Andrea Kline-Simon - Academia.edu (original) (raw)

Papers by Andrea Kline-Simon

Research paper thumbnail of Point Prevalence of Co-Occurring Behavioral Health Conditions and Associated Chronic Disease Burden Among Adolescents

Journal of the American Academy of Child & Adolescent Psychiatry, 2016

To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic m... more To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic medical conditions among adolescents in an integrated health system. The sample consisted of adolescents in an integrated health care system diagnosed with at least 1 of the 5 most prevalent BHCs in 2014 (n = 30,643), and patients without a BHC matched on age, sex, and medical home facility (n = 30,643). Electronic health record data was used to identify all adolescents aged 11 to 18 years with at least 1 BHC diagnosis on their diagnosis list, which included current and pre-existing diagnoses from an outpatient (including psychiatry and chemical dependency specialty treatment), inpatient, or emergency department visit at a Kaiser Permanente Northern California (KPNC) facility between January 1, 2014, and December 31, 2014. The odds of having general medical conditions and specific chronic diseases were compared between adolescents with and without BHCs. Among adolescents with at least 1 BHC in 2014, the 5 most common BHCs were: depressive disorders (42%), anxiety disorders (40%), attention-deficit/hyperactivity disorders (ADHDs; 37%), substance use disorders (SUDs; 10%), and bipolar spectrum disorders (8%). Overall, patients with a BHC did not have higher odds of any medical comorbidity compared with non-BHC patients. However, compared to individuals without BHCs, adolescents with depression (odds ratio [OR] = 1.16, 95% CI = 1.08-1.26), anxiety (OR = 1.30, 95% CI = 1.20-1.41), and substance use (OR = 1.25, 95% CI = 1.05-1.49) disorders had significantly higher odds of any medical comorbidities; individuals with ADHD and bipolar disorder did not differ from patients without BHCs. BHCs were common and were associated with a disproportionately higher burden of chronic medical disease among adolescents in a large, private health care delivery system. As comorbidity can lead to elevated symptom burden, functional impairment, and treatment complexity, the study findings call for implementation of effective collaborative models of care for these patients.

Research paper thumbnail of Smoking Trends Among Adults With Behavioral Health Conditions in Integrated Health Care: A Retrospective Cohort Study

Psychiatric Services, 2016

Individuals with behavioral health conditions (BHCs) smoke at high rates and have limited success... more Individuals with behavioral health conditions (BHCs) smoke at high rates and have limited success with quitting, despite impressive gains in recent decades in reducing the overall prevalence of smoking in the United States. This study examined smoking disparities among individuals with BHCs within an integrated health care delivery system with convenient access to tobacco treatments. The sample consisted of patients in an integrated health care delivery system in 2010-a group (N=155,733) with one or more of the five most prevalent BHCs (depressive disorders, anxiety disorders, substance use disorders, bipolar and related disorders, and attention-deficit hyperactivity disorder) and a group (N=155,733) without BHCs who were matched on age, sex, and medical home facility. The odds of smoking among patients with BHCs versus without BHCs were examined over four years using logistic regression generalized estimating equation models. Tobacco cessation medication utilization among a subset of smokers in 2010 was also examined. Although smoking prevalence decreased from 2010 to 2013 overall, the likelihood of smoking decreased significantly more slowly among patients with BHCs compared with patients without BHCs (p<.001), most notably among patients with substance use and bipolar and related disorders. Tobacco cessation medication use was low, and smokers with BHCs were more likely than smokers without BHCs to utilize these products (6.2% versus 3.6%, p<.001). Smoking decreased more slowly among individuals with BHCs compared with individuals without BHCs, even within an integrated health care system, highlighting the need to prioritize smoking cessation within specialty behavioral health treatment.

Research paper thumbnail of Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial

JAMA pediatrics, Jan 2, 2015

Early intervention for substance use is critical to improving adolescent outcomes. Studies have f... more Early intervention for substance use is critical to improving adolescent outcomes. Studies have found promising results for Screening, Brief Intervention, and Referral to Treatment (SBIRT), but little research has examined implementation. To compare SBIRT implementation in pediatric primary care among trained pediatricians, pediatricians working in coordination with embedded behavioral health care practitioners (BHCPs), and usual care (UC). The study is a 2-year (November 1, 2011, through October 31, 2013), nonblinded, cluster randomized, hybrid implementation and effectiveness trial examining SBIRT implementation outcomes across 2 modalities of implementation and UC. Fifty-two pediatricians from a large general pediatrics clinic in an integrated health care system were randomized to 1 of 3 SBIRT implementation arms; patients aged 12 to 18 years were eligible. Two modes of SBIRT implementation, (1) pediatrician only (pediatricians trained to provide SBIRT) and (2) embedded BHCP (BHC...

Research paper thumbnail of Predictors of Functional Outcomes Among Chronic Pain Patients Receiving Long-Term Opioid Treatment

Background. Little is known about the relationship between long-term opioid therapy and functiona... more Background. Little is known about the relationship between long-term opioid therapy and functional status among chronic pain patient populations. This paper examines the role of substance use, mental health conditions, and demographic characteristics in determining functional disability among long-term opioid therapy patients. Methods. 972 adult Kaiser Permanente Northern California (KPNC) members who were chronic, non-cancer pain patients receiving long-term opioid therapy, stratified by dosage levels, completed a telephone survey that measured functional outcomes with the disability interference score from the Graded Chronic Pain Scale Version 2.0. Results. Multiple logistic regression analyses found that higher depression severity was associated with greater disability (OR = 5.713 for Dose 1, OR = 4.604 for Dose 2, both p<.05), as was lower income (OR = 2.512 for Dose 3). Employment was predictive of lower disability (OR = 0.492 for Dose 1, OR = 0.299 for Dose 2, and OR = 0.16...

Research paper thumbnail of Adolescent SBIRT implementation in pediatric primary care: results from a randomized trial in an integrated health-care delivery system

Addiction Science & Clinical Practice, 2015

Research paper thumbnail of Smoking Prevalence and Use of Cessation Medications Among Patients With Psychiatric Disorders in an Integrated Health Care Delivery System: A Case-Control Study

Journal of Patient-Centered Research and Reviews, 2015

Research paper thumbnail of Screening for adolescent alcohol and drug use in pediatrics: predictors and implications for practice and policy

We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot stu... more We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot study of a screening, brief intervention, and referral to treatment (SBIRT) model of primary care-based adolescent behavioral health care. The survey (N = 437) examined PCP attitudes and knowledge, patient characteristics, and environmental influences, (e.g., mental health parity and medical marijuana laws). We examined how PCP, panel, and organizational characteristics influence screening practices. The pilot examined whether SBIRT versus usual care increased problem identification and specialty treatment rates and the feasibility of SBIRT in pediatric patients. Respondents were less concerned about alcohol than other drug use, rated alcohol use as more difficult to discuss (19% versus 15%) and diagnose (56% versus 70%) than depression, and were more comfortable discussing sexual practices than alcohol (32% versus 22%). They were more likely to screen boys than girls (male PCPs were even more likely: 23% versus 6% [p < 0.0001]). Self-reported screening rates were far higher than electronic medical record (EMR)-documented rates for all substances. Experience, specialty, and recent AOD training (all p < 0.05) predicted self-reported rates; only patient age predicted actual rates. Organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient characteristics in determining screening. Respondents reported that SBIRT was highly feasible and that it improved care; more (77) teens receiving SBIRT were referred for further assessment than those receiving usual care, and specialty treatment initiation increased from 8.73% to 12% (p < 0.0001). Organizational factors, lack of training, and discomfort with screening may impact adolescent screening and intervention.

Research paper thumbnail of Prevalence of behavioral health disorders and associated chronic disease burden in a commercially insured health system: findings of a case-control study

General hospital psychiatry, Jan 20, 2014

The objective was to examine prevalence of behavioral health disorders (BHDs) and co-occurring ch... more The objective was to examine prevalence of behavioral health disorders (BHDs) and co-occurring chronic medical conditions in a 3.4 million-member integrated health system. Clinical databases identified 255,993 patients diagnosed with the most prevalent BHDs (cases): depression, anxiety, substance use, bipolar spectrum and attention deficit and hyperactivity (ADHD); non-BHD matched controls were created for all unique cases. Cases and controls were compared for prevalence of general medical conditions and specific chronic diseases and the Charlson Comorbidity Index (CMI). The five most common BHDs were depression (58%), anxiety (42%), substance use (16%), bipolar spectrum (6%) and ADHD (4%). Compared to controls, patients with depression (80.1% vs. 66.3%), anxiety (78.0% vs. 63.0%), substance use (74.0% vs. 59.9%), bipolar (75.3% vs. 60.7%) and ADHD (60.6% vs. 53.1%; all P<.001) had significantly higher prevalence of any medical comorbidities. Excluding ADHD, BHD cases had higher ...

Research paper thumbnail of Functional Disability Among Chronic Pain Patients Receiving Long-Term Opioid Treatment

Journal of Social Work in Disability & Rehabilitation, 2012

Research paper thumbnail of Remission from alcohol and other drug problem use in public and private treatment samples over seven years

Drug and Alcohol Dependence, 2012

Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a ch... more Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects. Methods: The sample (n = 783) included consecutive admissions in ten public and private alcohol and other drug (AOD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use. Results: In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples. Conclusions: Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes.

Research paper thumbnail of Ten-year stability of remission in private alcohol and drug outpatient treatment: Non-problem users versus abstainers

Drug and Alcohol Dependence, 2012

Background: This study examined stability of remission in patients who were abstainers and non-pr... more Background: This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence? Methods: The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse. Results: Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users. Conclusions: Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year.

Research paper thumbnail of PS1-20: Integrating Alcohol and Drug Use Screening for Adolescents into Mental Health Settings: Rationale, Missed Opportunities and Outcomes

Clinical Medicine & Research, 2013

Research paper thumbnail of CB8-03: Models of Integrated Care for Adolescent Alcohol and Drug Use in Pediatrics: Predictors and Implications for Practice and Policy

Clinical Medicine & Research, 2012

Accepted By Abstract Software. Discussion: The proportion of children and adolescents with both n... more Accepted By Abstract Software. Discussion: The proportion of children and adolescents with both normal BP and normal BMI was 46.7% and decreased with age, while the proportion with both elevated BP and BMI rose from 7.8% to 20.0% with increasing age. Clinical and public policy initiatives to reduce the very high frequency of these risk factors in U.S. children and adolescents should be carefully considered.

Research paper thumbnail of PS1-01: Alcohol and Drug Use Among Chronic Opioid Therapy Patients

Clinical Medicine & Research, 2012

Background/Aims: Programs to translate the Diabetes Prevention Program (DPP) into effective real-... more Background/Aims: Programs to translate the Diabetes Prevention Program (DPP) into effective real-life interventions are needed. In the Call-2-Health pilot study we designed and tested a telephone-based intervention modeled on the DPP. Here we present the impact of Call-2-Health on participants' report of support from friends and family for diet changes. Social support may be critical to long-term maintenance of behavioral changes. Methods: Between September 2010 and January 2011, we mailed recruitment letters to 438 overweight English-speaking non-diabetic Group Health members aged 45-74 for whom electronic health records indicated at least one elevated blood glucose or HbA1c. We followed up with phone screening and laboratory tests to confirm eligibility and willingness to participate. Eligible and consenting participants (N=47; 49% men) were randomly assigned 1:1 to usual care (UC) and intervention groups (IG) for the 24-week study. The IG received 12 weekly intervention calls plus 4 maintenance calls over the subsequent 12 weeks. The interventionist delivered a DPP-based curriculum, using motivational interviewing and behavioral techniques to encourage exercise, dietary change, and weight loss. Three UC participants failed to complete the study; IG participants completed 95% of intervention calls. Study questionnaires included the Sallis Social Support scale for eating, completed at baseline and 24 weeks. Results: At baseline, the UC group had mean scores (95%CI) of 10.82 (7.93, 13.70) on the family and 8.55 (6.43, 10.66) on the friend diet encouragement scales. Mean scores for the IG were comparable, at 10.58 (8.09, 13.08) and 7.17 (6.03, 8.30). At 24 weeks, the measures remained essentially unchanged for UC and increased by 3.71 (1.56, 5.86) (p=0.016) and 3.46 (1.93, 4.99) (p=0.003) for the IG. At 24 weeks the mean weight lost for the IG was 8.6% of baseline weight (5.6, 11.5) as compared to 1.5% (-0.8, 3.9) for UC. Intervention participants' weight loss and their reported increase in dietary support were highly correlated (family r=0.70, friends r=0.64). Discussion: As compared to the usual care group, participants in the Call-2-Health phone intervention reported at 24 weeks a significant increase in supportive behaviors from friends and family regarding dietary change, with increases in support correlating strongly with weight loss success.

Research paper thumbnail of Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders

Alcoholism: Clinical and Experimental Research, 2013

Background: Treatment for alcohol disorders has traditionally been abstinence-oriented, but evalu... more Background: Treatment for alcohol disorders has traditionally been abstinence-oriented, but evaluating the merits of a low-risk drinking outcome as part of a primary treatment endpoint is a timely issue given new pertinent regulatory guidelines. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and problem severity outcomes among individuals with alcohol use disorders in a large private, not for profit, integrated care health plan.

Research paper thumbnail of Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy

Addiction Science & Clinical Practice, 2012

We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot stu... more We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot study of a screening, brief intervention, and referral to treatment (SBIRT) model of primary care-based adolescent behavioral health care. The survey (N = 437) examined PCP attitudes and knowledge, patient characteristics, and environmental influences, (e.g., mental health parity and medical marijuana laws). We examined how PCP, panel, and organizational characteristics influence screening practices. The pilot examined whether SBIRT versus usual care increased problem identification and specialty treatment rates and the feasibility of SBIRT in pediatric patients. Respondents were less concerned about alcohol than other drug use, rated alcohol use as more difficult to discuss (19% versus 15%) and diagnose (56% versus 70%) than depression, and were more comfortable discussing sexual practices than alcohol (32% versus 22%). They were more likely to screen boys than girls (male PCPs were even more likely: 23% versus 6% [p < 0.0001]). Self-reported screening rates were far higher than electronic medical record (EMR)-documented rates for all substances. Experience, specialty, and recent AOD training (all p < 0.05) predicted self-reported rates; only patient age predicted actual rates. Organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient characteristics in determining screening. Respondents reported that SBIRT was highly feasible and that it improved care; more (77) teens receiving SBIRT were referred for further assessment than those receiving usual care, and specialty treatment initiation increased from 8.73% to 12% (p < 0.0001). Organizational factors, lack of training, and discomfort with screening may impact adolescent screening and intervention.

Research paper thumbnail of Five-Year Healthcare Utilization and Costs Among Lower-Risk Drinkers Following Alcohol Treatment

Alcoholism: Clinical and Experimental Research, 2014

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients follo... more Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications. Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group. Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) and ED (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) and inpatient (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time. Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Research paper thumbnail of Point Prevalence of Co-Occurring Behavioral Health Conditions and Associated Chronic Disease Burden Among Adolescents

Journal of the American Academy of Child & Adolescent Psychiatry, 2016

To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic m... more To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic medical conditions among adolescents in an integrated health system. The sample consisted of adolescents in an integrated health care system diagnosed with at least 1 of the 5 most prevalent BHCs in 2014 (n = 30,643), and patients without a BHC matched on age, sex, and medical home facility (n = 30,643). Electronic health record data was used to identify all adolescents aged 11 to 18 years with at least 1 BHC diagnosis on their diagnosis list, which included current and pre-existing diagnoses from an outpatient (including psychiatry and chemical dependency specialty treatment), inpatient, or emergency department visit at a Kaiser Permanente Northern California (KPNC) facility between January 1, 2014, and December 31, 2014. The odds of having general medical conditions and specific chronic diseases were compared between adolescents with and without BHCs. Among adolescents with at least 1 BHC in 2014, the 5 most common BHCs were: depressive disorders (42%), anxiety disorders (40%), attention-deficit/hyperactivity disorders (ADHDs; 37%), substance use disorders (SUDs; 10%), and bipolar spectrum disorders (8%). Overall, patients with a BHC did not have higher odds of any medical comorbidity compared with non-BHC patients. However, compared to individuals without BHCs, adolescents with depression (odds ratio [OR] = 1.16, 95% CI = 1.08-1.26), anxiety (OR = 1.30, 95% CI = 1.20-1.41), and substance use (OR = 1.25, 95% CI = 1.05-1.49) disorders had significantly higher odds of any medical comorbidities; individuals with ADHD and bipolar disorder did not differ from patients without BHCs. BHCs were common and were associated with a disproportionately higher burden of chronic medical disease among adolescents in a large, private health care delivery system. As comorbidity can lead to elevated symptom burden, functional impairment, and treatment complexity, the study findings call for implementation of effective collaborative models of care for these patients.

Research paper thumbnail of Smoking Trends Among Adults With Behavioral Health Conditions in Integrated Health Care: A Retrospective Cohort Study

Psychiatric Services, 2016

Individuals with behavioral health conditions (BHCs) smoke at high rates and have limited success... more Individuals with behavioral health conditions (BHCs) smoke at high rates and have limited success with quitting, despite impressive gains in recent decades in reducing the overall prevalence of smoking in the United States. This study examined smoking disparities among individuals with BHCs within an integrated health care delivery system with convenient access to tobacco treatments. The sample consisted of patients in an integrated health care delivery system in 2010-a group (N=155,733) with one or more of the five most prevalent BHCs (depressive disorders, anxiety disorders, substance use disorders, bipolar and related disorders, and attention-deficit hyperactivity disorder) and a group (N=155,733) without BHCs who were matched on age, sex, and medical home facility. The odds of smoking among patients with BHCs versus without BHCs were examined over four years using logistic regression generalized estimating equation models. Tobacco cessation medication utilization among a subset of smokers in 2010 was also examined. Although smoking prevalence decreased from 2010 to 2013 overall, the likelihood of smoking decreased significantly more slowly among patients with BHCs compared with patients without BHCs (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001), most notably among patients with substance use and bipolar and related disorders. Tobacco cessation medication use was low, and smokers with BHCs were more likely than smokers without BHCs to utilize these products (6.2% versus 3.6%, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Smoking decreased more slowly among individuals with BHCs compared with individuals without BHCs, even within an integrated health care system, highlighting the need to prioritize smoking cessation within specialty behavioral health treatment.

Research paper thumbnail of Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial

JAMA pediatrics, Jan 2, 2015

Early intervention for substance use is critical to improving adolescent outcomes. Studies have f... more Early intervention for substance use is critical to improving adolescent outcomes. Studies have found promising results for Screening, Brief Intervention, and Referral to Treatment (SBIRT), but little research has examined implementation. To compare SBIRT implementation in pediatric primary care among trained pediatricians, pediatricians working in coordination with embedded behavioral health care practitioners (BHCPs), and usual care (UC). The study is a 2-year (November 1, 2011, through October 31, 2013), nonblinded, cluster randomized, hybrid implementation and effectiveness trial examining SBIRT implementation outcomes across 2 modalities of implementation and UC. Fifty-two pediatricians from a large general pediatrics clinic in an integrated health care system were randomized to 1 of 3 SBIRT implementation arms; patients aged 12 to 18 years were eligible. Two modes of SBIRT implementation, (1) pediatrician only (pediatricians trained to provide SBIRT) and (2) embedded BHCP (BHC...

Research paper thumbnail of Predictors of Functional Outcomes Among Chronic Pain Patients Receiving Long-Term Opioid Treatment

Background. Little is known about the relationship between long-term opioid therapy and functiona... more Background. Little is known about the relationship between long-term opioid therapy and functional status among chronic pain patient populations. This paper examines the role of substance use, mental health conditions, and demographic characteristics in determining functional disability among long-term opioid therapy patients. Methods. 972 adult Kaiser Permanente Northern California (KPNC) members who were chronic, non-cancer pain patients receiving long-term opioid therapy, stratified by dosage levels, completed a telephone survey that measured functional outcomes with the disability interference score from the Graded Chronic Pain Scale Version 2.0. Results. Multiple logistic regression analyses found that higher depression severity was associated with greater disability (OR = 5.713 for Dose 1, OR = 4.604 for Dose 2, both p<.05), as was lower income (OR = 2.512 for Dose 3). Employment was predictive of lower disability (OR = 0.492 for Dose 1, OR = 0.299 for Dose 2, and OR = 0.16...

Research paper thumbnail of Adolescent SBIRT implementation in pediatric primary care: results from a randomized trial in an integrated health-care delivery system

Addiction Science & Clinical Practice, 2015

Research paper thumbnail of Smoking Prevalence and Use of Cessation Medications Among Patients With Psychiatric Disorders in an Integrated Health Care Delivery System: A Case-Control Study

Journal of Patient-Centered Research and Reviews, 2015

Research paper thumbnail of Screening for adolescent alcohol and drug use in pediatrics: predictors and implications for practice and policy

We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot stu... more We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot study of a screening, brief intervention, and referral to treatment (SBIRT) model of primary care-based adolescent behavioral health care. The survey (N = 437) examined PCP attitudes and knowledge, patient characteristics, and environmental influences, (e.g., mental health parity and medical marijuana laws). We examined how PCP, panel, and organizational characteristics influence screening practices. The pilot examined whether SBIRT versus usual care increased problem identification and specialty treatment rates and the feasibility of SBIRT in pediatric patients. Respondents were less concerned about alcohol than other drug use, rated alcohol use as more difficult to discuss (19% versus 15%) and diagnose (56% versus 70%) than depression, and were more comfortable discussing sexual practices than alcohol (32% versus 22%). They were more likely to screen boys than girls (male PCPs were even more likely: 23% versus 6% [p < 0.0001]). Self-reported screening rates were far higher than electronic medical record (EMR)-documented rates for all substances. Experience, specialty, and recent AOD training (all p < 0.05) predicted self-reported rates; only patient age predicted actual rates. Organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient characteristics in determining screening. Respondents reported that SBIRT was highly feasible and that it improved care; more (77) teens receiving SBIRT were referred for further assessment than those receiving usual care, and specialty treatment initiation increased from 8.73% to 12% (p < 0.0001). Organizational factors, lack of training, and discomfort with screening may impact adolescent screening and intervention.

Research paper thumbnail of Prevalence of behavioral health disorders and associated chronic disease burden in a commercially insured health system: findings of a case-control study

General hospital psychiatry, Jan 20, 2014

The objective was to examine prevalence of behavioral health disorders (BHDs) and co-occurring ch... more The objective was to examine prevalence of behavioral health disorders (BHDs) and co-occurring chronic medical conditions in a 3.4 million-member integrated health system. Clinical databases identified 255,993 patients diagnosed with the most prevalent BHDs (cases): depression, anxiety, substance use, bipolar spectrum and attention deficit and hyperactivity (ADHD); non-BHD matched controls were created for all unique cases. Cases and controls were compared for prevalence of general medical conditions and specific chronic diseases and the Charlson Comorbidity Index (CMI). The five most common BHDs were depression (58%), anxiety (42%), substance use (16%), bipolar spectrum (6%) and ADHD (4%). Compared to controls, patients with depression (80.1% vs. 66.3%), anxiety (78.0% vs. 63.0%), substance use (74.0% vs. 59.9%), bipolar (75.3% vs. 60.7%) and ADHD (60.6% vs. 53.1%; all P<.001) had significantly higher prevalence of any medical comorbidities. Excluding ADHD, BHD cases had higher ...

Research paper thumbnail of Functional Disability Among Chronic Pain Patients Receiving Long-Term Opioid Treatment

Journal of Social Work in Disability & Rehabilitation, 2012

Research paper thumbnail of Remission from alcohol and other drug problem use in public and private treatment samples over seven years

Drug and Alcohol Dependence, 2012

Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a ch... more Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects. Methods: The sample (n = 783) included consecutive admissions in ten public and private alcohol and other drug (AOD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use. Results: In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples. Conclusions: Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes.

Research paper thumbnail of Ten-year stability of remission in private alcohol and drug outpatient treatment: Non-problem users versus abstainers

Drug and Alcohol Dependence, 2012

Background: This study examined stability of remission in patients who were abstainers and non-pr... more Background: This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence? Methods: The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse. Results: Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users. Conclusions: Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year.

Research paper thumbnail of PS1-20: Integrating Alcohol and Drug Use Screening for Adolescents into Mental Health Settings: Rationale, Missed Opportunities and Outcomes

Clinical Medicine & Research, 2013

Research paper thumbnail of CB8-03: Models of Integrated Care for Adolescent Alcohol and Drug Use in Pediatrics: Predictors and Implications for Practice and Policy

Clinical Medicine & Research, 2012

Accepted By Abstract Software. Discussion: The proportion of children and adolescents with both n... more Accepted By Abstract Software. Discussion: The proportion of children and adolescents with both normal BP and normal BMI was 46.7% and decreased with age, while the proportion with both elevated BP and BMI rose from 7.8% to 20.0% with increasing age. Clinical and public policy initiatives to reduce the very high frequency of these risk factors in U.S. children and adolescents should be carefully considered.

Research paper thumbnail of PS1-01: Alcohol and Drug Use Among Chronic Opioid Therapy Patients

Clinical Medicine & Research, 2012

Background/Aims: Programs to translate the Diabetes Prevention Program (DPP) into effective real-... more Background/Aims: Programs to translate the Diabetes Prevention Program (DPP) into effective real-life interventions are needed. In the Call-2-Health pilot study we designed and tested a telephone-based intervention modeled on the DPP. Here we present the impact of Call-2-Health on participants' report of support from friends and family for diet changes. Social support may be critical to long-term maintenance of behavioral changes. Methods: Between September 2010 and January 2011, we mailed recruitment letters to 438 overweight English-speaking non-diabetic Group Health members aged 45-74 for whom electronic health records indicated at least one elevated blood glucose or HbA1c. We followed up with phone screening and laboratory tests to confirm eligibility and willingness to participate. Eligible and consenting participants (N=47; 49% men) were randomly assigned 1:1 to usual care (UC) and intervention groups (IG) for the 24-week study. The IG received 12 weekly intervention calls plus 4 maintenance calls over the subsequent 12 weeks. The interventionist delivered a DPP-based curriculum, using motivational interviewing and behavioral techniques to encourage exercise, dietary change, and weight loss. Three UC participants failed to complete the study; IG participants completed 95% of intervention calls. Study questionnaires included the Sallis Social Support scale for eating, completed at baseline and 24 weeks. Results: At baseline, the UC group had mean scores (95%CI) of 10.82 (7.93, 13.70) on the family and 8.55 (6.43, 10.66) on the friend diet encouragement scales. Mean scores for the IG were comparable, at 10.58 (8.09, 13.08) and 7.17 (6.03, 8.30). At 24 weeks, the measures remained essentially unchanged for UC and increased by 3.71 (1.56, 5.86) (p=0.016) and 3.46 (1.93, 4.99) (p=0.003) for the IG. At 24 weeks the mean weight lost for the IG was 8.6% of baseline weight (5.6, 11.5) as compared to 1.5% (-0.8, 3.9) for UC. Intervention participants' weight loss and their reported increase in dietary support were highly correlated (family r=0.70, friends r=0.64). Discussion: As compared to the usual care group, participants in the Call-2-Health phone intervention reported at 24 weeks a significant increase in supportive behaviors from friends and family regarding dietary change, with increases in support correlating strongly with weight loss success.

Research paper thumbnail of Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders

Alcoholism: Clinical and Experimental Research, 2013

Background: Treatment for alcohol disorders has traditionally been abstinence-oriented, but evalu... more Background: Treatment for alcohol disorders has traditionally been abstinence-oriented, but evaluating the merits of a low-risk drinking outcome as part of a primary treatment endpoint is a timely issue given new pertinent regulatory guidelines. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and problem severity outcomes among individuals with alcohol use disorders in a large private, not for profit, integrated care health plan.

Research paper thumbnail of Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy

Addiction Science & Clinical Practice, 2012

We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot stu... more We describe findings from a web survey of pediatric primary care providers (PCPs) and a pilot study of a screening, brief intervention, and referral to treatment (SBIRT) model of primary care-based adolescent behavioral health care. The survey (N = 437) examined PCP attitudes and knowledge, patient characteristics, and environmental influences, (e.g., mental health parity and medical marijuana laws). We examined how PCP, panel, and organizational characteristics influence screening practices. The pilot examined whether SBIRT versus usual care increased problem identification and specialty treatment rates and the feasibility of SBIRT in pediatric patients. Respondents were less concerned about alcohol than other drug use, rated alcohol use as more difficult to discuss (19% versus 15%) and diagnose (56% versus 70%) than depression, and were more comfortable discussing sexual practices than alcohol (32% versus 22%). They were more likely to screen boys than girls (male PCPs were even more likely: 23% versus 6% [p < 0.0001]). Self-reported screening rates were far higher than electronic medical record (EMR)-documented rates for all substances. Experience, specialty, and recent AOD training (all p < 0.05) predicted self-reported rates; only patient age predicted actual rates. Organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient characteristics in determining screening. Respondents reported that SBIRT was highly feasible and that it improved care; more (77) teens receiving SBIRT were referred for further assessment than those receiving usual care, and specialty treatment initiation increased from 8.73% to 12% (p < 0.0001). Organizational factors, lack of training, and discomfort with screening may impact adolescent screening and intervention.

Research paper thumbnail of Five-Year Healthcare Utilization and Costs Among Lower-Risk Drinkers Following Alcohol Treatment

Alcoholism: Clinical and Experimental Research, 2014

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients follo... more Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications. Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group. Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) and ED (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) and inpatient (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time. Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.