S. Crystal - Academia.edu (original) (raw)

Papers by S. Crystal

Annals of Internal Medicine, 2006

The Public interest, 1987

IN 1979, the House Select Committee on Aging held hearings on abuse of the elderly by their famil... more IN 1979, the House Select Committee on Aging held hearings on abuse of the elderly by their families, which it titled, "The Hidden Problem." Several of the witnesses observed that while child abuse was "discovered" in the 1960s and spouse abuse in the 1970s, elder abuse would be discovered in the 1980s. They turned out to be largely correct. During the early 1980s, while few reliable data on the subject were generated, political and

Drug and Alcohol Dependence, 2015

s / Drug and Alcohol Dependence 146 (2015) e118–e201 e119 VASH may enable needed service use for ... more s / Drug and Alcohol Dependence 146 (2015) e118–e201 e119 VASH may enable needed service use for homeless Veterans, through links to housing and primary care. Financial support: VAGLA CSHIIP. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.241 Receipt of opioid therapy guidelineconcordant care among HIV+ and HIV− veterans J.R. Gaither1, E. Edelman1, W. Becker1,2, S. Crystal4, K. Gordon2, J. Goulet1,2, R. Kerns1,2, M. Skanderson3, D. Weisberg1, K. Bryant5, A. Justice1,2, D. Fiellin1 1 Yale University, New Haven, CT, United States 2 VA CT HCS, New Haven, CT, United States 3 VA Pittsburgh HCS, New Haven, CT, United States 4 Rutgers University, New Brunswick, NJ, United States 5 NIH/NIAAA, Bethesda, MD, United States Aims: To determine whether HIV+ and HIV− patients initiating opioid therapy (OT) are equally likely to receive care concordant with American Pain Society/American Academy of Pain Medicine opioid clinical practice guidelines. Methods: We performed a nested prospective cohort study on 17,961 patients from the Veterans Aging Cohort Study who initiated long-termOT (≥90-days) between 1999 and 2009. Unadjusted and adjusted models were used to evaluate associations between HIV status and outcomes on 12 indicators derived from national OT guidelines. We calculated summary scores (i.e., number of recommended indicators received per patient/number for which they were eligible×100) and examined trends in the receipt of individual indicators over time. Results: Receipt of guideline-concordant care was low for both patient groups. HIV+ patients (n=5,677) were more likely than HIV− patients (n=12,284) to receive a primary care provider (PCP) visit within 1 month (51% vs. 31%; p< .001); PCP follow-up within 6 months (89% vs. 73%; p< .001); urine drug tests (UDTs) within 1 month (8% vs. 6%; p< .001) and 6 months (18% vs. 14%; p< .001); a bowel regimen (31% vs. 25%; p< .001); and concurrent non-opioid pain medications (50% vs. 46%; p< .001). However, HIV+ patients were less likely to receive physical rehabilitation (24% vs. 31%; p< .001) or counseling (30% vs. 33%; p< .01) and more likely to receive sedative co-prescriptions (22% vs. 18%; p< .001). Overall, patients received no more than 35% of recommended care. Over time, we observed an increase in UDTs (10–19%; p for trend <.001) and a decrease in sedative co-prescriptions (22–17%; p for trend <.001). Conclusions: Strategies to increase the provision of OT guideline-concordant care are needed as the majority of HIV+ and HIV− patients receiving incident long-term OT did not receive recommended care and there were few clinically meaningful quality improvements over time. Financial support: F31DA035567, U24AA020794. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.242 Prevalence of illicit drug use among patients of community health centers in East Los Angeles and Tijuana Marianna Garcia1, Melvin Rico1, John Scholtz1, Mani Vahidi1, Guillermina Natera3, Ronald Andersen2, Ietza Bojorquez4, Julia Yacenda1, Miriam Arroyo3, Mario Gonzalez5, Lillian Gelberg1,2 1 Family Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States 2 UCLA School of Public Health, Los Angeles, CA, United States 3 National Institute of Psychiatry Ramon de la Fuente Muniz, Mexico City, Mexico 4 El Colegio de la Frontera Norte Department of Population Studies, Tijuana, Mexico 5 National Commission Against Addictions, Mexico

Research on Aging - RES AGING, 1998

The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 1995

Cross-sectional data from the Survey of Income and Program Participation were used to estimate th... more Cross-sectional data from the Survey of Income and Program Participation were used to estimate the impact of coresidence on the economic well-being of elderly widows and of coresident family members. Coresidence improves well-being for both the widow and the other participants in 51 percent of cases; improves it for the widow and diminishes it for the others in 28 percent of cases; and improves it for the others while diminishing it for the widow in 21 percent of cases. Among non-Whites, coresidence benefits the widow less, and other members more, than among Whites. A regression model of the economic benefit to elderly widows from coresidence was used to explain why non-White widows receive less benefit from coresidence than Whites. Much of the racial difference can be explained by differences in household composition and the lower earnings of adult males in the households of non-White elders. While coresidence is often thought of as a response to an elderly widow&amp;#39;s needs, her presence typically contributes to rather than diminishes the economic well-being of the household, and this is especially true among non-Whites.

The Journal of Clinical Psychiatry, 2014

This study estimates national trends and patterns in use of second-generation antipsychotics (SGA... more This study estimates national trends and patterns in use of second-generation antipsychotics (SGAs) for adjunctive treatment of nonpsychotic adult depression in office-based practice. Twelve consecutive years (1999-2010) of the National Ambulatory Medical Care Survey were analyzed to estimate trends and patterns of adjunctive SGA treatment for adult (≥ 18 years) nonpsychotic depression in office-based visits. Adjunctive SGA use was examined among all office visits in which depression was diagnosed (N = 7,767), excluding visits with diagnoses for alternative SGA indications (schizophrenia, bipolar disorder, pervasive development disorder, psychotic depression, dementia) and those without an active antidepressant prescription. From 1999 to 2010, 8.6% of adult depression visits included an SGA. SGA use rates increased from 4.6% in 1999-2000 to 12.5% in 2009-2010, with an adjusted odds ratio (AOR) for time trend of 2.78 (95% CI, 1.84-4.20). The increase in SGA augmentation was broad-based, with no significant differences in time trends between demographic and clinical subgroups. For the most recent survey years (2005-2010), SGA use rates were higher in visits to psychiatrists than to other physicians (AOR = 5.08; 95% CI, 2.96-8.73), visits covered by public than private insurance (AOR = 3.20; 95% CI, 2.25-4.54), visits with diagnosed major depressive disorder than other depressive disorders (AOR = 1.49; 95% CI, 1.08-2.06), and visits with diabetes, hyperlipidemia, or cardiovascular disease (AOR = 2.13; 95% CI, 1.12-4.03) and lower in visits by patients &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;amp;amp;amp;amp;amp;amp;amp;gt; 65 years than 18-44 years (AOR = 0.51; 95% CI, 0.32-0.82) and visits that included psychotherapy (AOR = 0.68; 95% CI, 0.47-0.96). Between 1999 and 2010, SGAs were increasingly accepted in the outpatient treatment of adult nonpsychotic depression.

Journal of Child and Adolescent Psychopharmacology, 2011

Background: Psychiatric treatment for children and adolescents with clinically significant aggres... more Background: Psychiatric treatment for children and adolescents with clinically significant aggression is common and often involves the use of antipsychotic medications. Increasingly, pediatricians are initiating or managing such treatments despite limited evidence on optimal diagnostic, psychosocial, and medication approaches for pediatric aggression. Aims: The objective of this study was to gather clinicians' and researchers' expertise concerning the treatment of maladaptive aggression, using expert consensus survey methods to aid the development of guidelines for pediatricians on the treatment of maladaptive aggression in youth (T-MAY). Methods: Forty-six experts (psychiatrists, pediatricians, and researchers) with >10 years of clinical and/or research experience in the treatment of pediatric aggression completed a 27-item survey (>400 treatment alternatives) about optimal diagnostic, psychosocial, and medication treatments. Data were analyzed using descriptive statistics and confidence intervals. Results: Expert consensus methodology clearly differentiated optimal versus nonoptimal treatment strategies for maladaptive aggression. In contrast to current practice trends, results indicated that experts support the use of psychosocial interventions and parent education and training before the use of medication for maladaptive aggression at every stage of medication treatment, from diagnosis to maintenance to medication discontinuation. Conclusion: Overall findings indicate that evidence-informed strategies for outpatient treatment of pediatric maladaptive aggression, guided by systematically derived expert opinions, are attainable. In light of the gap between the research literature and clinical practice, expert consensus opinion supports specific practices for optimal outpatient management in children and adolescents with severe and persistent behavioral difficulties.

Journal of Applied Social Psychology, 2000

Journal of Aging and Health, 2012

Objectives: We investigate, among older adult nursing home residents diagnosed with depression, w... more Objectives: We investigate, among older adult nursing home residents diagnosed with depression, whether depression treatment differs by race and schooling, and whether differences by schooling differ by race. We examine whether Blacks and less educated residents are placed in facilities providing less treatment, and whether differences reflect disparities in care. Method: Data from the 2006 Nursing Home Minimum Data Set for 8 states (n = 124,431), are merged with facility information from the Online Survey Certification and Reporting system. Logistic regressions examine whether resident and/or facility characteristics explain treatment differences; treatment includes antidepressants and/or psychotherapy. Results: Blacks receive less treatment (adj. OR = .79); differences by education are small. Facilities with more Medicaid enrollees, fewer high school graduates, or more Blacks provide less treatment. Discussion: We found disparities at the resident and facility level. Facilities serving a low-SES (socioeconomic status), minority clientele tend to provide less depression care, but Blacks also receive less depression treatment than Whites within nursing homes (NHs).

Health Services Research, 2002

OBJECTIVE: To compare medical expenditures for the elderly (≥65 years old) over the last year of ... more OBJECTIVE: To compare medical expenditures for the elderly (≥65 years old) over the last year of life with those for non-terminal years. DATA SOURCE: 1992-96 Medicare Current Beneficiary Survey (MCBS) data from about 10,000 elderly persons each year. STUDY DESIGN: Medical expenditures for the last year of life and non-terminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. DATA COLLECTION: The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. PRINCIPAL FINDINGS: From 1992-96, mean annual medical expenditures (1996 dollars) for persons 65 and older were 37,581duringthelastyearoflifeversus37,581 during the last year of life versus 37,581duringthelastyearoflifeversus7,365 for non-terminal years. Mean total last year of life expenditures did not differ greatly by age at death. However, non-Medicare last year of life expenditures were higher and Medicare last year of life expenditures were lower for those dying at older ages. Last year of life expenses constituted 22% of all medical, 26% of Medicare, 18% of all non-Medicare expenditures and 25% of Medicaid expenditures. CONCLUSIONS: While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end of life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care.

Health Economics, 2012

This paper studies the impact of regulatory stringency, as measured by the statewide deficiency c... more This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that reliance on antipsychotics by nursing homes is responsive to state regulatory enforcement. Nursing homes reduce their use of antipsychotics in response to the number and type of deficiencies received by facilities in the state.

Health Affairs, 2009

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications... more Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.

The Gerontologist, 2003

Purpose: The burden of prescription drug costs on Medicare beneficiaries has become a critical po... more Purpose: The burden of prescription drug costs on Medicare beneficiaries has become a critical policy issue in improving the Medicare program, yet few studies have provided detailed and current information on that burden. The present study estimates total and out-of-pocket expenditures for prescription drugs and the burden of these costs in relation to income among the elderly population. We also compare spending and burden across major subgroups of the elderly population, as defined by socioeconomic and health characteristics, and we distinguish the impact of these factors by using multivariate models. Design and Methods: The study uses nationally representative data on Medicare beneficiaries from the 1997 Medicare Current Beneficiary Survey Cost and Use files. The study estimates out-ofpocket prescription drug spending and burden through ordinary least square, median, and logistic regression models with corrections for the complex survey design. Results: Our results show that in 1997, nearly 8% of the older population, more than 2.3 million people, spent greater than 10% of their income on prescription drugs. Despite pharmacy coverage, out-of-pocket cost burden fell most heavily on women and those with chronic health conditions. Burden was also higher among those with self-purchased supplemental coverage. Implications: The impact of Medicare reform proposals on these subgroups has to be carefully evaluated.

The Gerontologist, 1992

A survey of 485 single-room occupancy housing (SRO) residents in New York City found elderly resi... more A survey of 485 single-room occupancy housing (SRO) residents in New York City found elderly residents strongly preferred to remain in centrally located neighborhoods where apartment housing was beyond their means; did not wish to share a housing unit; and had little confidence that they could find acceptable housing if they lost their present unit. For many elderly residents, SROs meet needs not easily met by available alternatives. Results suggest the need to maintain this housing option for older persons and replace losses that have accompanied gentrification in many central city areas.

The Gerontologist, 1986

... the Elderly Stephen Crystal, PhD 1 Economic disadvantage is widely perceived to be typical of... more ... the Elderly Stephen Crystal, PhD 1 Economic disadvantage is widely perceived to be typical of the elderly. ... Another way to estimate the relative income of the elderly and the nonelderly is to examine household income on a per-person basis. ...

Family & Community Health, 1989

ABSTRACT

Evidence-Based Mental Health, 2005

Clinical Infectious Diseases, 2012

CHEST Journal, 2006

Limited data prior to highly active antiretroviral therapy (HAART) suggested the possibility of a... more Limited data prior to highly active antiretroviral therapy (HAART) suggested the possibility of an increased risk of COPD among those persons with HIV infection. We sought to determine whether HIV infection is associated with increased prevalence of COPD in the era of HAART. Prospective observational study of 1,014 HIV-positive and 713 HIV-negative men who were enrolled in the Veterans Aging Cohort 5 Site Study. COPD was determined by patient self-report and International Classification of Diseases, ninth revision (ICD-9), diagnostic codes. Cigarette smoking and injection drug use (IDU) were determined by self-report, and alcohol abuse was determined by ICD-9 diagnostic codes. Laboratory and pharmacy data were obtained from electronic medical records. The prevalence of COPD as determined by ICD-9 codes was 10% in HIV-positive subjects and 9% in HIV-negative subjects (p = 0.4), and as determined by patient self-report was 15% and 12%, respectively (p = 0.04). After adjusting for age, race/ethnicity, pack-years of smoking, IDU, and alcohol abuse, HIV infection was an independent risk factor for COPD. HIV-infected subjects were approximately 50 to 60% more likely to have COPD than HIV-negative subjects (by ICD-9 codes: odds ratio [OR], 1.47; 95% confidence interval [CI], 1.01 to 2.13; p = 0.04 ; by patient self-report: OR, 1.58; 95% CI, 1.14 to 2.18; p = 0.005). HIV infection was an independent risk factor for COPD, when determined either by ICD-9 codes or patient self-report. Health-care providers should be aware of the increased likelihood of COPD among their HIV-positive patients. The possibility that HIV infection increases susceptibility to and/or accelerates COPD deserves further investigation and has implications regarding the pathogenesis of COPD.