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Background: Disease burden estimates rarely consider comorbidity. Using a recently developed methodology for integrating information about comorbidity into disease burden estimates, we examined the comparative burdens of nine mental and 10 chronic physical disorders in the National Comorbidity Survey Replication (NCS-R).Methods: Face-to-face interviews in a national household sample (n = 5,692) assessed associations of disorders with scores on a visual analog scale (VAS) of perceived health. Multiple regression analysis with interactions for comorbidity was used to estimate these associations. Simulation was used to estimate incremental disorder-specific effects adjusting for comorbidity.Results: The majority of respondents (74.9%) reported one or more disorders. Of respondents with disorders, 73.8-98.2% reported having at least one other disorder. The best-fitting model to predict VAS scores included disorder main effects and interactions for number of disorders. Adjustment for comorbidity reduced individual-level disorder-specific burden estimates substantially, but with considerable between-disorder variation (0.07-0.69 ratios of disorder-specific estimates with and without adjustment for comorbidity). Four of the five most burdensome disorders at the individual level were mental disorders based on bivariate analyses (panic/agoraphobia, bipolar disorder, posttraumatic stress disorder, major depression) but only two based on multivariate analyses, adjusting for comorbidity (panic/agoraphobia, major depression). Neurological disorders, chronic pain conditions, and diabetes were the other most burdensome individual-level disorders. Chronic pain conditions, cardiovascular disorders, arthritis, insomnia, and major depression were the most burdensome societal-level disorders.Conclusions: Adjustments for comorbidity substantially influence estimates of disease burden, especially those of mental disorders, underlining the importance of including information about comorbidity in studies of mental disorders. [ABSTRACT FROM AUTHOR]

Background: Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections.Methods: A population- and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests.Results: One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P = .02), non-fee-for-service compensation (P = .008), and National Cancer Institute cancer center designation (P = .006) were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P = .003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI = -.1% to 9.2%, P = .09). Postoperative complications did not differ by type of surgery (all P > .05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P = .05).Conclusions: Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection. [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite evidence that childhood adversities (CAs) are associated with increased risk of mental disorders, little is known about their associations with disorder-related impairment. We report the associations between CAs and functional impairment associated with 12-month DSM-IV disorders in a national sample. METHOD: We used data from the US National Comorbidity Survey Replication (NCS-R). Respondents completed diagnostic interviews that assessed 12-month DSM-IV disorder prevalence and impairment. Associations of 12 retrospectively reported CAs with impairment among cases (n=2242) were assessed using multiple regression analysis. Impairment measures included a dichotomous measure of classification in the severe range of impairment on the Sheehan Disability Scale (SDS) and a measure of self-reported number of days out of role due to emotional problems in the past 12 months. RESULTS: CAs were positively and significantly associated with impairment. Predictive effects of CAs on the SDS were particularly pronounced for anxiety disorders and were significant in predicting increased days out of role associated with mood, anxiety and disruptive behavior disorders. Predictive effects persisted throughout the life course and were not accounted for by disorder co-morbidity. CAs associated with maladaptive family functioning (MFF; parental mental illness, substance disorder, criminality, family violence, abuse, neglect) were more consistently associated with impairment than other CAs. The joint effects of co-morbid MFF CAs were significantly subadditive. Simulations suggest that CAs account for 19.6% of severely impairing disorders and 17.4% of days out of role. CONCLUSIONS: CAs predict greater disorder-related impairment, highlighting the ongoing clinical significance of CAs at every stage of the life course. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the need for survey mode adjustments to hospital care evaluations by discharged inpatients and develop the appropriate adjustments.Data Source: A total of 7,555 respondents from a 2006 national random sample of 45 hospitals who completed the CAHPS Hospital (HCAHPS [Hospital Consumer Assessments of Healthcare Providers and Systems]) Survey.Study Design/data Collection/extraction Methods: We estimated mode effects in linear models that predicted each HCAHPS outcome from hospital-fixed effects and patient-mix adjustors.Principal Findings: Patients randomized to the telephone and active interactive voice response (IVR) modes provided more positive evaluations than patients randomized to mail and mixed (mail with telephone follow-up) modes, with some effects equivalent to more than 30 percentile points in hospital rankings. Mode effects are consistent across hospitals and are generally larger than total patient-mix effects. Patient-mix adjustment accounts for any nonresponse bias that could have been addressed through weighting.Conclusions: Valid comparisons of hospital performance require that reported hospital scores be adjusted for survey mode and patient mix. [ABSTRACT FROM AUTHOR]

Background and Purpose: Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services.Methodology/Approach: We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment.Findings: Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers.Practice Implications: To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change. [ABSTRACT FROM AUTHOR]

This study examined problems pertaining to the health and well-being of Army spouses during deployment, comparing those whose experienced extensions of their partners' deployments with those whose partners returned home on time or early. It used data from a 2004 survey of 798 spouses of active duty personnel. Controlling for demographic and deployment characteristics, spouses who experienced extensions fared worse on an array of measures, including mental well-being (e.g., feelings of depression), household strains (e.g., problems with household and car maintenance), and some areas of their jobs (having to stop work or to work fewer hours). There were no statistically significant differences regarding problems pertaining to their overall health, marriage, other work issues, finances, relationships with Army families, or safety. However, spouses who experienced extensions were more likely to perceive the Army negatively during deployment. These findings suggest that deployment extensions may exacerbate certain problems and frustrations for Army spouses. [ABSTRACT FROM AUTHOR]

OBJECTIVES: While lower socioeconomic status (SES) is related to higher risk for alcohol dependence, minority race-ethnicity is often associated with lower risk. This study attempts to clarify the nature and extent of social inequalities in alcohol dependence by investigating the effects of SES and race-ethnicity on the development of alcohol dependence following first alcohol use. DESIGN: Cross-sectional analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093). Survival analysis was used to model alcohol dependence onset according to education, race-ethnicity and their interaction. SETTING: United States, 2001-2. RESULTS: Compared with non-Hispanic white people, age-adjusted and sex-adjusted risks of alcohol dependence were lower among black people (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.63 to 0.78), Asians (OR = 0.65, CI = 0.49 to 0.86) and Hispanics (OR = 0.68, CI = 0.58 to 0.79) and higher among American Indians (OR = 1.37, CI = 1.09 to 1.73). Individuals without a college degree had higher risks of alcohol dependence than individuals with a college degree or more; however, the magnitude of risk varied significantly by race-ethnicity (chi(2) for the interaction between education and race-ethnicity = 19.7, df = 10, p = 0.03); odds ratios for less than a college degree were 1.12, 1.46, 2.24, 2.35 and 10.99 among Hispanics, white people, black people, Asians, and American Indians, respectively. There was no association between education and alcohol dependence among Hispanics. CONCLUSIONS: Race-ethnicity differences in the magnitude of the association between education and alcohol dependence suggest that aspects of racial-ethnic group membership mitigate or exacerbate the effects of social adversity. [ABSTRACT FROM AUTHOR]

PURPOSE: . The authors propose a Bayesian approach for estimating competing risks for inputs to disease simulation models. This approach is suggested when modeling a disease that causes a large proportion of all-cause mortality, particularly when mortality from the disease of interest and other-cause mortality are both affected by the same risk factor. METHODS: . The authors demonstrate a Bayesian evidence synthesis by estimating other-cause mortality, stratified by smoking status, for use in a simulation model of lung cancer. National (US) survey data linked to death registries (National Health Interview Survey [NHIS]-Multiple Cause of Death files) were used to fit cause-specific hazard models for 3 causes of death (lung cancer, heart disease, and all other causes), controlling for age, sex, race, and smoking status. Synthesis of NHIS data with national vital statistics data on numbers and causes of deaths was performed in WinBUGS (version 1.4.1, MRC Biostatistics Unit, UK). Correction for inconsistencies between the NHIS and vital statistics data is described. A published cohort study was a source of prior information for smoking-related mortality. RESULTS: . Marginal posterior densities of annual mortality rates for lung cancer and other-cause death (further divided into heart disease and all other causes), stratified by 5-year age interval, race (white and black), gender, and smoking status (current, former, never), were estimated, specific to a time period (1987-1995). Overall, black current smokers experienced the highest mortality rates. CONCLUSIONS: . Bayesian evidence synthesis is an effective method for estimation of cause-specific mortality rates, stratified by demographic factors. [ABSTRACT FROM AUTHOR]

Objective: Despite growing interest in adult attention deficit hyperactivity disorder (ADHD), little is known about its prevalence or correlates.Method: A screen for adult ADHD was included in a probability subsample (N=3,199) of 18-44-year-old respondents in the National Comorbidity Survey Replication, a nationally representative household survey that used a lay-administered diagnostic interview to assess a wide range of DSM-IV disorders. Blinded clinical follow-up interviews of adult ADHD were carried out with 154 respondents, oversampling those with positive screen results. Multiple imputation was used to estimate prevalence and correlates of clinician-assessed adult ADHD.Results: The estimated prevalence of current adult ADHD was 4.4%. Significant correlates included being male, previously married, unemployed, and non-Hispanic white. Adult ADHD was highly comorbid with many other DSM-IV disorders assessed in the survey and was associated with substantial role impairment. The majority of cases were untreated, although many individuals had obtained treatment for other comorbid mental and substance-related disorders.Conclusions: Efforts are needed to increase the detection and treatment of adult ADHD. Research is needed to determine whether effective treatment would reduce the onset, persistence, and severity of disorders that co-occur with adult ADHD. [ABSTRACT FROM AUTHOR]

Purpose: Treatment information collected by cancer registries can be used to monitor the provision of guideline-recommended chemotherapy to colorectal cancer patients. Incomplete information may bias comparisons of these rates. We developed statistical methods that combine data from a registry and physicians' records to assess hospital quality.Data: From California Cancer Registry data, we selected all patients (n=12,594) newly diagnosed with stage III colon cancer or stage II or III rectal cancer from 428 hospitals during the years 1994 to 1998. To assess rates and predictors of underreporting of chemotherapy, we surveyed physicians treating 1449 of these patients from 98 hospitals during the years 1996 to 1997.Methods: Using Bayesian statistical models, we imputed unobserved treatments. We studied the impact of underreporting on provider profiling by comparing rankings, estimates, and credible intervals based only on registry data to those incorporating physician survey data.Results: Analyses that account for incompleteness of reporting yielded wider credible intervals for provider profiles than those that ignored such incompleteness. Among the 109 (25%) hospitals in the highest quartile of chemotherapy rates according to the registry data, 16 were not so classified when incomplete reporting was taken into account. With the more comprehensive model, 12 hospitals could be identified that ranked in the top quartile with probability>0.90.Conclusion: Estimates of adjusted hospital chemotherapy rates based solely on cancer registry data overstate the precision of assessments of hospital quality. Using additional information from a physician survey and applying rigorous statistical models, better inferences can be drawn about provider quality. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the associations among hospital-level scores from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital pilot survey within and across different services (surgery, obstetrics, medical), and to evaluate differences between hospital- and patient-level analyses.Data Source: CAHPS Hospital pilot survey data provided by the Centers for Medicare and Medicaid Services.Study Design: Responses to 33 questionnaire items were analyzed using patient- and hospital-level exploratory factor analytic (EFA) methods to identify both a patient-level and hospital-level composite structures for the CAHPS Hospital survey. The latter EFA was corrected for patient-level sampling variability using a hierarchical model. We compared results of these analyses with each other and to separate EFAs conducted at the service level. To quantify the similarity of assessments across services, we compared correlations of different composites within the same service with those of the same composite across different services.Data Collection: Cross-sectional data were collected during the summer of 2003 via mail and telephone from 19,720 patients discharged from November 2002 through January 2003 from 132 hospitals in three states.Principal Findings: Six factors provided the best description of inter-item covariation at the patient level. Analyses that assessed variability across both services and hospitals suggested that three dimensions provide a parsimonious summary of inter-item covariation at the hospital level. Hospital-level factor structures also differed across services; as much variation in quality reports was explained by service as by composite.Conclusions: Variability of CAHPS scores across hospitals can be reported parsimoniously using a limited number of composites. There is at least as much distinct information in composite scores from different services as in different composite scores within each service. Because items cluster slightly differently in the different services, service-specific composites may be more informative when comparing patients in a given service across hospitals. When studying individual-level variability, a more differentiated structure is probably more appropriate. [ABSTRACT FROM AUTHOR]

Objective: To identify a parsimonious subset of reliable, valid, and consumer-salient items from 33 questions asking for patient reports about hospital care quality.Data Source: CAHPS Hospital Survey pilot data were collected during the summer of 2003 using mail and telephone from 19,720 patients who had been treated in 132 hospitals in three states and discharged from November 2002 to January 2003.Methods: Standard psychometric methods were used to assess the reliability (internal consistency reliability and hospital-level reliability) and construct validity (exploratory and confirmatory factor analyses, strength of relationship to overall rating of hospital) of the 33 report items. The best subset of items from among the 33 was selected based on their statistical properties in conjunction with the importance assigned to each item by participants in 14 focus groups.Principal Findings: Confirmatory factor analysis (CFA) indicated that a subset of 16 questions proposed to measure seven aspects of hospital care (communication with nurses, communication with doctors, responsiveness to patient needs, physical environment, pain control, communication about medication, and discharge information) demonstrated excellent fit to the data. Scales in each of these areas had acceptable levels of reliability to discriminate among hospitals and internal consistency reliability estimates comparable with previously developed CAHPS instruments.Conclusion: Although half the length of the original, the shorter CAHPS hospital survey demonstrates promising measurement properties, identifies variations in care among hospitals, and deals with aspects of the hospital stay that are important to patients' evaluations of care quality. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many different surveys have been used to evaluate the performance of medical groups, but there is a growing recognition that standardization could be helpful to consumers, purchasers, and others. OBJECTIVES: We sought to develop a version of the Consumer Assessment of Health Plans Study (CAHPS) survey for use with medical groups (G-CAHPS) and assess its reliability and validity. RESEARCH DESIGN: The research team reviewed existing instruments and conducted patient focus groups in 4 sites to identify aspects of care that were especially important to patients when evaluating medical groups. We tested a draft instrument in 75 cognitive interviews with adults 18 years of age or older in Knoxville, St. Louis, and California and pretests in 4 groups of adults in Boston and Denver. We then surveyed random samples of patients from medical groups and practice sites in California, Knoxville, St. Louis, and Denver. We analyzed the psychometric characteristics of the instrument. RESULTS: Data support the reliability and validity of 3 multi-item measures of access, office staff service, and patient clinician communication. Measures related to specialty care and preventive counseling did not differentiate among medical groups. CONCLUSIONS: The G-CAHPS instrument provides an assessment of selected aspects of care that are important to consumers and could be a useful complement to the plan-level CAHPS instrument. [ABSTRACT FROM AUTHOR]

OBJECTIVES: When comparing the scores from Consumer Assessment of Health Plans Study (CAHPS) surveys across health plans, it is important to adjust for patient characteristics (casemix) that are not under the control of the plan but that affect plan ratings. Our goal was to develop casemix models for pediatric CAHPS surveys. METHODS: We analyzed responses to the pediatric CAHPS 2.0 surveys from 50,583 Medicaid beneficiaries and 43,579 persons with private health insurance. We identified patient characteristics with the most substantial impact on scores and assessed casemix models that include different combinations of adjusters. In addition, we tested whether casemix coefficients differed between the Medicaid and commercial samples and across health plans. RESULTS: Parent age and education and child health status and race were important casemix adjustment variables for pediatric CAHPS surveys. Child age and gender had smaller effects. The relationship between patient characteristics and CAHPS scores was different in the Medicaid and commercial samples for some variables. The effects of a patient's characteristics on ratings and report scores were not consistent across Medicaid plans but more consistent for commercial plans. CONCLUSIONS: Our analyses indicate that plan scores on the pediatric CAHPS survey should be adjusted for plan differences in casemix. Users should consider estimating separate models for Medicaid and commercially insured respondents. Such models should adjust for child health status, parent age, and parent education. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of this study was to evaluate the payment implications of substituting the Minimum Data Set-Post Acute Care (MDS-PAC) for the FIM trade mark instrument for use in the planned prospective payment system (PPS) for inpatient rehabilitation hospitals. FIM trade mark is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activites, Inc. RESEARCH DESIGN: We used a prospective cross-sectional design using consecutive sampling. SUBJECTS: We studied all Medicare admissions with stays of 3 days or more over a 2-month period to 50 inpatient rehabilitation hospitals in 22 states. MEASUREMENTS AND METHODS: Each participating institution completed both the FIM and the MDS-PAC assessments on all participants. Items from the MDS-PAC were combined and translated to create 'FIM-like' items. We assessed agreement of classification into prospective payment cells using FIM assessment data and also using MDS-PAC data. Statistical adjustments were applied to improve the level of agreement. RESULTS: The mean differences between the FIM motor and cognitive scales and their MDS-PAC translations were 2.4 (mean = 45) and 0.0 (mean = 28), respectively, with scale correlations of.85 and.84. Weighted kappas on individual items ranged from.32 to.64. There were substantial hospital-specific differences in scoring. Payment cell classification using FIM data agreed with that using MDS-PAC data only 56% of the time. Twenty percent of the facilities experienced revenue shifts larger than 10%. CONCLUSION: Despite better item-level agreement than previously observed, poor payment cell agreement and substantial revenue shifts indicated that the MDS-PAC should not be substituted for the FIM trade mark instrument in the rehabilitation hospital PPS. [ABSTRACT FROM AUTHOR]

BACKGROUND: Population-based cancer registries represent a potentially valuable tool to evaluate treatment; however, information on the completeness of registry treatment data is sparse. OBJECTIVE: To evaluate the completeness of registry treatment data for patients with colorectal cancer and to identify predictors of complete reporting. RESEARCH DESIGN: We surveyed physicians or reviewed office records of 1956 northern California patients diagnosed with colorectal cancer during 1996 to 1997 to assess the completeness of registry data regarding use of adjuvant chemotherapy and radiation therapy. RESULTS: For patients with a record of receipt of chemotherapy in either the registry or physician survey, information was in the original registry records for 82.0%. In the multivariate analysis, completeness of chemotherapy reporting was lower for patients aged 65 to 74, those with colon cancer, and those treated in teaching hospitals; and higher for patients treated in hospitals that are part of a large health maintenance organization (HMO). For patients with a record of receipt of radiation therapy, information was in the original registry records for 90.2%. In the multivariate analysis, completeness of radiation therapy reporting was higher for patients aged 18 to 54 and those treated in HMO hospitals. CONCLUSIONS: Because the completeness of the registry treatment data varied by patient and hospital characteristics, use of registry data without supplementation could bias estimates of the proportion of patients treated, and of the patient and provider characteristics associated with treatment. Enhanced cancer registry data could be a valuable component of population-based cancer data systems for assessing quality of cancer care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program. METHODS: 1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted chi2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics. RESULTS: Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to 'know-how'--that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes. CONCLUSIONS: This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency. [ABSTRACT FROM AUTHOR]

Context: Substantial racial disparities exist in use of some health services. Whether managed care could reduce racial disparities in the use of preventive services is not known.Objective: To determine whether the magnitude of racial disparity in influenza vaccination is smaller among managed care enrollees than among those with fee-for-service insurance.Design, Setting, and Participants: The 1996 Medicare Current Beneficiary Survey of a US cohort of 13 674 African American and white Medicare beneficiaries with managed care and fee-for-service insurance.Main Outcome Measures: Percentage of respondents (adjusted for sociodemographic characteristics, clinical comorbid conditions, and care-seeking attitudes) who received influenza vaccination and magnitude of racial disparity in influenza vaccination, compared among those with managed care and fee-for-service insurance.Results: Eight percent of the beneficiaries were African American and 11% were enrolled in managed care. Overall, 65.8% received influenza vaccination. Whites were substantially more likely to be vaccinated than African Americans (67.7% vs 46.1%; absolute disparity, 21.6%; 95% confidence interval [CI], 18.2%-25.0%). Managed care enrollees were more likely than those with fee-for-service insurance to receive influenza vaccination (71.2% vs 65.4%; difference, 5.8%; 95% CI, 3.6%-8.3%). The adjusted racial disparity in fee-for-service was 24.9% (95% CI, 19.6%-30.1%) and in managed care was 18.6% (95% CI, 9.8%-27.4%). These adjusted racial disparities were both statistically significant, but the absolute percentage point difference in racial disparity between the 2 insurance groups (6.3%; 95% CI, -4.6% to 17.2%) was not.Conclusion: Managed care is associated with higher rates of influenza vaccination for both whites and African Americans, but racial disparity in vaccination is not reduced in managed care. Our results suggest that additional efforts are needed to adequately address this disparity. [ABSTRACT FROM AUTHOR]

Responses to the Consumer Assessments of Health Plans Survey (CAHPS) are related to respondent characteristics. CAHPS procedures include casemix adjustment to remove effects of difference in respondent characteristics on comparative plan ratings, under the assumption that casemix coefficients are homogeneous across plans. The authors analyzed data from the Washington state CAHPS demonstration, fitting hierarchical models in which coefficients of casemix variables and intercepts could vary by plan. They estimated the impact of variability in casemix coefficients on plan adjustments and also assessed the implications for differential effects of individual characteristics at different plans. Estimated between-plan variability of coefficients was small, but the data are consistent with substantially larger variability. The potential impact of this variability on adjustments for plans was small relative to the magnitude of the adjustments. Comparisons between plans for individuals, however, could be affected substantially. This methodology could be useful wherever casemix adjustment is applied. [ABSTRACT FROM AUTHOR]

A meta-analysis of 25 epidemiological studies estimated the prevalence of recent Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) major depression (MD) among U.S. military personnel. Best estimates of recent prevalence (standard error) were 12.0% (1.2) among currently deployed, 13.1% (1.8) among previously deployed, and 5.7% (1.2) among never deployed. Consistent correlates of prevalence were being female, enlisted, young (ages 17-25), unmarried, and having less than a college education. Simulation of data from a national general population survey was used to estimate expected lifetime prevalence of MD among respondents with the sociodemographic profile and none of the enlistment exclusions of Army personnel. In this Simulated sample, 16.2% (3.1) of respondents had lifetime MD and 69.7% (8.5) of first onsets occurred before expected age of enlistment. Numerous methodological problems limit the results of the meta-analysis and simulation. The article closes with a discussion of recommendations for correcting these problems in future surveillance and operational stress studies. [ABSTRACT FROM AUTHOR]

The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain. [ABSTRACT FROM AUTHOR]

Background: Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders.Methods: We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services.Results: The prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents.Conclusions: Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments. [ABSTRACT FROM AUTHOR]