the 12-month diagnosed prevalence of behavioral health disorders (BHDs) among Massachusetts Medicare and Medicaid (MassHealth) members 55 years of age and older during calendar year 2005. Although population-based estimates of prevalence of BHDs among the elderly are available in only a few selected studies, none of them describe Massachusetts. With an expected rise in the number of elderly people with psychiatric disorders, a better understanding of the prevalence of mental illness and addictions in this population is needed to plan for services and supports

Chronic physical conditions in older adults with mental illness and/ or substance use disorders

OBJECTIVES: To examine the association between mental illness and chronic physical conditions in older adults and investigate whether co-occurring substance use disorders (SUDs) are associated with greater risk of chronic physical conditions beyond mental illness alone. DESIGN: A retrospective cross-sectional study. SETTING: Medicare and Medicaid programs in Massachusetts. PARTICIPANTS: Massachusetts Medicare and Medicaid members aged 65 and older as of January 1, 2005 (N = 679,182). MEASUREMENTS: Diagnoses recorded on Medicare and Medicaid claims were used to identify mental illness, SUDs, and 15 selected chronic physical conditions. RESULTS: Community-dwelling older adults with mental illness or SUDs had higher adjusted risk for 14 of the 15 selected chronic physical conditions than those without these disorders; the only exception was eye diseases. Moreover, those with co-occurring SUDs and mental illness had the highest adjusted risk for 11 of these chronic conditions. For residents of long-term care facilities, mental illness and SUDs were only moderately associated with the risk of chronic physical conditions. CONCLUSION: Community-dwelling older adults with mental illness or SUDs, particularly when they co-occurred, had substantially greater medical comorbidity than those without these disorders. For residents of long-term care facilities, the generally uniformly high medical comorbidity may have moderated this relationship, although their high prevalence of mental illness and SUDs signified greater healthcare needs. These findings strongly suggest the imminent need for integrating general medical care, mental health services, and addiction health services for older adults with mental illness or SUDs. Geriatrics Society

Behavioral Disorders and Diabetes-Related Outcomes Among Massachusetts Medicare and Medicaid Beneficiaries

Objective: The study investigated whether Massachusetts beneficiaries of Medicare, Medicaid, or both programs who have behavioral disorders have higher rates of diabetes-related complications and hospitalizations. Methods: This was a retrospective study using merged Medicare and Medicaid claims data from Massachusetts in 2004 and 2005. The study included beneficiaries who had type 2 diabetes, who stayed in nursing homes for fewer than 90 days, and who were enrolled in Medicare or Medicaid (or both) for at least ten months during the study period. ICD-9-CM and Current Procedural Terminology codes were used to identify diabetes complications (eye complications, nephropathy, neuropathy, ischemic heart disease, cerebrovascular disease, lower-limb amputations, and diabetes-related hospitalizations). The rates of adverse diabetes outcomes were compared across behavioral disorders as identified by ICD-9-CM diagnoses. While adjusting for case mix, multivariate logistic regressions were performed to compare the odds of adverse diabetes outcomes among people with mental or substance use disorders with those without these disorders. Results: A total of 106,174 individuals met inclusion criteria. Results from adjusted analysis showed a mixed picture of the relationships between behavioral disorders and adverse diabetes outcomes. Although substance use disorders were associated with higher odds of lower-limb amputations and diabetes-related hospitalizations, beneficiaries with schizophrenia or paranoid states had lower odds of adverse diabetes outcomes. Conclusions: Medicaid and Medicare beneficiaries with alcohol or drug use disorders had higher rates of adverse diabetes outcomes than other groups, whereas beneficiaries with mental disorders had lower rates of diabetes-related complications. (Psychiatric Services 62:659–665, 2011

Behavioral Health Disorders and Adherence to Measures of Diabetes Care Quality

Objective: To investigate whether Medicare and/or Medicaid beneficiaries with behavioral health disorders (BHDs) receive lower quality diabetes care. Study Design: Retrospective observational study using merged Medicare and Medicaid claims data from Massachusetts in calendar years 2004 and 2005. Methods: The study included beneficiaries who had type 2 diabetes, stayed at nursing homes for fewer than 90 days, and were enrolled in Medicare and/or Medicaid for at least 10 months during the study period. We used Current Procedural Terminology (CPT) codes to identify the receipt of 4 measures of diabetes care quality (ie, glycated hemoglobin tests, low-density lipoprotein cholesterol tests, nephropathy tests, eye examinations). The rates of adherence (defined by proportions of beneficiaries receiving appropriate services for each measure) were compared across different types of BHDs as identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses. Multivariate logistic regression was used to compare the odds of adherence among beneficiaries who had BHDs with the odds among beneficiaries who had no BHDs, while adjusting for case mix. Results: A total of 106,174 individuals met inclusion criteria. Results from adjusted analysis showed a mixed picture of the relationships between BHDs and adherence to quality measures. While substance use disorders were associated with lower adherence to quality measures, beneficiaries with diagnoses of schizophrenia or paranoid states had higher odds for adherence to quality measures. Conclusions: Individuals with diabetes and substance use disorders receive lower quality diabetes care. Further studies to examine the factors associated with this disparity are needed

The evidence doesn\u27t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine

Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003-07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety

Twelve-month Diagnosed Prevalence of Behavioral Health Disorders among Elderly Medicare and Medicaid Members

Objectives: We examined the 12-month diagnosed prevalence of behavioral health disorders (BHDs) and dementia among elderly Medicare and Medicaid members in Massachusetts by primary payment source group (dual eligible, Medicare only, and Medicaid only) and age group (65-74 years, 75-84 years, and 85 years and older). Design: A retrospective cross-sectional study. Setting: Medicare and Medicaid programs. Participants: Massachusetts Medicare or Medicaid enrollees age 65 and older as of January 1, 2005, (N = 679,182). Measurements: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes recorded on Medicare and Medicaid claims were used to identify the BHDs. Results: The 12-month diagnosed prevalence was 19.4% for any BHD and 11.2% for dementia. The most common BHDs by disease category were major depression (severe mental illness [SMI]), other depression (other mental illness [OMI]), and alcohol abuse or dependence (subtance use disorder [SUD]). Dual eligibles had a considerably higher diagnosed prevalence of any BHD (38.8%), compared with 16.1% in the Medicare only group. The 12-month diagnosed prevalence of SMI, OMI, and dementia was higher in the older-age groups. Co-occurring SUD was higher for younger dual eligibiles. Dementia and mental illness co-occurred at much higher rates for dual eligibles than for either of the single-insurance groups. This combination increased with age in all three groups. Conclusions: The 12-month prevalence of BHDs and dementia among elderly dual eligibles was disproportionately higher than other elderly Medicare or Medicaid members. However, access barriers to behavioral health services for this vulnerable population could be significant because Medicare and Medicaid payment limitations resulted in financial disincentives for providing these services. Copyright (C) 2011 American Association for Geriatric Psychiatr

Factors associated with Medicaid patients\u27 access to buprenorphine treatment

Some studies have shown that patients entering buprenorphine treatment differ from those in other modalities. This study compares Massachusetts Medicaid beneficiaries who received buprenorphine, methadone or other treatment for opioid addiction in 2007. Patients\u27 characteristics and comorbidities were identified through claims data, and associations between these factors and treatment type were investigated using multivariate analysis. Among patients receiving opioid agonist treatments, patients with prior buprenorphine treatment, HIV, bipolar disease, and other substance use disorders were more likely to receive buprenorphine treatment compared with methadone, whereas patients with heart failure, diabetes, hepatitis C, major depression, and anxiety were less likely to receive buprenorphine treatment. These differences may suggest variability in patient access, treatment preferences, and a need for different levels of services in different modalities. This information is important for understanding the impact of this new treatment in Medicaid populations and for developing treatment systems to best meet patients\u27 needs

Comprehending the allergen repertoire of shrimp for precision molecular diagnosis of shrimp allergy.

BACKGROUND: Clinical management of shrimp allergy is hampered by the lack of accurate tests. Molecular diagnosis has been shown to more accurately reflect the clinical reactivity but the full spectrum of shrimp allergens and their clinical relevance are yet to be established. We therefore sought to comprehend the allergen repertoire of shrimp, investigate and compare the sensitization pattern and diagnostic value of the allergens in allergic subjects of two distinct populations. METHODS: Sera were collected from 85 subjects with challenge-proven or doctor-diagnosed shrimp allergy in Hong Kong and Thailand. The IgE-binding proteins of Penaeus monodon were probed by Western blotting and identified by mass spectrometry. Recombinant shrimp allergens were synthesized and analyzed for IgE sensitization by ELISA. RESULTS: Ten IgE-binding proteins were identified, and a comprehensive panel of 11 recombinant shrimp allergens was generated. The major shrimp allergens among Hong Kong subjects were troponin C (Pen m 6) and glycogen phosphorylase (Pen m 14, 47.1%), tropomyosin (Pen m 1, 41.2%) and sarcoplasmic-calcium binding protein (Pen m 4, 35.3%), while those among Thai subjects were Pen m 1 (68.8%), Pen m 6 (50.0%) and fatty acid-binding protein (Pen m 13, 37.5%). Component-based tests yielded significantly higher area under curve values (0.77-0.96) than shrimp extract-IgE test (0.70-0.75). Yet the best component test differed between populations; Pen m 1-IgE test added diagnostic value only in the Thai cohort, whereas sensitizations to other components were better predictors of shrimp allergy in Hong Kong patients. CONCLUSION: Pen m 14 was identified as a novel shrimp allergen predictive of challenge outcome. Molecular diagnosis better predicts shrimp allergy than conventional tests, but the relevant component is population dependent