This Month’s Highlights

The past ten years have seen greater use of assertive community treatment (ACT) and the growth of recovery-oriented approaches to care. In 2007 Washington launched a network of recovery-oriented ACT teams with the goal of reducing state psychiatric hospital use. Three studies this month present findings from an evaluation of this initiative. In the first, Joseph P. Morrissey, Ph.D., and colleagues compared 450 ACT recipients with 450 matched consumers who were receiving usual care and found that ACT participation led to an average reduction of 32 to 33 state hospital days per year, or annual savings of about $11,000 to $13,000 per person in state hospital costs. The effects were most notable among individuals who were high users of the state hospital at baseline, with annual per-person reductions of about $17,000 to $20,000 (page 303). In the second study, Marisa E. Domino, Ph.D., and colleagues investigated the timing of ACT’s effects in the same sample, partly to determine whether the “ACT-for-life” mandate—the principle of unlimited treatment duration—was necessary for some consumers. Cost differences for ACT recipients were largest immediately after enrollment and tapered to insignificance at 27 months, leading the authors to conclude that—at least in terms of hospitalization outcomes—exposure to ACT could be reduced for some consumers (page 312). In the third study, Gary S. Cuddeback, Ph.D., and colleagues used a recently developed tool that measures ACT fidelity to determine whether Washington ACT teams with greater fidelity helped consumers achieve better outcomes (page 318).

Three articles describe studies that examined various aspects of medication prescribing. In the first, Haiden A. Huskamp, Ph.D., and colleagues analyzed prescribing data for more than 30,000 physicians to identify factors that contributed to their early adoption of antipsychotics that entered the market between 1996 and 2006 (page 324). Understanding factors that influence providers’ treatment choices is essential to ensure appropriate prescribing and improve the quality of care, as Kara Zivin, Ph.D., notes in a Taking Issue commentary on this study (page 295). In the second study, which identified potentially inappropriate benzodiazepine prescriptions in a sample of 2,320 elderly persons in Quebec, Pierre-Alexandre Dionne, M.Sc., and colleagues found greater use of acute care and higher costs associated with benzodiazepine-related drug interactions (page 331). The third study assessed the effects of a series of FDA advisories issued between 2005 and 2007 that warned about the health risks of stimulant drugs used to treat ADHD. Rachel Kornfield, M.A., and coinvestigators expected to find lower prescription rates for these medications as the advisories came out, but instead they found little discernible effect (page 339).

In a study by Marc I. Rosen, Ph.D., and colleagues, 384 veterans who were seeking disability benefits for service-connected PTSD were asked to rate the quality of the compensation and pension examinations that determined their eligibility and to assess the examiners’ interpersonal qualities and competence. Ratings were generally high. However, African-American veterans were less satisfied than Caucasian veterans with the quality of their examinations and rated the examiners as having significantly worse interpersonal qualities. Because approval of disability claims has far-reaching implications, it is important to explore these disparities, the authors concluded (page 354).

Since 2008, Massachusetts has had universal health insurance with an individual mandate, putting the state ahead of the national curve in terms of health care reform. Whereas only about 3% of the state’s population is uninsured, rates are much higher among patients who use behavioral health services. A research team led by Victor Capoccia, Ph.D., sought reasons for the discrepancy by conducting focus groups and structured interviews with policy makers, providers, and service users. The study pinpointed “churn” as a particular problem for users of behavioral health care. Churn occurs when persons are disenrolled from their subsidized health plan even though they remain eligible and then must be reenrolled, disrupting care and adding to the burden and cost of plan administration. The researchers found that many factors contributing to churn were related to the policies and procedures that drive the system. They discuss changes both in the system infrastructure and in outreach, enrollment, and recertification procedures that can sustain enrollment and avoid churn (page 360).