Faculty Bibliography

Importance/UNASSIGNED:There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment. Objective/UNASSIGNED:To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment. Design Setting and Participants/UNASSIGNED:This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned. Exposures/UNASSIGNED:Plan assignment. Main Outcomes and Measures/UNASSIGNED:Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment. Results/UNASSIGNED:Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans. Conclusions and Relevance/UNASSIGNED:The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.

BACKGROUND:The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered a level of care (LOC) concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC. METHODS:The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC. RESULTS:Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30). CONCLUSION/CONCLUSIONS:This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.

OBJECTIVE/UNASSIGNED:Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns. METHODS/UNASSIGNED:An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded. RESULTS/UNASSIGNED:Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation. CONCLUSIONS/UNASSIGNED:An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

OBJECTIVE:The nature of associations between recent cannabis use and negative symptoms, positive symptoms, and neurocognitive deficits remains unclear. In a relatively large sample of well-characterized patients with first-episode psychosis, we hypothesized that, compared to first-episode patients without cannabis use in the three months prior to first hospitalization, those having used cannabis would have lesser negative symptoms, greater positive symptoms, and no differences in cognitive functioning. Dose-response relationships were also examined. METHODS:Between 2008 and 2013, 247 first-episode psychosis patients were assessed during their hospitalization at one of six participating inpatient psychiatric units. Measures included the Longitudinal Substance Use Recall for 12 Weeks instrument, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, and the MATRICS Consensus Cognitive Battery (MCCB). RESULTS:Anhedonia-asociality was significantly lower among those using cannabis in the past three months (10.7±4.6 v. 12.1±4.4, p=.023). Delusions were more severe among those having used cannabis (19.3±8.4 v. 15.9±9.1, p=.005), as was bizarre behavior (p=.01). There were no significant differences between those using and not using cannabis across nine MCCB measures. Correlations between the "dose" of cannabis and all of these measures were not significant. CONCLUSIONS:Compared to those without cannabis use, those who use cannabis in recent months have lesser anhedonia-asociality, greater delusion and bizarre behavior severity, and no significant differences in neurocognition. Such characterizations could shed light on subgroups of individuals with first-episode psychosis, as well as risk factors for cannabis use in the early course of these disorders.

BACKGROUND:The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder. METHODS:A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data. DISCUSSION/CONCLUSIONS:This study will provide the field with a strong test of a multicomponent intervention to improve providers' capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system. TRIAL REGISTRATION/BACKGROUND:Trial # NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020.

To understand mental health clinics' chronic disease screening and prevention activities, we surveyed mental health clinics in New York State regarding 16 preventive services. Both numerical and qualitative data were collected. Responding clinics (123, 24.7%) were most likely to report having up-to-date screening/management of tobacco use (114, 92.7%) and were most likely to refer out for infectious disease and cancer screening (57.7%-62.6%). Compared to private/non-profit clinics, county- and state-operated clinics were more likely to refer out for infectious disease screening and to ensure up-to-date: lipid disorder screening, abnormal glucose screening, HIV screening, and cancer screenings. Clinics reported a need for: (1) hiring more (dedicated) medical staff; (2) providing staff trainings; (3) educating patients; and (4) integrating with patients' primary care providers. Implementing proven approaches-and developing new ones-for enhanced chronic disease prevention activities through improvements in policy, staffing, and reimbursement is warranted in mental health clinics.

OBJECTIVE:Recent years have witnessed growing interest in the role of the social environment in the development and outcomes of schizophrenia. We investigated whether neighborhood characteristics are associated with two important prognostic factors in early-course psychosis, age at onset of psychosis (AOP) and duration of untreated psychosis (DUP). METHODS:Data were collected from patients admitted to the hospital for first-episode schizophrenia-spectrum disorder. We collected data on perceived neighborhood disorder during childhood/adolescence and extracted data on 13 neighborhood characteristics from the American Community Survey based upon individual addresses. Four neighborhood-level factors were derived from factor analysis. Multiple logistic regression analyses assessed the association between specific neighborhood characteristics and the two prognostic factors (earlier AOP and longer DUP) in early-course psychosis. RESULTS:143 participants had valid addresses geo-coded. Neighborhood-level residential instability was associated with an earlier AOP (OR = 1.760; p = 0.022) even after controlling for known risk factors (OR = 2.026; p = 0.020) and also after controlling for individual-level residential instability (OR = 1.917; p = 0.037). The general socioeconomic status neighborhood factor (OR = 1.119; p = 0.019) and perceived neighborhood disorder (OR = 1.075; p = 0.005) were associated with a longer DUP. But only perceived neighborhood disorder (OR = 1.146; p = 0.011) remained significant, and general socioeconomic status was close to significant (OR = 1.215; p = 0.062), after controlling for individual-level predictors and socioeconomic status. CONCLUSIONS:This study found evidence that neighborhood-level characteristics (in this case, residential instability) may be associated with earlier AOP, and perceptions of neighborhood disorder are associated with a longer treatment delay. Socioenvironmental factors should be more consistently considered going forward in research on early psychotic disorders.

OBJECTIVE/UNASSIGNED:Individuals with serious mental illness are overrepresented in correctional populations. However, little is known about the representation of persons with serious mental illness at earlier stages in the criminal justice process. This research sought to measure the prevalence of arrestees in New York State who were treated for a major mental illness in the year before their arrest and to assess whether these individuals had a disproportionate rate of incarceration. METHODS/UNASSIGNED:Approximately 600,000 individuals arrested in New York State between January 1, 2010, and December 31, 2013, were matched against public mental health records to identify defendants diagnosed as having a major mental illness in the 12 months before their arrest. RESULTS/UNASSIGNED:Between 4% and 6% of the arrestees were diagnosed as having a major mental illness during a mental health service visit in the 12 months prior to their arrest. A major mental illness diagnosis was associated with more than a 50% increase in the odds of a jail sentence for misdemeanor arrestees, after the analyses controlled for the other case characteristics. Conversely, it was unrelated to the likelihood of a prison sentence given a felony arrest, but it did moderate the effect of other case characteristics within the group of arrestees with felonies. CONCLUSIONS/UNASSIGNED:Differential adjudication of misdemeanor arrestees with a major mental illness diagnosis appears to contribute to their overrepresentation within the jail population. The role that poverty and pretrial incarceration may play in this relationship was not explored in this research and should be the subject of future investigation.

BACKGROUND:Epidemiologic reports available on synthetic cannabinoids (SCs) have focused on sociodemographics, indicating high prevalence of SC use predominantly among white, relatively affluent, males. However, there is emerging evidence suggesting high SC prevalence among socioeconomically disadvantaged, racial/ethnic minority males. OBJECTIVES/OBJECTIVE:The purpose of this study is to investigate the risk correlates of SC use among psychosocial vulnerable communities. METHOD/METHODS:The sample of 100 participants was recruited from two harm reduction-focused, community-based organizations in the South Bronx and East Harlem neighborhoods in New York City. Consented individuals 18 years and older underwent a 30- minute survey ascertaining sociodemographics, psychosocial characteristics, SC and polydrug use characteristics, and mental health history. RESULTS:The study population was majority male (61%), Latino (56%), commonly diagnosed with psychiatric illness (67%), and with a mean age of 45.4. Those reporting SC use (74%) were more likely to be male, homeless, and report polydrug use. After adjustment, being male (AOR = 5.64), homelessness (AOR = 4.88) along with cocaine (AOR = 5.63) and opiate use (AOR = 31.1) were independently associated with SC use. The most common reasons for using SC were affordability, inability to detect SC in drug tests, and perceived physical and emotional benefits. Conclusion/importance: This work is significant in expanding the populations thought to be impacted by and understanding social disparities related to SC use. Further investigation is needed to assess the relationship between concomitant use of SC and other drug, particularly opiates. This may suggest that the sequelae of one drug may enhance or alleviate the effects of the other.