Search

Supplementary Material 6

BackgroundMedications for alcohol use disorder (MAUD) are underutilized in mental health settings. Increasing use of MAUD requires increasing both the availability of these medications and the demand by individuals who could benefit. Few studies have explored the views of individuals with severe mental illness and alcohol use disorder about MAUD. We sought to examine, among individuals treated in publicly funded community mental health clinics, perceived need for and attitudes toward MAUD.MethodsWe conducted 8 focus groups with 87 participants treated in public mental health clinics in Los Angeles County. We aimed to include individuals with a current or past AUD diagnosis and individuals helping others (e.g., a family member) who drink. We examined responses using domains associated with the Health Belief Model to identify factors that shape acceptance of MAUD.ResultsParticipants were 53% female; most were minorities. Average age was 47years (SD=11). Twenty-four reported never drinking, 13 of whom had a current or past diagnosis of AUD. Twenty-two reported drinking 4 or more times per week. Three-quarters had not heard of naltrexone. Participants understood that alcohol use has severe adverse consequences and perceived themselves to be highly susceptible to these consequences. Regarding attitudes toward MAUD, participants described an internal locus of control (e.g., their own desires, actions, and effort) as central to addressing problem drinking; this shaped their views that MAUD would have only modest benefits and potentially high burden. Those individuals who had tried MAUD expressed the most optimism about its effectiveness.ConclusionsParticipants worried MAUD would impede the development of self-control over drinking by fostering dependence on medication and undermining self-discipline. Client education and counseling that emphasizes MAUD as a tool to build clients' self-control may increase demand for these medications in mental health settings.

Supplemental material, sj-pdf-1-ult-10.1177_1742271X20935911 for UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS framework by Judith Johnson, Jane Arezina, Liz Tomlin, Siobhan Alt, Jon Arnold, Sarah Bailey, Hannah Beety, Ruth Bender-Atik, Louise Bryant, Jen Coates, Sam Collinge, Jo Fishburn, Jane Fisher, Jan Fowler, Tracey Glanville, Julian Hallett, Ailith Harley-Roberts, Gill Harrison, Karen Horwood, Catriona Hynes, Lindsay Kimm, Alison McGuinness, Lucy Potter, Liane Powell, Janelle Ramsay, Pieta Shakes, Roxanne Sicklen, Alexander Sims, Tomasina Stacey, Anushka Sumra, Samantha Thomas, Karen Todd, Jacquie Torrington, Rebecca Trueman, Lorraine Walsh, Katherine Watkins, Gill Yaz and Natasha K Hardicre in Ultrasound

Supplemental material, sj-pdf-1-ult-10.1177_1742271X20935911 for UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS framework by Judith Johnson, Jane Arezina, Liz Tomlin, Siobhan Alt, Jon Arnold, Sarah Bailey, Hannah Beety, Ruth Bender-Atik, Louise Bryant, Jen Coates, Sam Collinge, Jo Fishburn, Jane Fisher, Jan Fowler, Tracey Glanville, Julian Hallett, Ailith Harley-Roberts, Gill Harrison, Karen Horwood, Catriona Hynes, Lindsay Kimm, Alison McGuinness, Lucy Potter, Liane Powell, Janelle Ramsay, Pieta Shakes, Roxanne Sicklen, Alexander Sims, Tomasina Stacey, Anushka Sumra, Samantha Thomas, Karen Todd, Jacquie Torrington, Rebecca Trueman, Lorraine Walsh, Katherine Watkins, Gill Yaz and Natasha K Hardicre in Ultrasound

ImportanceIndividuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. The relationship between measures of treatment quality and mortality for these individuals is unknown.ObjectiveTo examine the association between 5 quality measures and 12- and 24-month mortality.Design, setting and participantsRetrospective cohort study of patients with co-occurring mental illness (schizophrenia, bipolar disorder, post-traumatic stress disorder and major depression) and substance use disorders who received care for these disorders paid for by the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.Main outcomes measureMortality 12 and 24 months after the end of the observation period.ResultsAll measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant.Conclusions and relevanceThis is the first study to show an association between process-based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures. By devising strategies to improve performance on these measures, health care systems may be able to decrease the mortality of this vulnerable population.

Investigators from RAND Corporation and community treatment providers at Behavioral Health Services joined forces to test an intervention to improve services for patients with co-occurring mental disorders. In the course of working together, the partners confronted many of the issues that typify research-practice collaborations in community settings. The researchers' applied theoretical understanding and the counselors' intimacy with patient responses combined to strengthen the intervention. However, counselors' discomfort with some protocols and changes reflecting the extremely dynamic nature of the community-based research setting complicated the study execution and interpretation. Despite these challenges, the intervention improved the counselors' ability to identify and respond appropriately to patients' co-occurring disorders, and one of its components was associated with improved patient outcomes. The experience also demonstrated the advisability of consulting collaboratively with clinic staff during the planning of studies and the pretesting of study protocols.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.