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Integrated Medical Care for Patients With Serious Psychiatric Illness
A Randomized Trial
Benjamin G. Druss, MD, MPH;
Robert M. Rohrbaugh, MD;
Carolyn M. Levinson, MPH;
Robert A. Rosenheck, MD
Arch Gen Psychiatry. 2001;58:861-868.
ABSTRACT
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Background This randomized trial evaluated an integrated model of primary medical
care for a cohort of patients with serious mental disorders.
Methods A total of 120 individuals enrolled in a Veterans Affairs (VA) mental
health clinic were randomized to receive primary medical care through an integrated
care initiative located in the mental health clinic (n = 59) or through the
VA general medicine clinic (n = 61). Veterans who obtained care in the integrated
care clinic received on-site primary care and case management that emphasized
preventive medical care, patient education, and close collaboration with mental
health providers to improve access to and continuity of care. Analyses compared
health process (use of medical services, quality of care, and satisfaction)
and outcomes (health and mental health status and costs) between the groups
in the year after randomization.
Results Patients treated in the integrated care clinic were significantly more
likely to have made a primary care visit and had a greater mean number of
primary care visits than those in the usual care group. They were more likely
to have received 15 of the 17 preventive measures outlined in clinical practice
guidelines. Patients assigned to the integrated care clinic had a significantly
greater improvement in health as measured by the physical component summary
score of the 36-Item Short-Form Health Survey than patients assigned to the
general medicine clinic (4.7 points vs -0.3 points, P<.001). There were no significant differences between the 2 groups
in any of the measures of mental health symptoms or in total health care costs.
Conclusion On-site, integrated primary care was associated with improved quality
and outcomes of medical care.
INTRODUCTION
AN EXTENSIVE literature has demonstrated a link between availability
of primary care services and improved quality and outcomes of medical care.1, 2 Primary medical care may be particularly
important for vulnerable populations, for whom geographic and socioeconomic
disadvantage may make it difficult to successfully obtain access to appropriate
medical care.3 Patients with mental illness
constitute one such vulnerable population. Socioeconomic disadvantage,4 difficulties in obtaining and maintaining health insurance,5 symptoms such as cognitive limitations and lack of
motivation, and physician discomfort in treating these patients may all combine
to limit these individuals' ability to obtain medical care.6
For patients with mental illnesses treated in the public sector, specialty
mental health clinics are likely to be the first, and often the only, points
of contact with the health care system.7 During
the mid-1970s, mental health care policymakers began to advocate for public
sector psychiatrists to be designated as primary care providers.8, 9
More recent proposals have suggested providing psychiatrists with additional
medical training to permit them to provide their patients with a full range
of medical services.10 However, public sector
mental health care facilities rarely devote substantial time or resources
to their patients' medical care.11 When researchers
have taken medical histories and administered physical examinations to patients
treated in these clinics, fewer than half of the medical illnesses had previously
been recognized.12, 13
There is almost no literature describing or evaluating programs for
improving the medical care of patients with mental illnesses. To our knowledge,
only one previous article14 in the literature
described a program integrating medical treatment for patients with serious
mental disorders; the authors of that article concluded that such models appeared
feasible and warranted systematic study using randomized designs.
This study compares the delivery of integrated medical care provided
in a mental health clinic with usual care in a general medicine clinic for
patients with serious mental disorders. We test the hypothesis that integrated
care can increase access to primary care services, raise quality of preventive
care, and improve health-related quality of life.
SUBJECTS AND METHODS
SUBJECTS
Subjects were recruited from a Veterans Affairs (VA) mental health clinic
treating approximately 5000 outpatients at an academic medical center. All
mental health care providers were asked to refer any patients whom they thought
would benefit from primary care to be assigned a medical treater. All patients
were eligible for enrollment in the study except for those who had a current
primary care provider or an urgent or multiple serious chronic problems. Patients
who already had a primary care provider listed in VA electronic records (approximately
half of the clinic's 5000 patients) were not eligible for enrollment. The
family practitioner prescreened referrals to the clinic, which was authorized
to treat routine but not urgent or complex medical problems. Patients determined
by the family practitioner to have had a medical hospitalization in the past
6 months or 4 or more serious chronic conditions were referred to the general
medical clinics.
A research assistant obtained informed consent from all eligible referrals
who agreed to participate in the study. Participants were then randomized
to receive care in either the integrated care clinic or the VA general medicine
clinic (usual care), using computer-generated random numbers. The recruitment
and study procedures were approved by local VA and university institutional
review boards.
INTEGRATED CARE
The psychiatry service assumed clinical responsibility for the primary
medical care of all patients randomized to the integrated care intervention
and paid the salaries of all clinic staff through clinical funds. The clinic
was located contiguous to the mental health clinics.
The clinic was staffed by a nurse practitioner (1 full-time equivalent
[FTE]), a part-time family practitioner (0.5 FTE), a nurse case manager (1
FTE), and an administrative assistant (0.5 FTE). The medical nurse practitioner
was the main provider of basic medical care. The family practitioner supervised
the nurse practitioner and acted as a liaison to physicians in the psychiatry
and medical services. The registered nurse provided patient education, liaison
with mental health care providers, and case management services. The administrative
assistant scheduled appointments and took telephone messages for the clinic.
Clinic staff emphasized patient education, preventive services, and
close contact with mental health care providers, including e-mail, telephone,
and face-to-face discussion about patients. Patients were prompted with telephone
reminders the day before appointments, and whenever possible, clinic appointments
were scheduled immediately following mental health visits to minimize barriers
to attendance. When appointments were missed, clinic staff made active efforts
to reschedule visits through contacting patients, their family members, and/or
mental health care providers.
One provider from the integrated clinic served as a liaison to each
of 3 mental health teams, attending weekly team meetings. Mental health care
providers were notified about patients' medical status, were asked to keep
the integrated care clinic abreast of changes in patients' psychiatric status,
and were encouraged to coordinate efforts with the integrated care clinic
to ensure that patients attended medical appointments and followed through
with needed medical tests.
USUAL CARE
Veterans randomized to the usual care group in this study were referred
to the VA general medicine clinic, located in a building adjacent to the mental
health clinic. For each patient randomized to usual care, a referral form
was sent and verbal contact was made with the clinic administrator. This process
ensured that all veterans referred for care were provided a primary care provider,
following the referral pattern that was available before introduction of the
integrated care clinic.
Twenty-nine veterans assigned to the general medicine clinic were treated
by a medical attending physician, 28 by a nurse practitioner or physician
assistant, and 11 by a medical resident. Similar to findings in larger studies,15 we did not find significant differences in process
or outcomes of care across provider types in the general medicine clinic (although
there was limited statistical power for these subanalyses).
MEASURES
Service Use
Use of the following categories of service was assessed at baseline
and then for each 6-month period after entry into the study: for medical visits,
primary care visits (ie, visits to usual source of care as identified in VA
administrative records), visits to specialty or consultant providers, inpatient
days, and number of emergency department visits; for psychiatric visits, outpatient
visits, inpatient days, and emergency department visits.
Data on VA service use were gathered from the hospital's administrative
records. Data on service use outside the VA for the same types of services
were collected in interviews at baseline, 6-month, and 12-month follow-up.
Non-VA services comprised 14% of outpatient specialty visits and 8% of inpatient
days across the treatment conditions.
Quality of Preventive Care
Indicators of quality of preventive care were drawn from US Preventive
Services Task Force16 and VA17
guidelines. Because of the cohort's low socioeconomic status, high levels
of substance use, and lack of primary care at baseline, all participants were
considered high risk and thus eligible for interventions such as influenza
vaccine and hepatitis screening, which are generally targeted toward such
high-risk populations. Compliance with these services were drawn from review
of electronic and paper medical records every 6 months.
Satisfaction
Satisfaction with medical care was rated using a 47-item questionnaire
that covered the following subdomains: access, provider characteristics (information,
attention to patient preferences, emotional support, and courtesy), coordination,
continuity of care, and overall care.18, 19
The score for each subscale was calculated as the mean number of questions
in that domain for which the individuals reported difficulties during either
the 6-month or 12-month follow-up.
Physical and Mental Health Status
The 36-Item Short-Form Health Survey (SF-36) is a well-validated measure
of health status constructed for use in the Medical Outcomes Study.20, 21, 22 The physical component
summary23 was the primary clinical outcome
measure for the study. For patients with serious mental disorders, the physical
subscales have been demonstrated to have good internal consistency, test-retest
reliability, and concurrent and discriminative validity.24, 25
Because the SF-36 mental subscales are less useful in this population,24 we instead mainly relied on the Symptom Checklist–9026 and the Addiction Severity Index27
to assess mental symptoms at baseline at follow-up. These were assessed in
unblinded interviews at baseline and every 6 months after randomization. The
interviews were conducted by a research assistant with master's degree–level
training and extensive interview experience.
Costs
Costs were calculated by multiplying the number of units of each type
of service by the mean unit costs for those services. Local VA unit costs
were drawn from the cost distribution report, a facility-by-facility accounting
of inpatient and outpatient expenditures that identifies both direct and indirect
costs of care, including staff salaries, equipment costs, and depreciation
costs.28, 29
Direct costs for the integrated care clinic were calculated based on
staff salaries and benefits and other expenditures, including equipment. Unit
costs for the integrated care clinic were calculated by multiplying those
costs by the ratio of direct to indirect costs for the psychiatry service
and then dividing the clinic expenditures by the typical number of clinic
visits during the period of study, following a method described previously.28
For non-VA services, inpatient mental and general medical unit costs
were based on national inpatient expenditure data published by the American
Hospital Association.30 Outpatient unit costs
(general medical, specialty medical, and mental health) were based on mean
US fees for office visits by specialty.31
STATISTICAL ANALYSIS
All analyses were conducted as intention to treat. To ensure that randomization
was successful, bivariate tests were first used to compare baseline demographic,
diagnostic, and health status variables between the 2 groups. Bivariate tests
were also used to compare the baseline characteristics of dropouts to the
remainder of the sample.
Dichotomous service use, satisfaction, and quality of preventive care
variables were analyzed as comparisons between groups during the year after
randomization. Since there were no significant baseline differences between
the 2 groups in demographic, diagnostic, or health status variables (Table 1), bivariate tests were used to
compare each of these variables between groups.
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Table 1. Baseline Characteristics of Study Sample*
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Random regression was used for analyses of primary outcomes (health
status and costs) during the study period. This method makes it possible to
compare the difference in change between groups over time and to conduct intention-to-treat
analyses that include subjects with missing data at 1 or more follow-up periods.33 Each equation modeled the dependent variable as a
function of randomization group, period (baseline, 6-month, or 1-year follow-up),
and the group x time interaction, which represents the difference in
change between the 2 groups over time.
Because cost estimates are highly nonnormally distributed, cost differences
were modeled using censored normal models for log-transformed cost plus $1.
Means were retransformed from the log scale using the smearing estimator technique
developed by Duan.34, 35
Analyses were conducted using the SAS system, version 8.0 (SAS Institute
Inc, Cary, NC). All tests of statistical significance were 2-tailed and used
an  level of P<.05.
RESULTS
SCREENING AND ENROLLMENT PROCESS
Of 211 patients referred for primary care medical services, 181 were
eligible for randomization (Figure 1).
Altogether, 30 patients had multiple chronic conditions or urgent needs that
required direct referral to the general medicine clinic. A total of 120 patients
consented to participate (Figure 1).
Of the 61 veterans who declined, most (51%) opted out of randomization to
be assigned directly to the integrated care clinic.
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Screening and enrollment process.
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Of the 120 veterans who were initially randomized, 76.3% completed the
6-month follow-up survey, 69.2% completed 12-month follow-up, and 66.7% completed
both 6- and 12-month surveys. There were similar rates of attrition in the
2 clinics (Figure 1). There were
no statistically significant differences in demographic, diagnostic, or health
status variables between those with and without missing 6- or 12-month survey
data. Because VA utilization, quality, and cost measures were collected via
administrative and chart review, data for these variables were available for
100% of subjects randomized into the study. Data for use of non-VA services
(a small portion of overall service use) were available only for individuals
who completed the follow-up surveys.
IMPLEMENTATION AND CONTENT OF INTEGRATED AND USUAL CARE
Four of the 120 subjects were transferred from the integrated care clinic
to the general medicine clinic after randomization. Three of these were found
to have urgent medical conditions on initial evaluation, and the fourth was
transferred because of a language barrier. There were no significant baseline
differences between these crossovers and the remainder of the sample. No subjects
assigned to the general medicine clinic were transferred or used any services
in the integrated care clinic.
The case manager kept records of interventions that she provided throughout
the study period. (These interventions were recorded for the clinic as a whole
rather than linked to specific participants in the study.) During the study,
the case manager recorded 739 interventions: (1) telephone reminders to patients
about upcoming appointments and blood tests (29%), (2) escorting patients
to medical appointments (23%), (3) booking transportation from home to the
clinic or specialty clinics (18%), (4) communicating with providers in other
clinics (17%), (5) picking up medications at the pharmacy (7%), and (6) making
home visits to patients' homes to deliver medications or equipment (6%). In
addition to these specific interventions, the case manager provided general
psychosocial support to patients, encouraging them to call or visit if any
problems arose.
Discussions with administrators in both the mental health and general
medical clinics confirmed that there were no similar medical case management
services targeted toward individuals with mental disorders in either of these
2 settings.
BASELINE CHARACTERISTICS
There were no significant differences between the 2 groups in demographic,
diagnostic, or health status data at the time of randomization except for
prevalence of cardiac disease, which was higher in the integrated care group.
Almost all patients were male, reflecting the veteran population from which
the sample was drawn. Using an algorithm developed by the National Advisory
Mental Health Council that includes diagnosis, Global Assessment of Functioning
score, and hospitalization history,32 more
than three quarters of patients met criteria for severe mental illness.
After enrollment in the study, a similar range of medical problems was
reported in chart reviews among patients with at least 1 visit in each of
the 2 groups. During the 1-year study period, more than half of patients with
at least 1 visit in each group were found to have at least 1 medical diagnosis
not previously recorded in their VA medical records (Table 1).
SERVICE USE
Patients in the integrated clinic were significantly more likely than
those in the general medicine clinic to make a primary care visit in the year
after referral (91.5% vs 72.1%;  21 = 7.5, P = .006) (Table 2).
They were also significantly less likely to have an emergency department visit
during the year after referral than those in the general medicine clinics
(11.9% vs 26.2%; P = .04). There were no significant
differences in rates of other categories of service use across the 2 treatment
conditions.
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Table 2. Service Use in the Year After Randomization
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QUALITY OF PREVENTIVE CARE
Fewer than half (44.2%) of patients had received 1 or more of the preventive
interventions in any setting in the year before baseline; on average, patients
had received a mean of 1.2 of the possible 17 measures (Table 3). In the year after random assignment, patients in the integrated
care clinic were significantly more likely than those in the general medicine
clinic to have received 15 of the 17 preventive measures. The 2 groups had
similar rates of hemoccult testing. Veterans in the integrated care clinic
were significantly less likely than those in the general medicine clinic to
have one of the indicators, use of a pneumonia vaccine (Pneumovax). However,
among patients 65 years and older, the typical target population for use of
this vaccination,16 these differences were
not significant.
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Table 3. Quality of Preventive Care (12-Month)
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SATISFACTION WITH MEDICAL CARE
In the year after randomization, veterans assigned to the integrated
care clinic reported significantly fewer problems in 6 of 8 satisfaction domains:
access, attention to patient preferences, courtesy, coordination, continuity,
and overall care (Table 4). The
largest effect was in continuity of care, where only 1.3% of those in integrated
care reported a problem, compared with 22.5% of those in the general medical
clinic. There was no significant difference between the 2 groups on satisfaction
with emotional support or information.
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Table 4. Satisfaction With Medical Care*
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PHYSICAL AND MENTAL HEALTH STATUS
During the year after randomization, subjects in the integrated care
clinic had a 4.7-point increase (ie, improvement) in the physical component
summary score, whereas subjects in the general medicine clinic had a 0.3-point
decline in the score (Table 5). In random regression models, the group x time interaction, which reflects
the difference in change between the 2 groups, was significant (t170 = 3.7, P<.001). Although
there are no absolute guidelines for clinically significant change on the
physical component summary, the average change throughout 1 year in the intervention
group (4.7 points) is similar to the effect size seen for effective treatment
of duodenal ulcers.36
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Table 5. Health and Mental Health Status
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None of the corresponding group x time interactions for the Symptom
Checklist–90 (t160 = 1.62, P = .11), the alcohol (t171 = 0.86, P = .39) or drug (t172 = 0.53, P = .6) subscales
of the Addiction Severity Index, or the SF-36 mental component summary (t170 = 0.17, P = .87)
were statistically significant (Table 5).
COSTS
The mean costs per subject treated in the integrated care clinic (logged
and then retransformed) were $13 010 (SD, $13 271) vs $14 543
(SD, $15 871) for patients in the general medicine clinic. The group
x time interaction term was not significant in the random regression
model (t238 = -0.43, P = .67). Primary care costs in the integrated care clinic were estimated
at $1582 per patient ($266 per visit), in contrast to $398 per patient ($148
per visit) for the general medicine clinic (t238 = 2.4, P = .02 for group x time interaction
in random regression model). This was largely a function of the fact that
because the clinic was in its startup phase, clinicians did not have full
caseloads. There were no other significant differences in specific components
of costs. The significant difference in primary care costs appeared to be
offset by large nonsignificant difference in impatient costs between the 2
groups after follow-up ($2673 in the general medical clinic vs $410 in the
integrated care clinic group; t238 = -1.32, P = .19).
COMMENT
The study found that for a cohort of patients with serious mental illness,
integrated, on-site delivery of primary care was feasible, promoted greater
access to primary care and preventive care, and resulted in a significantly
larger improvement in health status than usual care. Although the confidence
intervals around cost estimates are wide because of the modest sample size,
the intervention appeared to be cost neutral when considering total health
care expenditures for subjects in each group.
Before baseline, the subjects had received little medical care. Half
of medical problems were not documented in VA records, and patients had very
low rates of preventive services. Rates of primary care visits and preventive
care improved for both the integrated care and the general medicine clinics,
implying that any referral for primary care can provide an important first
step in improving access to medical care for patients with serious mental
disorders. However, patients in the integrated care clinic improved substantially
more than those in the general medical clinics. This improvement appeared
to be specific to physical health domains, rather than a more general effect
on emotional well-being or mental symptoms.
At least 2 broad categories of "active ingredients" in the clinic may
have contributed to improved outcomes. First, the clinic used additional staff
resources to improve access and adherence to care, including outreach by the
case manager, extra time for visits in the clinic, and flexibility in scheduling
appointments. This clinic targeted a caseload of only half that carried by
practitioners in the VA general medical clinics. However, the clinic provided
added value for those additional expenditures in terms of improved quality
and clinical outcomes of care. Furthermore, the intervention appeared to be
cost neutral in terms of overall expenditures, which are predominantly a function
of inpatient rather than outpatient service use.
The second way in which the clinic is likely to have improved care was
through a basic reorganization that allowed greater integration of medical
and mental health care services. At its most fundamental level, integration
involves breaking down boundaries to improve the transfer of information.37 Integration across service lines has been shown to
improve care for patients with serious mental illness38, 39
and in the treatment of depression in primary care.40, 41, 42
For the integrated care clinic, the on-site location, common chart, and enhanced
channels of communication, including joint meetings, e-mail, and in-person
contact, facilitated the development of common goals and sharing of information
between medical and mental health care providers.
The study has several limitations. The sampling strategy was based on
referrals rather than a population-based sampling strategy. The modest sample
size provided only limited statistical power for cost estimates, particularly
for inpatient service use, in which SDs are highest and distributions least
normal. A sample size of 3 to 4 times that used in the present study would
probably be needed to make more definitive statements about differences in
costs or cost-effectiveness between integrated and usual care.43
The sample size and length of follow-up did not allow for the measurement
of more distal outcomes, such as mortality and adverse medical events. Limited
resources did not permit the use of blinded interviews, although the possibility
of interviewer bias was mitigated by the use of standardized, structured interviews.
Similarly, it was impossible to blind participants to their treatment assignment,
raising the possibility of bias due to knowledge of that assignment (ie, a
Hawthorne effect).
Finally, the VA has a unique population and structural characteristics
that may limit generalizability to non-VA settings.44, 45, 46
Most notably, mental health and medical care are already provided in a quasi-integrated
fashion in the VA, since both types of services are provided in the same facility.7 The fact that community mental health centers and
other public sector mental health facilities do not have in-house medical
facilities increases both the potential challenges and benefits of providing
on-site primary care in those facilities.
Despite these limitations, the study provides evidence that integrating
medical treatment can improve the care and health status of patients with
serious mental disorders. We hope that the study can serve as an impetus for
further research and program development focused on improving medical care
in this vulnerable population.
AUTHOR INFORMATION
Accepted for publication April 3, 2001.
This study was funded in part by the VA Connecticut Mental Illness Research,
Education, and Clinical Center and by grant K08 MH01556 from the National
Institute of Mental Health, Rockville, Md.
We thank Elizabeth Rogers, MD, and Thomas Kosten, MD, who provided expert
guidance in designing the clinic and invaluable administrative support in
its implementation. We also express our gratitude to Madeleine Pellerin, APRN,
Marilyn Ollayos, RN, and Brian Tobin, MD, without whose superb clinical work
the study could not have been possible.
From the Departments of Psychiatry (Drs Druss, Rohrbaugh, and Rosenheck
and Ms Levinson) and Public Health (Drs Druss and Rosenheck), Yale University,
and Northeast Program Evaluation Center, VA Healthcare System (Ms Levinson),
West Haven, Conn.
Corresponding author and reprints: Benjamin G. Druss, MD, MPH, 950
Campbell Ave/116A, West Haven, CT 06516 (e-mail: benjamin.druss{at}yale.edu).
REFERENCES
| |
1. Starfield B. Primary Care: Balancing Health Needs, Services, and
Technology. New York, NY: Oxford University Press; 1998.
2. Hensrud DD. Clinical preventive medicine in primary care: background and practice,
3: delivering preventive screening services. Mayo Clin Proc. 2000;75:381-385.
ISI
| PUBMED
3. Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res. 1995;30:253-273.
ISI
| PUBMED
4. Aro S, Aro H, Keskimaki I. Socio-economic mobility among patients with schizophrenia or major
affective disorder: a 17-year retrospective follow-up. Br J Psychiatry. 1995;166:759-767.
FREE FULL TEXT
5. Druss BG, Rosenheck RA. Mental disorders and access to medical care in the US. Am J Psychiatry. 1998;155:1775-1777.
FREE FULL TEXT
6. Druss BG, Bradford DW, Rosenheck RA, Radford M, Krumholz H. Mental disorders and use of cardiovascular procedures after myocardial
infarction. JAMA. 2000;283:506-511.
FREE FULL TEXT
7. Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated health care setting. Psychiatr Serv. 2000;51:890-892.
FREE FULL TEXT
8. Oken D, Fink PJ. General psychiatry: a primary care specialty. JAMA. 1976;235:1973-1974.
FULL TEXT
|
ISI
| PUBMED
9. Fink PJ, Oken D. The role of psychiatry as a primary care specialty. Arch Gen Psychiatry. 1976;33:998-1003.
ISI
| PUBMED
10. Shore JH. Psychiatry at a crossroad: our role in primary care. Am J Psychiatry. 1996;153:1398-1403.
FREE FULL TEXT
11. Faulkner LR, Bloom JD, Bray JD, Maricle R. Medical services in community mental health programs. Hosp Community Psychiatry. 1986;37:1045-1047.
FREE FULL TEXT
12. Koran LM, Sox HC Jr, Marton KI, Moltzen S, Sox CH, Kraemer HC, Imai K, Kelsey TG, Rose TG Jr, Levin LC, Chandra S. Medical evaluation of psychiatric patients, I: results in a state mental
health system. Arch Gen Psychiatry. 1989;46:733-740.
ABSTRACT
13. Koryani EK. Morbidity and rate of undiagnosed physical illness in a psychiatric
clinic population. Arch Gen Psychiatry. 1979;36:414-419.
ABSTRACT
14. Felker B, Workman E, Stanley-Tilt C, Albanese R, Short D. The psychiatric primary care team: a new program to provide medical
care to the chronically mentally ill. Med Psychiatry. 1998;1:36-41.
15. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W, Cleary PD, Friedewald WT, Siu AL, Shelanski ML. Primary care outcomes in patients treated by nurse practitioners or
physicians. JAMA. 2000;283:59-68.
FREE FULL TEXT
16. DiGuiseppi C, ed, Atkins D, ed, Woolf SH, ed. Report of the U.S. Preventive Services Task Force. 2nd ed. Alexandria: Virginia International Medical Publishing Inc;
1996.
17. Veterans Health Administration. Health Promotion and Disease Prevention. Washington, DC: Dept of Veterans Affairs; 1996.
18. Young GJ, Meterko M, Desai KR. Patient satisfaction with hospital care: effects of demographic and
institutional characteristics. Med Care. 2000;38:325-354.
FULL TEXT
|
ISI
| PUBMED
19. Rosenheck R, Wilson NJ, Meterko M. The influence of patient and hospital factors on consumer satisfaction
with inpatient mental health treatment. Psychiatr Serv. 1997;48:1553-1561.
FREE FULL TEXT
20. Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework
and item selection. Med Care. 1992;30:473-483.
ISI
| PUBMED
21. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), III: tests of data
quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40-66.
ISI
| PUBMED
22. McHorney CA, Ware JE, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric
and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-263.
ISI
| PUBMED
23. Ware JE, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36
health profile and summary measures: summary of results from the Medical Outcomes
Study. Med Care. 1995;33:AS264-AS279.
24. Russo J, Trujillo CA, Wingerson D, Decker K, Ries R, Wetzler H, Roy-Byrne P. The MOS 36-Item Short Form Health Survey: reliability, validity, and
preliminary findings in schizophrenic outpatients. Med Care. 1998;36:752-756.
FULL TEXT
|
ISI
| PUBMED
25. Tunis SL, Croghan TW, Heilman DK, Johnstone BM, Obenchain RL. Reliability, validity, and application of the Medical Outcomes Study
36-Item Short-Form Health Survey (SF-36) in schizophrenic patients treated
with olanzapine versus haloperidol. Med Care. 1999;37:678-691.
FULL TEXT
|
ISI
| PUBMED
26. Deragatis LR, Lipman RS, Lovi L. SCL-90: an outpatient psychiatric scale: preliminary report. Psychopharmacol Bull. 1973;9:13-28.
PUBMED
27. McClellan T, Luborsky L, Woody G, O'Brien CP. An improved diagnostic evaluation instrument for substance abuse patients:
the Addiction Severity Index. J Nerv Ment Dis. 1980;168:26-33.
ISI
| PUBMED
28. Rosenheck RA, Neale M, Frisman L. Issues in estimating the cost of innovative mental health programs. Psychiatr Q. 1995;66:9-31.
FULL TEXT
|
ISI
| PUBMED
29. Rosenheck R, Cramer J, Xu W, Thomas J, Henderson W, Frisman L, Fye C, Charney D. A Comparison of clozapine and haloperidol in hospitalized patients
with refractory schizophrenia. N Engl J Med. 1997;337:809-815.
FREE FULL TEXT
30. American Hospital Association. Hospital Statistics. Chicago, Ill: Healthcare InfoSource; 1998.
31. Physician Marketplace Statistics: Profiles for Detailed
Specialties, Selected States, and Practice Arrangements. Chicago, Ill: American Medical Association; 1998.
32. National Advisory Mental Health Council. Health care reform for Americans with severe mental illnesses. Am J Psychiatry. 1993;150:1447-1465.
FREE FULL TEXT
33. Gibbons RD, Hedeker D, Elkin I, Waternaux C, Kramer HG, Greenhouse JB, Shea MT, Imber SD, Sotsky SM, Watkins JT. Some conceptual and statistical issues in analysis of longitudinal
data. Arch Gen Psychiatry. 1993;50:739-750.
ABSTRACT
34. Duan N. Smearing estimate: a nonparametric retransformation method. J Am Stat Assoc. 1982;78:605-610.
35. Duan N, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand of medical care. J Business Econ Stat. 1983;1:115-126.
36. Rampal P, Martin C, Marquis P, Ware JE, Bonfils S. A quality of life study in five hundred and eighty-one duodenal ulcer
patients: maintenance versus intermittent treatment with nizatidine. Scand J Gastroenterol Suppl. 1994;206(29 suppl):44-51.
37. Stinchcombe AL. Information and Organizations. Berkeley: University of California Press; 1990.
38. Drake RE, Mueser KT. Psychosocial approaches to dual diagnosis. Schizophr Bull. 2000;26:105-118.
39. Drake RE, McHugo GJ, Bebout RR, Becker DR, Harris M, Bond GR, Quimby E. A randomized clinical trial of supported employment for inner-city
patients with severe mental disorders. Arch Gen Psychiatry. 1999;56:627-633.
FREE FULL TEXT
40. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines: impact on
depression in primary care. JAMA. 1995;273:1026-1031.
ABSTRACT
41. Katon W, Robinson P, Von Korff M, Lin E, Bush T, Ludman E, Simon G, Walker E. A multifaceted intervention to improve treatment of depression in primary
care. Arch Gen Psychiatry. 1996;53:924-932.
FREE FULL TEXT
42. Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, Bush T, Russo J, Ludman E. Stepped collaborative care for primary care patients with persistent
symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109-1115.
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