Publications by authors named "Benjamin L�� Cook"

21 Publications

  • Page 1 of 1

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity.

Health Serv Res 2021 Aug 5;56(4):581-591. Epub 2021 Feb 5.

Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts, USA.

Objective: To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.

Data Sources: Five percent random sample of Medicare claims from 2009 to 2016.

Study Design: We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design.

Data Collection/extraction Methods: Not applicable.

Principal Findings: MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.

Conclusions: We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.
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http://dx.doi.org/10.1111/1475-6773.13625DOI Listing
August 2021

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees.

JAMA Netw Open 2020 10 1;3(10):e2019854. Epub 2020 Oct 1.

Harvard Medical School, Boston, Massachusetts.

Importance: Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population.

Objective: To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI.

Design, Setting, And Participants: This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020.

Exposures: Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014.

Main Outcomes And Measures: Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes.

Results: The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008).

Conclusions And Relevance: This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.19854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545309PMC
October 2020

Addressing Major Health Disparities Related to Coronavirus for People With Behavioral Health Conditions Requires Strength-Based Capacity Building and Intentional Community Partnership.

World Med Health Policy 2020 Aug 27. Epub 2020 Aug 27.

Far from being an equalizer, as some have claimed, the COVID-19 pandemic has exposed just how vulnerable many of our social, health, and political systems are in the face of major public health shocks. Rapid responses by health systems to meet increased demand for hospital beds while continuing to provide health services, largely via a shift to telehealth services, are critical adaptations. However, these actions are not sufficient to mitigate the impact of coronavirus for people from marginalized communities, particularly those with behavioral health conditions, who are experiencing disproportional health, economic, and social impacts from the evolving pandemic. Helping these communities weather this storm requires partnering with existing community-based organizations and local governments to rapidly and flexibly meet the needs of vulnerable populations.
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http://dx.doi.org/10.1002/wmh3.364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461022PMC
August 2020

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences.

Qual Health Res 2020 10 25;30(12):1833-1850. Epub 2020 Jul 25.

Cambridge Health Alliance, Massachusetts, USA.

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino ( = 4), non-Hispanic/Latino Black ( = 8), or non-Hispanic/Latino White ( = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.
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http://dx.doi.org/10.1177/1049732320937663DOI Listing
October 2020

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences.

Qual Health Res 2020 10 25;30(12):1833-1850. Epub 2020 Jul 25.

Cambridge Health Alliance, Massachusetts, USA.

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino ( = 4), non-Hispanic/Latino Black ( = 8), or non-Hispanic/Latino White ( = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.
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http://dx.doi.org/10.1177/1049732320937663DOI Listing
October 2020

Differences in BMI between Mexican and Colombian patients receiving antipsychotics: results from the International Study of Latinos on Antipsychotics (ISLA).

Ethn Health 2020 05 7;25(4):598-605. Epub 2018 Mar 7.

Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL, USA.

The objective of this study is to examine the association of country of residence with body mass index (BMI) between Mexican and Colombian patients exposed to antipsychotics. We hypothesize that there will be a significant association between country of residence and BMI and that Mexican patients will have higher BMI than their Colombian counterparts. The International Study of Latinos on Antipsychotics (ISLA) is a multisite, international, cross sectional study of adult Latino patients exposed to antipsychotics in two Latin American Countries (i.e. Mexico and Colombia). Data were collected from a total of 205 patients (149 from Mexico and 56 from Colombia). The sites in Mexico included outpatient clinics in Mexicali, Monterrey and Tijuana. In Colombia, data were collected from outpatient clinics in Bogotá. For this study we included patients attending outpatient psychiatric community clinics that received at least one antipsychotic (new and old generation) for the last 3 months. A linear regression model was used to determine the association of country of residence with BMI for participants exposed to an antipsychotic. After controlling for demographics, behaviors, biological and comorbid psychiatric variables, there was a significant difference between Colombia vs. Mexico in the BMI of patients exposed to antipsychotics ( = 4.9;  < 0.05). Our hypotheses were supported. These results suggest that differences in BMI in patients exposed to antipsychotics in Mexico and Colombia may reflect differences in prevalence of overweight/obesity at the population level in the respective countries, and highlights the involvement of other risk factors, which may include genetics.
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http://dx.doi.org/10.1080/13557858.2018.1439894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224311PMC
May 2020

A decline in depression treatment following FDA antidepressant warnings largely explains racial/ethnic disparities in prescription fills.

Depress Anxiety 2017 12 29;34(12):1147-1156. Epub 2017 Sep 29.

Center for Multicultural Mental Health Research, Cambridge Health Alliance & Harvard Medical School, Cambridge, MA, USA.

Background: The Food and Drug Administration's 2004 antidepressant warning was followed by decreases in antidepressant prescribing for youth. This was due to declines in all types of depression treatment, not just the intended changes in antidepressant prescribing patterns. Little is known about how these patterns varied by race/ethnicity.

Method: Data are Medicaid claims from four U.S. states (2002-2009) for youth ages 5-17. Interrupted time series analyses measured changes due to the warning in levels and trends, by race/ethnicity, of three outcomes: antidepressant prescription fills, depression treatment visits, and incident fluoxetine prescription fills.

Results: Prewarning, antidepressant fills were increasing across all racial/ethnic groups, fastest for White youth. Postwarning, there was an immediate drop and continued decline in the rate of fills among White youth, more than double the decline in the rate among Black and Latino youth. Prewarning, depression treatment visits were increasing for White and Latino youth. Postwarning, depression treatment stabilized among Latinos, but declined among White youth. Prewarning, incident fluoxetine fills were increasing for all groups. Postwarning, immediate increases and increasing trends of fluoxetine fills were identified for all groups.

Conclusions: Antidepressant prescription fills declined most postwarning for White youth, suggesting that risk information may have diffused less rapidly to prescribers or caregivers of minorities. Decreases in depression treatment visits help to explain the declines in antidepressant prescribing and were largest for White youth. An increase in incident fluoxetine fills, the only medication indicated for pediatric depression at the time, suggests that the warning may have shifted prescribing practices.
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http://dx.doi.org/10.1002/da.22681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895183PMC
December 2017

A decline in depression treatment following FDA antidepressant warnings largely explains racial/ethnic disparities in prescription fills.

Depress Anxiety 2017 12 29;34(12):1147-1156. Epub 2017 Sep 29.

Center for Multicultural Mental Health Research, Cambridge Health Alliance & Harvard Medical School, Cambridge, MA, USA.

Background: The Food and Drug Administration's 2004 antidepressant warning was followed by decreases in antidepressant prescribing for youth. This was due to declines in all types of depression treatment, not just the intended changes in antidepressant prescribing patterns. Little is known about how these patterns varied by race/ethnicity.

Method: Data are Medicaid claims from four U.S. states (2002-2009) for youth ages 5-17. Interrupted time series analyses measured changes due to the warning in levels and trends, by race/ethnicity, of three outcomes: antidepressant prescription fills, depression treatment visits, and incident fluoxetine prescription fills.

Results: Prewarning, antidepressant fills were increasing across all racial/ethnic groups, fastest for White youth. Postwarning, there was an immediate drop and continued decline in the rate of fills among White youth, more than double the decline in the rate among Black and Latino youth. Prewarning, depression treatment visits were increasing for White and Latino youth. Postwarning, depression treatment stabilized among Latinos, but declined among White youth. Prewarning, incident fluoxetine fills were increasing for all groups. Postwarning, immediate increases and increasing trends of fluoxetine fills were identified for all groups.

Conclusions: Antidepressant prescription fills declined most postwarning for White youth, suggesting that risk information may have diffused less rapidly to prescribers or caregivers of minorities. Decreases in depression treatment visits help to explain the declines in antidepressant prescribing and were largest for White youth. An increase in incident fluoxetine fills, the only medication indicated for pediatric depression at the time, suggests that the warning may have shifted prescribing practices.
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http://dx.doi.org/10.1002/da.22681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895183PMC
December 2017

Measuring Geographic "Hot Spots" of Racial/Ethnic Disparities: An Application to Mental Health Care.

J Health Care Poor Underserved 2016 ;27(2):663-84

This article identifies geographic "hot spots" of racial/ethnic disparities in mental health care access. Using data from the 2001-2003 Collaborative Psychiatric Epidemiology Surveys(CPES), we identified metropolitan statistical areas(MSAs) with the largest mental health care access disparities ("hot spots") as well as areas without disparities ("cold spots"). Racial/ethnic disparities were identified after adjustment for clinical need. Richmond, Virginia and Columbus, Georgia were found to be hot spots for Black-White disparities, regardless of method used. Fresno, California and Dallas, Texas were ranked as having the highest Latino-White disparities and Riverside, California and Houston, Texas consistently ranked high in Asian-White mental health care disparities across different methods. We recommend that institutions and government agencies in these "hot spot" areas work together to address key mechanisms underlying these disparities. We discuss the potential and limitations of these methods as tools for understanding health care disparities in other contexts.
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http://dx.doi.org/10.1353/hpu.2016.0091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598772PMC
April 2018

Assessing the Individual, Neighborhood, and Policy Predictors of Disparities in Mental Health Care.

Med Care Res Rev 2017 08 4;74(4):404-430. Epub 2016 May 4.

5 Northeastern University, Boston, MA, USA.

This study assesses individual- and area-level predictors of racial/ethnic disparities in mental health care episodes for adults with psychiatric illness. Multilevel regression models are estimated using data from the Medical Expenditure Panel Surveys linked to area-level data sets. Compared with Whites, Blacks and Latinos live in neighborhoods with higher minority density, lower average education, and greater specialist mental health provider density, all of which predict lesser mental health care initiation. Neighborhood-level variables do not have differential effects on mental health care by race/ethnicity. Racial/ethnic disparities arise because minorities are more likely to live in neighborhoods where treatment initiation is low, rather than because of a differential influence of neighborhood disadvantage on treatment initiation for minorities compared with Whites. Low rates of initiation in neighborhoods with a high density of specialists suggest that interventions to increase mental health care specialists, without a focus on treating racial/ethnic minorities, may not reduce access disparities.
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http://dx.doi.org/10.1177/1077558716646898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865608PMC
August 2017

Translating disparities research to policy: a qualitative study of state mental health policymakers' perceptions of mental health care disparities report cards.

Psychol Serv 2014 Nov;11(4):377-87

Center for Multicultural Mental Health Research, Cambridge Health Alliance.

Report cards have been used to increase accountability and quality of care in health care settings, and to improve state infrastructure for providing quality mental health care services. However, to date, report cards have not been used to compare states on racial/ethnic disparities in mental health care. This qualitative study examines reactions of mental health care policymakers to a proposed mental health care disparities report card generated from population-based survey data of mental health and mental health care utilization. We elicited feedback about the content, format, and salience of the report card. Interviews were conducted with 9 senior advisors to state policymakers and 1 policy director of a national nongovernmental organization from across the United States. Four primary themes emerged: fairness in state-by-state comparisons; disconnect between the goals and language of policymakers and researchers; concerns about data quality; and targeted suggestions from policymakers. Participant responses provide important information that can contribute to making evidence-based research more accessible to policymakers. Further, policymakers suggested ways to improve the structure and presentation of report cards to make them more accessible to policymakers, and to foster equity considerations during the implementation of new health care legislation. To reduce mental health care disparities, effort is required to facilitate understanding between researchers and relevant stakeholders about research methods, standards for interpretation of research-based evidence, and its use in evaluating policies aimed at ameliorating disparities.
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http://dx.doi.org/10.1037/a0037978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228957PMC
November 2014

Characteristics of community mental health clinics associated with treatment engagement.

Psychiatr Serv 2014 Aug;65(8):1020-5

Objectives: Past literature documents many individual predictors of treatment engagement among mental health clients in community settings, but few studies have examined clinic characteristics that may be associated with treatment engagement. With data from a patient activation and self-management trial, this study examined the variation in demographic and clinic characteristics across community mental health clinics and whether this variation predicted differences in treatment engagement in mental health services.

Methods: Chart reviews were conducted for 638 clients of 12 community mental health clinics. Client attendance records were collected for a one-year period to examine engagement (defined as the ratio of kept versus scheduled appointments). Adjusting for client variability, the investigators examined which clinic-level characteristics were associated with treatment engagement.

Results: Clinics varied significantly in their clients' demographic characteristics and engagement in mental health care. Providing case management and offering transportation vouchers or free parking at the clinic were associated with lower engagement. However, offering outreach was associated with greater engagement.

Conclusions: The results of this study suggest that certain clinic characteristics are associated with engagement in mental health services. These results demonstrate the difficulties faced by community mental health clinics in reducing no-show rates even in the face of strong efforts to improve engagement.
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http://dx.doi.org/10.1176/appi.ps.201300231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592722PMC
August 2014

Predictors of custody and visitation decisions by a family court clinic.

J Am Acad Psychiatry Law 2013 ;41(2):206-18

Natchaug Hospital, 189 Storrs Road, Mansfield Center, CT 06250, USA.

Children's psychological adjustment following parental separation or divorce is a function of the characteristics of the custodial parent, as well as the degree of postdivorce parental cooperation. Over time, custody has shifted from fathers to mothers and currently to joint arrangements. In this retrospective chart review of family court clinic records we examined predictors of custody and visitation. Our work improves on previous studies by assessing a greater number of predictor variables. The results suggest that parental emotional instability, antisocial behavior, and low income all decrease chances of gaining custody. The findings also show that income predicts whether a father is recommended for visitation rights and access to his child or children. Furthermore, joint custody is not being awarded as a function of parental postdivorce cooperation. At issue is whether parental emotional stability, antisocial behavior, and income are appropriate markers for parenting capacity and whether visitation rights and joint custody are being decided in a way that serves the child's best interests.
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October 2013

Differences in diffusion of FDA antidepressant risk warnings across racial-ethnic groups.

Psychiatr Serv 2013 May;64(5):466-71, 471.e1-4

Cambridge Health Alliance Center for Multicultural Mental Health Research, 120 Beacon St., Somerville, MA 02143, USA.

OBJECTIVE Numerous articles have identified that medical technologies diffuse more rapidly among non-Latino whites compared with other racial-ethnic groups. However, whether health risk warnings also diffuse differentially across racial-ethnic minority groups is uncertain. This study assessed racial-ethnic variation in children's antidepressant use before and after the 2004 black-box warning concerning risks of antidepressants for youths. METHODS Data consisted of responses for white, black, and Latino youths ages five through 17 from the 2002-2008 Medical Expenditure Panel Survey (N=44,422). The dependent variable was any antidepressant use in the prior year. Independent variables were race-ethnicity, year, psychological impairment, income, insurance status, region, and parents' education level. Logistic regression models were used to assess antidepressant use conditional on race-ethnicity, time, interaction between race-ethnicity and time, need, socioeconomic status, and Institute of Medicine-concordant estimates of disparities in predicted antidepressant use before and after the warning. RESULTS The warnings affected antidepressant use differentially for whites, blacks, and Latinos. Usage rates among whites decreased from 3.3 to 2.1 percentage points between prewarning and postwarning, whereas usage rates remained steady among Latinos and increased among blacks. Findings were significant in multiple regression analyses, in which predictions were adjusted for need. CONCLUSIONS The findings indicate that health safety information on antidepressant usage among children diffused faster among whites than nonwhites, suggesting the need to improve infrastructure for delivering important health messages to racial-ethnic minority populations.
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http://dx.doi.org/10.1176/appi.ps.201200087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686566PMC
May 2013

Racial-ethnic differences in incident olanzapine use after an FDA advisory for patients with schizophrenia.

Psychiatr Serv 2013 Jan;64(1):83-7

Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115, USA.

Objective: Prior investigations suggest that olanzapine use declined rapidly after a U.S. Food and Drug Administration (FDA) communication and consensus statement warning of the drug's increased metabolic risks, but whether declines differed by racial-ethnic groups is unknown.

Methods: Changes in olanzapine use over time by race-ethnicity was assessed among 7,901 Florida Medicaid enrollees with schizophrenia.

Results: Prior to the advisory, 57% of second-generation antipsychotic fills among Hispanics were for olanzapine, compared with 40% for whites or blacks (adjusted risk difference [ARD]=.17, 95% confidence interval [CI]=.13-.20). Olanzapine use declined among all racial-ethnic groups. Although Hispanics had greater olanzapine use than whites in each period, the differences in absolute risk were only 3% by the latest study period (ARD=.03, CI=.01-.04).

Conclusions: After the FDA communication and consensus statement were issued, differences in olanzapine use between white and Hispanic enrollees narrowed considerably. Identifying high-use subgroups for targeted delivery of drug safety information may help eliminate any existing differences in prescribing.
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http://dx.doi.org/10.1176/appi.ps.201200002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572912PMC
January 2013

Mental health communications skills training for medical assistants in pediatric primary care.

J Behav Health Serv Res 2013 Jan;40(1):20-35

Mathematica Policy Research, Inc, Washington, DC 20002, USA.

Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.
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http://dx.doi.org/10.1007/s11414-012-9292-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287209PMC
January 2013

Unmet need for treatment for substance use disorders across race and ethnicity.

Drug Alcohol Depend 2012 Sep 2;125 Suppl 1:S44-50. Epub 2012 Jun 2.

Abt Associates, Cambridge, MA 02138, United States. Norah

Background: The objective was to analyze disparities in unmet need for substance use treatment and to observe variation across different definitions of need for treatment.

Methods: Data were analyzed from the 2002 to 2005 National Survey of Drug Use and Health and the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regressions estimated the likelihood of specialty substance use treatment across the two data sets. Parallel variables for specialty, informal and any substance abuse treatment were created. Perceived need and normative need for substance use treatment were defined, with normative need stratified across lifetime disorder, past twelve month disorder, and heavy alcohol/any illicit drug use. Treatment rates were analyzed, comparing Blacks, Asians and Latinos to non-Latino whites across need definitions, and adjusting for age, sex, household income, marital status, education and insurance.

Results: Asians with past year substance use disorder had a higher likelihood of unmet need for specialty treatment than whites. Blacks with past year disorder and with heavy drinking/illicit drug use had significantly lower likelihood of unmet need. Latinos with past year disorder had a higher likelihood of unmet need for specialty substance abuse treatment. Asians with heavy drinking/illicit drug use had lower likelihood of unmet need.

Conclusions: The findings suggest that pathways to substance abuse treatment differ across groups. Given high rates of unmet need, a broad approach to defining need for treatment is warranted. Future research to disentangle social and systemic factors from factors based on diagnostic criteria is necessary in the identification of need for treatment.
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http://dx.doi.org/10.1016/j.drugalcdep.2012.05.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435455PMC
September 2012

Adjusting for Health Status in Non-Linear Models of Health Care Disparities.

Health Serv Outcomes Res Methodol 2009 Mar;9(1):1-21

Center for Multicultural Mental Health Research, Cambridge Health Alliance - Harvard Medical School, 120 Beacon Street, 4 floor, Somerville, MA 02143, 617-503-8449.

This article compared conceptual and empirical strengths of alternative methods for estimating racial disparities using non-linear models of health care access. Three methods were presented (propensity score, rank and replace, and a combined method) that adjust for health status while allowing SES variables to mediate the relationship between race and access to care. Applying these methods to a nationally representative sample of blacks and non-Hispanic whites surveyed in the 2003 and 2004 Medical Expenditure Panel Surveys (MEPS), we assessed the concordance of each of these methods with the Institute of Medicine (IOM) definition of racial disparities, and empirically compared the methods' predicted disparity estimates, the variance of the estimates, and the sensitivity of the estimates to limitations of available data. The rank and replace and combined methods (but not the propensity score method) are concordant with the IOM definition of racial disparities in that each creates a comparison group with the appropriate marginal distributions of health status and SES variables. Predicted disparities and prediction variances were similar for the rank and replace and combined methods, but the rank and replace method was sensitive to limitations on SES information. For all methods, limiting health status information significantly reduced estimates of disparities compared to a more comprehensive dataset. We conclude that the two IOM-concordant methods were similar enough that either could be considered in disparity predictions. In datasets with limited SES information, the combined method is the better choice.
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http://dx.doi.org/10.1007/s10742-008-0039-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845167PMC
March 2009

Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes.

Med Care 2007 Nov;45(11):1076-82

Mathematica Policy Research Inc., 600 Maryland Avenue, Washington, DC 20024, USA.

Background: Primary care providers (PCPs) play a critical role in the identification and treatment of child and adolescent mental health problems but few studies have examined parents' attitudes on receiving advice about child mental health from a PCP and whether attitudes are associated with race or ethnicity.

Objective: To determine if race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP.

Subjects: Data were collected during 773 visits to 54 PCPs in 13 diverse clinics. Families were 56.5% white, 33.3% African American, and 10.1% Hispanic.

Measures: The parent reported attitudes associated with receiving advice about child mental health from the PCP. The parent completed the Strengths and Difficulties Questionnaire to report youth mental health. PCPs completed measures of psychosocial orientation, confidence in mental health treatment skills, and the accessibility of mental health specialists.

Results: Hispanics were more likely than Non-Hispanics to agree that PCPs should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the PCP. African Americans were significantly less willing than whites and Hispanics to allow their child to receive medication for mental health but did not differ in their willingness to visit a therapist.

Conclusions: Race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP. Primary care may be a good point of intervention for Hispanic youth with mental health needs.
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http://dx.doi.org/10.1097/MLR.0b013e31812da7fdDOI Listing
November 2007

Measuring trends in mental health care disparities, 2000 2004.

Psychiatr Serv 2007 Dec;58(12):1533-40

Mathematica Policy Research Inc, Cambridge, MA 02139, USA.

Objective: This study measured trends in disparities in mental health care by use of an improved method that applies the Institute of Medicine (IOM) definition of racial-ethnic disparities.

Methods: Data from the 2000-2001 and 2003-2004 Medical Expenditure Panel Surveys were used to estimate trends in two global measures of racial-ethnic disparities in mental health care: having any mental health visit and total mental health care expenditure in the past year. Disparities between African Americans, Hispanics, and white Americans were examined by applying a new methodology based on the IOM definition of racial disparity that adjusts for health status and allows for mediation of racial-ethnic disparities through socioeconomic factors. Results found by use of this measure are contrasted with unadjusted means.

Results: African-American-white and Hispanic-white disparities in any use of mental health care worsened from 2000-2001 to 2003-2004 when the IOM definition was used; however, these trends were not evident in the unadjusted comparison. No significant African-American-white disparities were found in total mental health expenditures. Hispanic-white disparities in total mental health expenditures were significant within each time period and increased between 2000-2001 and 2003-2004.

Conclusions: The mental health care system continues to provide less care to persons in African-American and Hispanic minority groups than to whites, suggesting the need for policy initiatives to improve services for these minority groups. Future efforts at identifying trends in disparities in mental health services should use methodologies that adjust for health status and allow socioeconomic factors to mediate differences.
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http://dx.doi.org/10.1176/ps.2007.58.12.1533DOI Listing
December 2007

Implementing the Institute of Medicine definition of disparities: an application to mental health care.

Health Serv Res 2006 Oct;41(5):1979-2005

Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115, USA.

Objective: In a recent report, the Institute of Medicine (IOM) defines a health service disparity between population groups to be the difference in treatment or access not justified by the differences in health status or preferences of the groups. This paper proposes an implementation of this definition, and applies it to disparities in outpatient mental health care.

Data Sources: Health Care for Communities (HCC) reinterviewed 9,585 respondents from the Community Tracking Study in 1997-1998, oversampling individuals with psychological distress, alcohol abuse, drug abuse, or mental health treatment. The HCC is designed to make national estimates of service use.

Study Design: Expenditures are modeled using generalized linear models with a log link for quantity and a probit model for any utilization. We adjust for group differences in health status by transforming the entire distribution of health status for minority populations to approximate the white distribution. We compare disparities according to the IOM definition to other methods commonly used to assess health services disparities.

Principal Findings: Our method finds significant service disparities between whites and both blacks and Latinos. Estimated disparities from this method exceed those for competing approaches, because of the inclusion of effects of mediating factors (such as income) in the IOM approach.

Conclusions: A rigorous definition of disparities is needed to monitor progress against disparities and to compare their magnitude across studies. With such a definition, disparities can be estimated by adjusting for group differences in models for expenditures and access to mental health services.
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http://dx.doi.org/10.1111/j.1475-6773.2006.00583.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955294PMC
October 2006
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