Publications by authors named "Steven C Marcus"

199 Publications

Implementing Person-Centered Care Planning: A Randomized Controlled Trial.

Psychiatr Serv 2021 Jun 26;72(6):641-646. Epub 2021 Mar 26.

Silver School of Social Work, New York University, New York City (Stanhope); School of Social Work, University of Minnesota, Minneapolis (Choy-Brown); School of Social Work, Boise State University, Boise, Idaho (Williams); School of Social Policy and Practice, University of Pennsylvania, Philadelphia (Marcus).

Objective: Person-centered care is a key quality indicator and central to promoting integrated and recovery-oriented services. Person-centered care planning (PCCP) is a manualized intervention promoting the collaborative cocreation of a recovery-oriented care service plan on the basis of an individual's most valued life goals. This cluster randomized controlled trial tested the effect of PCCP training on person-centered care delivery in community mental health clinics.

Methods: Fourteen clinic sites were randomly assigned to receive either PCCP training (N=7; experimental condition) or service planning as usual (N=7; control condition). Data were collected from online surveys, and service plans were completed by 60 provider teams. The Person-Centered Care Planning Assessment Measure was administered via chart review at baseline, 12 months, and 18 months, and surveys were used to measure supervision, implementation leadership, and program type. The main effect was examined with linear mixed-effects regression models, with observations over time.

Results: Analyses controlling for service user and program characteristics revealed that at 12 months, the group assigned to PCCP training showed significant improvements in delivering person-centered care compared with the control group (b=1.10, SE=0.50, p=0.03). At 18 months, this effect was even more pronounced (b=1.47, SE=0.50, p=0.01), representing a medium-to-large effect size of d=0.71 (95% confidence interval=0.23-1.20).

Conclusions: These findings indicate that training providers in PCCP increases provider competency in delivering person-centered care. Using an objective measure of person-centered care, the authors show that a comprehensive training strategy can target both the philosophical shift and the technical skills needed to promote client recovery.
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http://dx.doi.org/10.1176/appi.ps.202000361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192424PMC
June 2021

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

JAMA 2021 03;325(10):952-961

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

Design, Setting, And Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

Exposures: Part D coverage during the observation year (January 1-December 31, 2018).

Main Outcomes And Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

Conclusions And Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.
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http://dx.doi.org/10.1001/jama.2021.1195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944381PMC
March 2021

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff.

J Emerg Nurs 2021 May 17;47(3):426-436.e5. Epub 2021 Feb 17.

Introduction: Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

Methods: A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

Results: Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

Discussion: Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.
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http://dx.doi.org/10.1016/j.jen.2020.12.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122035PMC
May 2021

The Changing Landscape of Community Mental Health Care: Availability of Treatment Services in National Data, 2010-2017.

Psychiatr Serv 2021 02 18;72(2):204-208. Epub 2020 Dec 18.

Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Cummings); Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Smith, Marcus), Leonard Davis Institute of Health Economics (Smith), and School of Social Policy and Practice (Cullen, Marcus), University of Pennsylvania, Philadelphia.

Objective: The authors sought to describe changes in availability of crisis and substance use treatment services in U.S. mental health facilities (including outpatient and inpatient facilities) from 2010 to 2017.

Methods: Using National Mental Health Services Survey data, the authors of this descriptive study examined changes in the proportion of facilities providing crisis and substance use treatment services during the 2010-2017 period.

Results: Although the proportion of outpatient facilities offering treatment for substance use increased significantly during the period studied (adjusted relative risk [ARR]=1.05, 95% confidence interval [CI]=1.01-1.10), the proportion of outpatient facilities offering crisis services significantly decreased, including emergency psychiatric walk-in services (ARR=0.81, 95% CI=0.75-0.88) and crisis intervention (ARR=0.88, 95% CI=0.83-0.93).

Conclusions: Mental health facilities are an integral piece of the behavioral health safety net and need to respond to changes in service needs. Findings suggest that mental health facilities have not shifted their services mix to address the ongoing suicide epidemic.
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http://dx.doi.org/10.1176/appi.ps.201900546DOI Listing
February 2021

Migraine Patients With Cardiovascular Disease and Contraindications: An Analysis of Real-World Claims Data.

J Prim Care Community Health 2020 Jan-Dec;11:2150132720963680

NYU Langone Medical Center, New York, NY, USA.

Introduction: Triptans, the most commonly prescribed acute treatments for migraine attacks are, per FDA labeling, contraindicated in cardiovascular (CV) disease patients and have warnings and precautions for those with CV risk factors.

Methods: Headache specialists, cardiologists, and health economics and outcomes researchers convened to identify diagnostic codes for: (1) CV diseases contraindicating triptans based on FDA labeling; (2) conditions comprising "other significant underlying CV disease"; and (3) CV risk factors included as warnings and precautions for triptans. A retrospective, cross-sectional analysis of commercially insured adult US migraine patients in the 2017 Optum Clinformatics Data Mart (CDM) and the 2017 IBM Watson Health MarketScan Commercial Claims database was used to estimate the proportion of migraine patients with CV contraindications and warnings and precautions to triptans.

Results: Of the 56,662 migraine patients analyzed from Optum CDM, 13.5% had ≥1 CV disease as specified in triptan labeling and an additional 8.5% had ≥1 "other CV disease" judged by the panel to constitute a "significant underlying CV disease" (total: 22.0% migraine patients). Of 176 724 migraine patients analyzed from MarketScan, 12.2% had ≥1 CV disease as specified in the labeling and an additional 8.0% had ≥1 "other significant underlying CV disease" (total: 20.2% of migraine patients). An additional 25.4% and 25.1% of migraine patients had ≥2 CV risk factors in Optum CDM and MarketScan. In total, 47.4% and 45.3% of migraine patients in both databases had a CV disease specified as a contraindication, an "other CV disease" endorsed as significant, or ≥2 CV risk factors identified as warnings and precautions to triptans.

Conclusions: Analyses of more than 230,000 people with migraine showed that ≥20% of commercially insured US migraine patients have a CV condition that specifically contraindicates triptan treatment, and an additional 25% have ≥2 CV risk factors identified as warnings and precautions to triptans.
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http://dx.doi.org/10.1177/2150132720963680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585888PMC
June 2021

Migraine Patients With Cardiovascular Disease and Contraindications: An Analysis of Real-World Claims Data.

J Prim Care Community Health 2020 Jan-Dec;11:2150132720963680

NYU Langone Medical Center, New York, NY, USA.

Introduction: Triptans, the most commonly prescribed acute treatments for migraine attacks are, per FDA labeling, contraindicated in cardiovascular (CV) disease patients and have warnings and precautions for those with CV risk factors.

Methods: Headache specialists, cardiologists, and health economics and outcomes researchers convened to identify diagnostic codes for: (1) CV diseases contraindicating triptans based on FDA labeling; (2) conditions comprising "other significant underlying CV disease"; and (3) CV risk factors included as warnings and precautions for triptans. A retrospective, cross-sectional analysis of commercially insured adult US migraine patients in the 2017 Optum Clinformatics Data Mart (CDM) and the 2017 IBM Watson Health MarketScan Commercial Claims database was used to estimate the proportion of migraine patients with CV contraindications and warnings and precautions to triptans.

Results: Of the 56,662 migraine patients analyzed from Optum CDM, 13.5% had ≥1 CV disease as specified in triptan labeling and an additional 8.5% had ≥1 "other CV disease" judged by the panel to constitute a "significant underlying CV disease" (total: 22.0% migraine patients). Of 176 724 migraine patients analyzed from MarketScan, 12.2% had ≥1 CV disease as specified in the labeling and an additional 8.0% had ≥1 "other significant underlying CV disease" (total: 20.2% of migraine patients). An additional 25.4% and 25.1% of migraine patients had ≥2 CV risk factors in Optum CDM and MarketScan. In total, 47.4% and 45.3% of migraine patients in both databases had a CV disease specified as a contraindication, an "other CV disease" endorsed as significant, or ≥2 CV risk factors identified as warnings and precautions to triptans.

Conclusions: Analyses of more than 230,000 people with migraine showed that ≥20% of commercially insured US migraine patients have a CV condition that specifically contraindicates triptan treatment, and an additional 25% have ≥2 CV risk factors identified as warnings and precautions to triptans.
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http://dx.doi.org/10.1177/2150132720963680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585888PMC
June 2021

Effect of Peer Mentors in Diabetes Self-management vs Usual Care on Outcomes in US Veterans With Type 2 Diabetes: A Randomized Clinical Trial.

JAMA Netw Open 2020 09 1;3(9):e2016369. Epub 2020 Sep 1.

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Diabetes is a substantial public health issue. Peer mentoring is a low-cost intervention for improving glycemic control in patients with diabetes. However, long-term effects of peer mentoring and creation of sustainable models are not well studied.

Objective: Assess the effects of a peer support intervention for improving glycemic control in patients with diabetes and evaluate a model in which former mentees serve as mentors.

Design, Setting, And Participants: A randomized clinical trial was conducted from September 27, 2012, to March 21, 2018, at the Corporal Michael J. Crescenz Medical Center. US veterans with type 2 diabetes aged 30 to 75 years with hemoglobin A1C (HbA1c) greater than 8% received support over 6 months from peers with prior poor glycemic control but who had achieved HbA1c less than or equal to 7.5% (phase 1). Phase 1 mentees were then randomized to become a mentor or not to new randomly assigned participants in phase 2. Outcomes were assessed at 6 and 12 months. Data were analyzed from October 5, 2016, to September 4, 2018.

Interventions: Mentors who received an initial training session and monthly reinforcement training were assigned 1 mentee and given $20 for each month they contacted their mentee at least weekly.

Main Outcomes And Measures: Primary outcome was HbA1c change at 6 months. Secondary outcomes included HbA1c change at 12 months and change in low-density lipoprotein, blood pressure, diabetes quality of life, and depression symptoms at 6 and 12 months.

Results: The study enrolled 365 participants into phase 1 and 122 participants into phase 2. Most participants were Black (341 [66%]) and male (454 [96%]), with a mean (SD) age of 60 (7.5) years. Mean phase 1 HbA1c change at 6 months for usual care was -0.20% (95% CI, -0.46% to 0.06%) vs -0.52% (95% CI, -0.76% to -0.29%) for mentees (P = .06). Mean phase 2 HbA1c change at 6 months for usual care was -0.46% (95% CI, -1.02% to 0.10%) vs 0.08% (95% CI, -0.42% to 0.57%) for mentees (P = .16). There were no differences in secondary outcomes or HbA1c levels at 12 months. There was no benefit to past mentees who became mentors.

Conclusions And Relevance: In this randomized clinical trial, a peer mentor intervention did not improve 6-month HbA1c levels and did not have sustained benefits.

Trial Registration: ClinicalTrials.gov Identifier: NCT01651117.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.16369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489832PMC
September 2020

Public insurance expansions and mental health care availability.

Health Serv Res 2020 08;55(4):615-625

School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA.

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.

Study Design: A quasi-experimental differences-in-differences design using observational data.

Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.
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http://dx.doi.org/10.1111/1475-6773.13311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375998PMC
August 2020

Public insurance expansions and mental health care availability.

Health Serv Res 2020 08;55(4):615-625

School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA.

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.

Study Design: A quasi-experimental differences-in-differences design using observational data.

Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.
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http://dx.doi.org/10.1111/1475-6773.13311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375998PMC
August 2020

Public insurance expansions and mental health care availability.

Health Serv Res 2020 08;55(4):615-625

School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA.

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.

Study Design: A quasi-experimental differences-in-differences design using observational data.

Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.
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http://dx.doi.org/10.1111/1475-6773.13311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375998PMC
August 2020

Comparison of healthcare resource utilization and costs among patients with migraine with potentially adequate and insufficient triptan response.

Cephalalgia 2020 06 29;40(7):639-649. Epub 2020 Mar 29.

University of Pennsylvania, Philadelphia, PA, USA.

Background: Triptans are the most commonly prescribed acute treatments for migraine; however, not all triptan users experience adequate response. Information on real-world resource use and costs associated with triptan insufficient response are limited.

Methods: A retrospective claims analysis using US commercial health plan data between 2012 and 2015 assessed healthcare resource use and costs in adults with a migraine diagnosis newly initiating triptans. Patients who either did not refill triptans but used other non-triptan medications or refilled triptans but also filled non-triptan medications over a 24-month follow-up period were designated as potential triptan insufficient responders. Patients who continued filling only triptans (i.e. triptan-only continuers) were designated as potential adequate responders. All-cause and migraine-related resource use and total (medical and pharmacy) costs over months 1-12 and months 13-24 were compared between triptan-only continuers and potential triptan insufficient responders.

Results: Among 10,509 new triptan users, 4371 (41%) were triptan-only continuers, 3102 (30%) were potential triptan insufficient responders, and 3036 (29%) did not refill their index triptan or fill non-triptan medications over 24 months' follow-up. Opioids were the most commonly used non-triptan treatment (68%) among potential triptan insufficient responders over 24 months of follow-up. Adjusted mean all-cause and migraine-related total costs were $5449 and $2905 higher, respectively, among potential triptan insufficient responders versus triptan-only continuers over the first 12 months.

Conclusions: In a US commercial health plan, almost one-third of new triptan users were potential triptan insufficient responders and the majority filled opioid prescriptions. Potential triptan insufficient responder patients had significantly higher all-cause and migraine-related healthcare utilization and costs than triptan-only continuers.
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http://dx.doi.org/10.1177/0333102420915167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273744PMC
June 2020

Acute treatment patterns in patients with migraine newly initiating a triptan.

Cephalalgia 2020 04 5;40(5):437-447. Epub 2020 Mar 5.

University of Pennsylvania, Philadelphia, PA, USA.

Background: Triptans are the most commonly used acute treatment for migraine. This study evaluated real-world treatment patterns following an initial triptan prescription to understand refill rates and use of non-triptan medications for the acute treatment of migraine.

Methods: Commercially-insured adult patients over 18 years of age with a triptan prescription between 1/1/2013 to 31/12/2013 were identified from the Optum Clinformatics™ Data Mart database, with date of the first triptan fill designated as index date. Inclusion was limited to those with no fills for a triptan in the 12 months prior to index date (i.e. new users or initiators of triptans) and continuous enrollment in the 12 months pre- and 24 months post-index date. Fills for index triptan, non-index triptan, and other acute treatments for migraine were assessed for up to 24 months post-index.

Results: Among 10,509 patients, 50.8% did not refill the initial triptan within 12 months and 43.6% did not refill within 24 months. In the 12 months post-index, 90.5% of patients used only one type of triptan, 8.4% used two different triptans, and 1.0% used three or more triptans. Among patients with and without a triptan refill, use of opioids (39% vs. 42%), non-steroidal anti-inflammatory drugs (22% vs. 22%), and butalbital-containing products (9% vs. 10%) were similar.

Conclusion: More than half of those who newly initiated a triptan did not refill their initial prescription, and less than 1 in 10 used two or more triptans within 12 months. High rates of non-triptan acute medication use were found over 12 and 24 months of follow-up, most commonly opioids.
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http://dx.doi.org/10.1177/0333102420905307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160749PMC
April 2020

Acute treatment patterns in patients with migraine newly initiating a triptan.

Cephalalgia 2020 04 5;40(5):437-447. Epub 2020 Mar 5.

University of Pennsylvania, Philadelphia, PA, USA.

Background: Triptans are the most commonly used acute treatment for migraine. This study evaluated real-world treatment patterns following an initial triptan prescription to understand refill rates and use of non-triptan medications for the acute treatment of migraine.

Methods: Commercially-insured adult patients over 18 years of age with a triptan prescription between 1/1/2013 to 31/12/2013 were identified from the Optum Clinformatics™ Data Mart database, with date of the first triptan fill designated as index date. Inclusion was limited to those with no fills for a triptan in the 12 months prior to index date (i.e. new users or initiators of triptans) and continuous enrollment in the 12 months pre- and 24 months post-index date. Fills for index triptan, non-index triptan, and other acute treatments for migraine were assessed for up to 24 months post-index.

Results: Among 10,509 patients, 50.8% did not refill the initial triptan within 12 months and 43.6% did not refill within 24 months. In the 12 months post-index, 90.5% of patients used only one type of triptan, 8.4% used two different triptans, and 1.0% used three or more triptans. Among patients with and without a triptan refill, use of opioids (39% vs. 42%), non-steroidal anti-inflammatory drugs (22% vs. 22%), and butalbital-containing products (9% vs. 10%) were similar.

Conclusion: More than half of those who newly initiated a triptan did not refill their initial prescription, and less than 1 in 10 used two or more triptans within 12 months. High rates of non-triptan acute medication use were found over 12 and 24 months of follow-up, most commonly opioids.
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http://dx.doi.org/10.1177/0333102420905307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160749PMC
April 2020

Acute treatment patterns in patients with migraine newly initiating a triptan.

Cephalalgia 2020 04 5;40(5):437-447. Epub 2020 Mar 5.

University of Pennsylvania, Philadelphia, PA, USA.

Background: Triptans are the most commonly used acute treatment for migraine. This study evaluated real-world treatment patterns following an initial triptan prescription to understand refill rates and use of non-triptan medications for the acute treatment of migraine.

Methods: Commercially-insured adult patients over 18 years of age with a triptan prescription between 1/1/2013 to 31/12/2013 were identified from the Optum Clinformatics™ Data Mart database, with date of the first triptan fill designated as index date. Inclusion was limited to those with no fills for a triptan in the 12 months prior to index date (i.e. new users or initiators of triptans) and continuous enrollment in the 12 months pre- and 24 months post-index date. Fills for index triptan, non-index triptan, and other acute treatments for migraine were assessed for up to 24 months post-index.

Results: Among 10,509 patients, 50.8% did not refill the initial triptan within 12 months and 43.6% did not refill within 24 months. In the 12 months post-index, 90.5% of patients used only one type of triptan, 8.4% used two different triptans, and 1.0% used three or more triptans. Among patients with and without a triptan refill, use of opioids (39% vs. 42%), non-steroidal anti-inflammatory drugs (22% vs. 22%), and butalbital-containing products (9% vs. 10%) were similar.

Conclusion: More than half of those who newly initiated a triptan did not refill their initial prescription, and less than 1 in 10 used two or more triptans within 12 months. High rates of non-triptan acute medication use were found over 12 and 24 months of follow-up, most commonly opioids.
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http://dx.doi.org/10.1177/0333102420905307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160749PMC
April 2020

The Relationship Between Evidence-Based Practices and Emergency Department Managers' Perceptions on Quality of Care for Self-Harm Patients.

J Am Psychiatr Nurses Assoc 2020 May/Jun;26(3):288-292. Epub 2019 Nov 21.

Steven C. Marcus, PhD, The University of Pennsylvania, Philadelphia, PA, USA.

To understand the extent to which implementation of evidence-based practices affects emergency department (ED) nurse managers' perceptions of quality of care provided to deliberate self-harm patients. ED nursing leadership from a nationally representative sample of 513 hospitals completed a survey on the ED management of deliberate self-harm patients, including the quality of care for deliberate self-harm patients on a 1 to 5 point Likert-type scale. Unadjusted and adjusted analyses, controlling for relevant hospital characteristics, examined associations between the provision of evidence-based practices and quality of care. The overall mean quality rating was 3.09. Adjusted quality ratings were higher for EDs that routinely engaged in discharge planning (β = 0.488) and safety planning (β = 0.736) processes. Ratings were also higher for hospitals with higher levels of mental health staff (β = 0.368) and for teaching hospitals (β = 0.319). Preliminary findings suggest a national institutional readiness for further implementation of evidence-based practices for deliberate self-harm patients.
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http://dx.doi.org/10.1177/1078390319889673DOI Listing
May 2021

Comparing Rates of Adverse Events and Medical Errors on Inpatient Psychiatric Units at Veterans Health Administration and Community-based General Hospitals.

Med Care 2019 11;57(11):913-920

School of Social Policy and Practice.

Objective: There is limited knowledge about how general hospitals and Veterans Health Administration (VHA) hospitals fare relative to each other on a broad range of inpatient psychiatry-specific patient safety outcomes.This research compares data from 2 large-scale epidemiological studies of adverse events (AEs) and medical errors (MEs) in inpatient psychiatric units, one in VHA hospitals and the other in community-based general hospitals.

Method: Retrospective medical record reviews assessed the prevalence of AEs and MEs in a sample of 4371 discharges from 14 community-based general hospitals (derived from 69,081 discharges at 85 hospitals) and a sample of 8005 discharges from 40 VHA hospitals (derived from 92,103 discharges at 105 medical centers). Rates of AEs and MEs across hospital systems were calculated, controlling for relevant patient and hospital characteristics.

Results: The overall rate of AEs and MEs in inpatient psychiatric units of VHA hospitals was 7.11 and 1.49 per 100 patient discharges; at community-based acute care hospitals, these rates were 13.48 and 3.01 per 100 patient discharges. The adjusted odds ratio of a patient experiencing an AE and a ME at community-based hospitals as compared with VHA hospitals was 2.11 and 2.08, respectively.

Conclusion: Although chart reviews may not document the complete nature and outcomes of care, even after controlling for differences in patient and hospital characteristics, psychiatric inpatients at community-based hospitals were twice as likely to experience AEs or MEs as inpatients at VHA hospitals. While community-based hospitals may lag behind VHA hospitals, both hospital systems should continue to pursue evidence-based improvements in patient safety. Future research aimed at changing hospital practices should draw on established strategies for bridging the gap from research to practice in order to improve the quality of care for this vulnerable patient population.
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http://dx.doi.org/10.1097/MLR.0000000000001215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813795PMC
November 2019

If You Could Change 1 Thing to Improve the Quality of Emergency Care for Deliberate Self-harm Patients, What Would It Be? A National Survey of Nursing Leadership.

J Emerg Nurs 2019 Nov 5;45(6):661-669. Epub 2019 Sep 5.

Introduction: Emergency departments increasingly treat patients for deliberate self-harm. This study sought to understand emergency department nursing leadership perspectives on how to improve the quality of emergency care for these patients.

Methods: ED nursing managers and directors from a national sample of 476 hospitals responded to an open-ended question asking for the 1 thing they would change to improve the quality of care for self-harm patients who present in their emergency departments. We identified and coded key themes for improving the emergency management of these patients, then examined the distribution of these themes and differences by hospital characteristics, including urbanicity, patient volume, and teaching status.

Results: Five themes regarding how to improve care for deliberate self-harm patients were identified: greater access to hospital mental health staff or treatment (26.4%); better access to community-based services and resources (26.4%); more inpatient psychiatric beds readily accessible (20.9%); separate safe spaces in the emergency department (18.6%); and dedicated staff coverage (7.8%). Endorsement of findings did not differ based on hospital characteristics.

Discussion: ED nursing leadership strongly endorsed the need for greater access to both hospital- and community-based mental health treatment resources for deliberate self-harm patients. Additional ED staff and training, along with greater continuity among systems of care in the community, would further improve the quality of emergency care for these patients. Broad policies that address the scarcity of mental health services should also be considered to provide comprehensive care for this high-risk patient population.

Key Words: Emergency department management of self-harm; Mental health care; Emergency nursing care.
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http://dx.doi.org/10.1016/j.jen.2019.06.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6870841PMC
November 2019

A repeated cross-sectional study of clinicians' use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia.

Implement Sci 2019 06 21;14(1):67. Epub 2019 Jun 21.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static.

Method: Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia's public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years (n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised.

Results: Clinicians were 80% female and averaged 37.52 years of age (SD = 11.40); there were no significant differences in clinician characteristics across waves (all ps > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 (M = 3.18) to wave 3 (M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques (p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use (p = .019) but no change in psychodynamic technique use (p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048).

Conclusions: System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.
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http://dx.doi.org/10.1186/s13012-019-0912-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588873PMC
June 2019

Effect of Outpatient Service Utilization on Hospitalizations and Emergency Visits Among Youths With Autism Spectrum Disorder.

Psychiatr Serv 2019 10 19;70(10):888-893. Epub 2019 Jun 19.

Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Mandell, Candon, Xie, Marcus), Leonard Davis Institute of Health Economics (Mandell, Candon, Epstein, Barry), and School of Social Policy and Practice, University of Pennsylvania, Philadelphia (Marcus); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Kennedy-Hendricks, Barry).

Objective: Psychiatric hospitalizations and emergency department (ED) visits occur more frequently for youths with autism spectrum disorder (ASD). One mechanism that may reduce the likelihood of these events is utilization of home and community-based care. Using commercial claims data and a rigorous analytical framework, this retrospective study examined whether spending on outpatient services for ASD, including occupational, physical, and speech therapies and other behavioral interventions, reduced the likelihood of psychiatric hospitalizations and ED visits.

Methods: The study sample was composed of >100,000 children and young adults with ASD and commercial insurance from every state between 2008 and 2012. The authors estimated maximum-likelihood complementary log-log link survival models with robust standard errors. The outcomes of interest were a hospitalization or an ED visit with an associated psychiatric diagnosis code ( 290 through 319) in a given week.

Results: An increase of $125 in weekly spending on ASD-specific outpatient services in the 7 to 14 weeks prior to a given week reduced the likelihood of a psychiatric hospitalization in that week by 2%. ASD-specific outpatient spending during the 6 weeks prior to a psychiatric hospitalization did not decrease risk of hospitalization. Spending on ASD-specific outpatient services did not reduce the likelihood of a psychiatric ED visit.

Conclusions: The financial burden associated with ASD is extensive, and psychiatric hospitalizations remain the most expensive type of care, costing more than $4,000 per week on average. Identifying the mechanisms by which psychiatric hospitalizations occur may reduce the likelihood of these events.
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http://dx.doi.org/10.1176/appi.ps.201800290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773491PMC
October 2019

Randomized Trial of a Computer-Assisted Intervention for Children With Autism in Schools.

J Am Acad Child Adolesc Psychiatry 2020 03 3;59(3):373-380. Epub 2019 Apr 3.

Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Objective: Computer-assisted interventions (CAIs) are popular for educating children with autism, but their effectiveness is not well established. This study evaluated the effectiveness of 1 CAI designed to improve children's language, cognitive, and academic skills, TeachTown: Basics, in a large urban school district.

Method: Teachers (n = 59) in autism support classrooms and their consented students in kindergarten through second grade (n = 154) were randomized to TeachTown: Basics or waitlist control. Child outcome was measured at baseline and after 1 academic year using the Bracken Basic Concepts Scale-Receptive and Expressive versions and the Differential Ability Scales, Second Edition (DAS-II). Random effects regression models that included clustering of time within students and students within classrooms were used to test whether the change over time in each outcome differed between groups.

Results: There were no statistically significant differences in outcomes for children who received TeachTown: Basics or treatment as usual. Increased time spent using TeachTown: Basics was associated with worse receptive language outcomes for children in the experimental group after 1 academic year. However, there was no association between minutes spent using TeachTown and changes in expressive language or DAS-II score.

Conclusion: Despite growing enthusiasm for CAIs in autism treatment, the present findings indicate that CAI might not be effective at improving language and cognitive outcomes for children with autism spectrum disorder. The decision to implement CAIs in schools should be carefully balanced against the evidence for effectiveness of these programs. Schools might be better served by investing in treatment strategies with established evidence.

Clinical Trial Registration Information: RCT of TeachTown in Autism Support Classrooms: Innovation and Exnovation; https://clinicaltrials.gov/; NCT02695693.
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http://dx.doi.org/10.1016/j.jaac.2019.03.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996249PMC
March 2020

Randomized Trial of a Computer-Assisted Intervention for Children With Autism in Schools.

J Am Acad Child Adolesc Psychiatry 2020 03 3;59(3):373-380. Epub 2019 Apr 3.

Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Objective: Computer-assisted interventions (CAIs) are popular for educating children with autism, but their effectiveness is not well established. This study evaluated the effectiveness of 1 CAI designed to improve children's language, cognitive, and academic skills, TeachTown: Basics, in a large urban school district.

Method: Teachers (n = 59) in autism support classrooms and their consented students in kindergarten through second grade (n = 154) were randomized to TeachTown: Basics or waitlist control. Child outcome was measured at baseline and after 1 academic year using the Bracken Basic Concepts Scale-Receptive and Expressive versions and the Differential Ability Scales, Second Edition (DAS-II). Random effects regression models that included clustering of time within students and students within classrooms were used to test whether the change over time in each outcome differed between groups.

Results: There were no statistically significant differences in outcomes for children who received TeachTown: Basics or treatment as usual. Increased time spent using TeachTown: Basics was associated with worse receptive language outcomes for children in the experimental group after 1 academic year. However, there was no association between minutes spent using TeachTown and changes in expressive language or DAS-II score.

Conclusion: Despite growing enthusiasm for CAIs in autism treatment, the present findings indicate that CAI might not be effective at improving language and cognitive outcomes for children with autism spectrum disorder. The decision to implement CAIs in schools should be carefully balanced against the evidence for effectiveness of these programs. Schools might be better served by investing in treatment strategies with established evidence.

Clinical Trial Registration Information: RCT of TeachTown in Autism Support Classrooms: Innovation and Exnovation; https://clinicaltrials.gov/; NCT02695693.
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http://dx.doi.org/10.1016/j.jaac.2019.03.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996249PMC
March 2020

Deliberate self-harm in older adults: A national analysis of US emergency department visits and follow-up care.

Int J Geriatr Psychiatry 2019 07 24;34(7):1058-1069. Epub 2019 Apr 24.

School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA.

Objective: To examine mental health care received by older adults following emergency department (ED) visits for deliberate self-harm.

Methods: This retrospective cohort analysis examined 2015 Medicare claims for adults ≥65 years of age with ED visits for deliberate self-harm (N = 16 495). We estimated adjusted risk ratios (ARR) for discharge disposition, ED coding of mental disorder, and 30-day follow-up mental health outpatient care.

Results: Most patients (76.9%) were hospitalized with lower likelihoods observed for African American patients (ARR = 0.86, 99% CI = 0.79-0.94) and patients with either one medical comorbidity (ARR = 0.91, 99% CI = 0.83-0.99) or two to three comorbidities (ARR = 0.93, 99% CI = 0.88-0.99). Hospitalization was associated with recent depression (ARR = 1.09, 99% CI = 1.03-1.16) and recent psychiatric inpatient care (ARR = 1.13, 99% CI = 1.04-1.22). Among patients discharged to the community (n = 3818), 56.4% received an ED mental disorder diagnosis. Predictors of an ED mental disorder diagnosis included younger age (65-69 years; ARR = 1.53, 99% CI = 1.31-1.78), recent mental health care in ED (ARR = 1.50, 99% CI = 1.29-1.74) or outpatient (ARR = 1.62, 99% CI = 1.44-1.82) settings, recent diagnosis of mental disorder (ARR = 1.61, 99% CI = 1.43-1.80), and other/unknown lethality methods of self-harm (ARR = 1.24, 99% CI = 1.01-1.52). Among community discharged patients, 39.0% received 30-day follow-up outpatient mental health care, which was most strongly predicted by an ED diagnosis of mental disorder (ARR = 2.65, 99% CI = 2.25-3.12) and prior outpatient mental health care (ARR = 2.62, 99% CI = 2.28-3.00).

Conclusion: Most older adult Medicare beneficiaries who present to EDs with self-harm are hospitalized. Of those who are discharged to the community, many are not diagnosed with mental disorder in the ED or receive timely follow-up mental health care.
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http://dx.doi.org/10.1002/gps.5109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579649PMC
July 2019
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