Aaron E. Carroll's Blog, page 12

How Neuroimaging Could Change Mental Health Care

Most mental health diagnoses are made without ever looking at the brain. Clinicians and researchers have debated for decades whether brain imaging is helpful and, while research on the technology is promising, there’s still much to be learned before it becomes a routine part of care.

The current approach to diagnosing mental illness is informed by the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychological Association. During an evaluation, a patient self-reports their symptoms, and the clinician uses the manual to find which disorder matches best.

Because the DSM was not developed with neuroscience (it was created before the invention of brain imaging tools available today), billions of dollars have gone towards research to identify biomarkers that can explain the biological causes of mental illnesses. That attempt produced little, but research on brain imaging technology carried on and a couple tools in particular have made notable headway.

The first is magnetic resonance imaging (MRI). MRIs can detect subtle abnormalities in structure and function in the brain between healthy subjects and patients with mental illness.

For example, MRI studies have found that those with bipolar disorder and major depressive disorder have thinner gray matter in various parts of the brain than healthy patients. Other studies have found atypical neural responses related to emotional processing and regulation in patients with mood disorders.

Beyond potential for diagnosis, brain imaging may also be able to validate clinical treatment. For example, MRI scans have even shown tangible differences in the brain after talk therapy.

One randomized study of 14 participants reported that 70% of patients with panic disorder showed visible healing in their brains after four therapy sessions, compared to 7% in the control group. Comparably, a randomized study of 59 patients found that those who received therapy for depression had increased amounts of gray matter in the cortex compared to those who did not receive therapy.

The second technology that has shown potential is single-photon emission computed tomography (SPECT). These nuclear tests capture three-dimensional images of blood flow activity in different regions of the brain. They can find abnormalities invisible on anatomical scans, such as ultrasounds.

While originally used to evaluate strokes and seizures, SPECT brain scans have recently been used in some psychiatric cases. For example, they are one of the most reliable tools to differentiate between diagnoses of post-traumatic stress disorder and traumatic brain injury, which have similar symptoms.

Brain imaging can also be a crucial tool to determine whether symptoms are a result of mental illness or other physical causes, like toxic exposure and head trauma.

For example, a review of 12 studies (over 1,600 participants) found that 6% of patients originally thought to be experiencing an episode of psychosis had a MRI scan abnormality that led to a change in their diagnosis or treatment. Some of the conditions found to explain their symptoms were encephalitis, brain tumors, and dementia.

A qualitative study found that SPECT scans help uncover brain trauma in complicated psychiatric cases as well. Since patients may fail to remember or report head trauma to their clinicians during a mental health assessment, SPECT can be used for diagnosis, prognosis, and treatment for patients with suspected traumatic brain injury.

All that said, there remain many unknowns.

For example, while there is evidence that brain imaging can reliably monitor brain function, there are no adequate large-scale studies to prove it helps diagnose psychiatric disorders. All studies to date have had small patient groups, and biomarker research requires large sample sizes to be more certain that what smaller studies have suggested aren’t erroneous.

There’s also more work to be done to clarify the extent to which findings generalize. For example, researchers at Yale University replicated a study monitoring brain activity of trauma-exposed, emergency department patients with a new population: Israeli trauma survivors. While they could match clusters of brain activity observed in the first study, they couldn’t find an association with post-traumatic stress disorder symptoms like the other had.

There also are limitations of current imaging technology. For example, it can’t be used by itself to differentiate disorders when they present similarly. One study found that white matter alterations in various parts of the brain were almost identical in patients with attention deficit/hyperactivity disorder and autism spectrum disorder.

It seems unlikely that brain imaging will become a routine diagnostic tool in mental health care anytime soon – there is too much still to learn. But the research that does exist is promising. For now, imaging is at least a helpful tool for clinicians to rule in or out causes other than mental health conditions.

Research for this piece was supported by Arnold Ventures.

The post How Neuroimaging Could Change Mental Health Care first appeared on The Incidental Economist.

Do Food Dyes Make Kids Wild Out?

Avoiding certain food dyes to help improve a child’s behavioral issues is common advice, and not just on TikTok! Several doctors stand behind this recommendation as well. But several doctors also prescribe vitamin D, and that’s usually pretty useless according to the data. So where do the data stand on food dyes?

 



The post Do Food Dyes Make Kids Wild Out? first appeared on The Incidental Economist.

Payers of Long-Term Services and Supports for Veterans

The United States’ population of older adults is growing and so, too, is the need for increased access to and investment in long-term services and supports (LTSS). One challenge for Veterans and their families in accessing LTSS is determining what coverage is available to pay for those services.

Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) both financially support LTSS for Veterans who need them, as do external programs such as Medicaid or long-term care insurance. The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief outlining the VBA, VHA and external programs available to Veterans and what their eligibility requirements are. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post Payers of Long-Term Services and Supports for Veterans first appeared on The Incidental Economist.

Navigating an Eating Disorder Crossover

TW: eating disorders

Anti-obesity medications are gaining popularity, but less discussed is the simultaneous rise in eating disorders. They’re more severe than ever, too, and many people seem to shift between disorders. This crossover could be because of how we diagnose and treat them.

Described broadly as disturbances in eating behaviors that can affect a person’s overall function, eating disorders affect over 28 million Americans, or 9% of the population. And lately, emergency department visits for young people struggling with one have .

Interestingly, some people seem to experience multiple types of eating disorders over their lifetimes. This crossover receives little attention, but the research that is available suggests that it may actually be relatively common.

A study from the late 1990s found that more than half of participants with Anorexia Nervosa developed Bulimia Nervosa at some point during 15 years of follow up. This was supported by later research, too. In the late 2010s, another study found that migration between eating disorder diagnoses occurred in over 60% of cases. Only a third of participants retained their original diagnosis at the end of follow up. Most recently in 2023, a review of 79 studies found that nearly a quarter of individuals with Bulimia crossed over to other diagnostic groups at follow up.

An eating disorder is difficult to manage by itself, but dealing with several over time may make it harder for patients to get the support they need.

First, the shame of switching to diagnoses can be a barrier to treatment. Some people with eating disorders attach their identity to their diagnosis. One study found that participants with Anorexia believe their diagnosis is the “golden tier” diagnosis because it correlates with having the most desirous physical appearance (by Eurocentric beauty standards). So, someone with Anorexia who gains weight and now experiences Binge Eating Disorder behaviors may be embarrassed to get help.

Clinicians may also be unaware that an individual is still struggling with an eating disorder at all. This is particularly true for patients with Anorexia who may appear to be recovering after gaining weight over a period of time. But the weight gain could actually be due to symptoms of another eating disorder.

So, how can we help clinicians detect a shift in eating disorder diagnosis and help patients feel comfortable disclosing these changes?

There needs to be greater awareness that diagnostic crossover even occurs. This is crucial to challenge the existing stigma people with eating disorders face and to destabilize the diagnostic hierarchy many patients perceive.

There’s also a need for more research. Questions remain about the causes of crossover, risk factors, and effective methods of support. (One study suggests comorbid affective disorders, like major depressive disorder, may be part of the answer.)

Lastly, there could be improvements made to the clinical manual used to diagnose eating disorders. For example, measures like body mass index and frequency of symptomatic episodes currently used to analyze the severity of disorders do not offer reliable information on the course of illness or outcomes. Also, diagnoses are usually made over three-month periods so minor fluctuations in weight and eating behaviors can lead to a completely different diagnosis. To avoid recurrent crossovers, some suggest viewing eating disorders as a single entity within which an individual may experience different symptoms at different points in time.

There’s still a lot to be learned about diagnostic crossover in eating disorders, but what we do know is patients experience it more than we think. With more awareness, research, and revisions to existing diagnostic assessments, hope remains that patients will receive better treatment in the future.

The post Navigating an Eating Disorder Crossover first appeared on The Incidental Economist.

How Do Geographic Variations affect Wait Times and Veteran Access?

A patient’s access to quality health care is a critical social determinant of health, impacting overall health outcomes and mortality rates. Barriers to access may include geographic limitations, the availability of various services, and the timeliness of care provision.

Veterans Health Administration (VHA) operates over 170 medical facilities and clinics in the United States, serving millions of Veterans. As one of the largest health systems in the country with significant patient demand, waiting to access care has been a crucial policy issue.

In response to documented access challenges, Congress enacted the Choice Act in 2014 and the MISSION Act in 2018. VHA then created wait time access standards for each specialty (e.g., 20 days for primary care and mental health care and 28 days for specialty care), meaning no Veteran should wait longer than the standard for an appointment in that specialty in VHA. These laws and policies may reduce wait times by enabling Veterans to receive care with private sector providers (i.e., community care) if VHA cannot meet the access standard.

Despite these initiatives, timely access to VHA care remains an inherent challenge for many Veterans, and monitoring wait times is important to understand the Veteran experience.

New Research

In October 2022, researchers at the Partnered Evidence-based Policy Resource Center (PEPReC) published a new paper titled “Geographic Variation in Appointment Wait Times for U.S. Military Veterans.” PEPReC researchers conducted the first national comparison of appointment wait times across both VHA and community care settings and all specialties.

Methods

This cross-sectional study included over 22 million appointments for about five million Veterans from January 2018 to June 2021. Appointments were categorized into primary care, mental health care, and all other specialties. The VHA enrollees in the sample were: 65.0% White, 77.3% male, 80.7% non-Hispanic, 49.3% married, and an average of 61.6 years old. VHA medical centers were organized by geographical regions called VISNs.

Data analysis comprised of four steps, including estimating mean and median wait times, estimating multivariate linear regression models to account for regional variations in the specialty mix (direct standardization), comparing and ranking VISNs across specialties, and lastly comparing appointment wait times between VHA and community care clinicians using 2-sided t tests.

Findings

PEPReC researchers found that community care appointments had longer mean wait times than VHA appointments for primary care, mental health care, and all other specialties (see table below). This was also true at a regional level in almost every VISN. Geographic variations in wait times were substantial, showing both a smaller range of and shorter wait times for all care categories (e.g., 22.4-43.4 days vs. 25.4-52.4 days in primary care) for VHA care compared to community care at the VISN level. Across all categories, less than 50% of community care appointments met their respective in-house VHA access standards.

Table 1: Average Appointment Wait Times (in days) for Each Care Category

Mean Appointment Wait Times (SD) in days

Community Care (non-VHA)VHAPrimary Care38.9 (8.2)29.0 (5.5)Mental Health Care43.9 (9.0)33.6 (4.6)Other Specialties41.9 (5.9)35.4 (2.7)

Conclusion:

The study had some noteworthy limitations. First, it exclusively focused on VHA data and the experiences of enrolled Veterans, so the findings may not be generalizable to a non-Veteran or an unenrolled Veteran population. Since the data lacked clinician identifiers for community care providers, it may not be representative of community care clinicians more broadly. Additionally, the results did not indicate the sources of geographic variation in wait times or whether those wait times were clinically appropriate.

Despite significant geographic variations in wait times, no distinct VISN meets the wait time access standards for any care category. Furthermore, community care appointments were found to be less likely to meet VHA’s in-house wait time access standards compared to VHA appointments. This implies that policies aimed to increasing Veteran access to community care clinicians may not necessarily result in shorter wait times in those regions. Moreover, it suggests that policies intended to improve Veterans’ access to community care may be insufficient in reducing wait times in many regions. However, certain strategies, such as increased telehealth usage, physician relocation incentives, or mobile deployment units, still hold the potential to improve in-house access for Veterans in underserved areas.

In summary, this study provides valuable insight into wait times across specialties and care settings for Veterans in the United States as access to care remains a pressing policy priority.

The post How Do Geographic Variations affect Wait Times and Veteran Access? first appeared on The Incidental Economist.

Deadline Extended for HSR Special Issue Call for Abstracts — Medicare and Medicaid at 60

This is cross-posted from the HSR website.

Submission deadline for abstracts has been extended to: Wednesday, January 31, 2024

Health Services Research (HSR) and the American Institutes for Research® (AIR) are partnering to publish a special issue on Medicare and Medicaid at 60. The issue will be edited by HSR Senior Associate Editor Marisa Elena Domino, PhD, Executive Director, Center for Health Information and Research, and professor, College of Health Solutions, Arizona State University, and Kelly Devers, PhD, Mai Hubbard, PhD, and Guido Cataife, PhD.

The purpose of this special issue is to provide rigorous and timely evidence for policymakers and other stakeholders about pressing issues related to the financing, organization, and delivery of U.S. health care through Medicare and Medicaid programs, using a prism of access, quality, equity, and costs.

The 60th anniversary of Medicare and Medicaid will occur in 2025. Through demonstration programs and other research, a lot has been learned about Medicare and Medicaid, but there is still a lot we still don’t know about access, quality, equity, and cost. Some key challenges in the U.S. health care system in these two major public insurance programs include:

Addressing high and rising health care spending and suboptimal quality outcomes, in a system where almost 1 in 10 people still lack health insurance.Improving overall population health, with a focus on the growing population of people with multiple chronic conditions and the role of health-related social needs in their care.Reducing health disparities and advancing equity across social, economic, demographic, and geographic dimensions.Complexities of multipayer alignment and lessons learned for Medicare and Medicaid through demonstrations and related efforts to optimize value-based payment approaches.

Within this context, this HSR special issue seeks to advance evidence and understanding related to the following broad topics:

Medicare as Change Agent: Past and Future—As the nation’s single largest health care payer, Medicare has significant purchasing power to drive systemwide change, especially related to payment reform and quality and patient safety initiatives. Examples of research questions in this topic area include:

What are the key lessons learned from Medicare’s push for accountable care through alternative payment models—what does and doesn’t work?What can other payers learn from these efforts? How has provider participation been incentivized in alternative payment models?Have Medicare quality and safety improvement efforts moved the needle on quality and safety?What do we know about the potential for Medicare to better address health-related social needs like housing, food, and transportation?What role has Medicare played in advancing more meaningful quality measurement, including patient-reported outcome measures (PROMs) and person-centered measurement?What have we learned from Medicare person/family engagement efforts and are there lessons for other payers?How has Medicare Advantage (MA) growth affected Traditional Medicare and the broader health care system?Are there adequate safeguards to ensure MA provider network adequacy for beneficiaries?How effective are Medicare policies in supporting an adequate health workforce?What is the evidence base that could inform Medicare Prescription Drug Price Negotiations?

Medicaid as Learning Laboratory—Across states, Medicaid programs differ significantly in eligibility, benefits, provider payments, and other dimensions. For example, the end of the public health emergency’s continuous enrollment requirement is playing out differently across states. Additionally, Medicaid pays for about half of all births in the country and is the nation’s largest payer of long-term care, including home- and community-based services to keep people out of nursing homes. Example research questions include:

What are the implications for access, quality, equity, and costs given Medicaid’s differing state policies?How well do alternative payment models work in state Medicaid programs?How effective are Medicaid efforts to decrease maternal and infant mortality and complications?Are there important innovations in state Medicaid programs to reduce costs, improve quality, and increase access?What efforts are working to improve care and reduce costs for beneficiaries dually eligible for Medicare and Medicaid?What are state Medicaid programs doing related to health-related social needs like housing, food, and transportation?What are states doing to engage patients, families, and communities to improve health and wellbeing?What’s the status of state Medicaid efforts to integrate physical and behavioral health care?How have Medicaid mandatory core quality measures impacted provider performance?

The deadline for initial submission of abstracts is extended to Wednesday, January 31, 2024. Abstracts may not exceed 300 words and must be formatted as indicated in Section 2.4.2.2 of the HSR Author Instructions (keywords not necessary). Studies can be based on quantitative, qualitative, or mixed methods data or can be literature reviews and syntheses.

Abstracts will be evaluated by a multidisciplinary review panel. Evaluation criteria include: (1) quality, rigor, and originality; (2) relevance to the special issue theme; and (3) clarity of writing and presentation. Authors of abstracts that most closely match the criteria will be invited to submit full manuscripts.

Invited manuscripts must follow the Author Instructions and undergo the same HSR peer review process as regular issue manuscripts. However, due to the strict timeline for publishing the special issue, the process may be shorter. Authors must be prompt in returning revisions. Invited articles will be published online on acceptance. Some accepted articles might not be selected for the special issue but will be published in a regular issue.

The expected publication date for the special issue is March 2025.

To submit an abstract for consideration, please email it with the corresponding author’s contact information to hsr@aha.org. Include “Medicare and Medicaid at 60” in the email subject line.

Key dates for authors
Submission deadline for abstracts: 31 January 2024
Full manuscript invitation: 5 February 2024
Full manuscript deadline: 1 April 2024
Special issue publication date: March 2025 but accepted articles will be posted earlier, after approval of proofs by authors

Questions? Please email Kelly Teagle at hsr@aha.org

The post Deadline Extended for HSR Special Issue Call for Abstracts — Medicare and Medicaid at 60 first appeared on The Incidental Economist.

We Need Caregivers’ Voices When Designing Effective Smart Home Technology

As more older Americans remain in their homes as they age, there is a growing need for long-term support and services. Smart home technology is becoming more popular to aid in this effort, but often forgotten in discussion about its uses and impacts is the caregiver.

Caregivers play a crucial role in supporting older adults who wish to age at home. According to the Centers for Disease Control and Prevention, about one-third of caregivers provide over 20 hours of care per week and around 10% are caring for someone with cognitive impairment. These are mostly informal caregivers, meaning they are family, friends, or neighbors performing their duties for free. Most caregivers are women and about 40% of them have at least two chronic conditions themselves.

Caregiving is a heavy burden as these individuals also raise families, hold jobs, and participate in their communities. This strain often results in poor health outcomes. Nearly 40% of caregivers report insufficient sleep and about 15% experience 14 or more mentally unhealthy days each month.

As such, tools that could ease some of this burden and create better health outcomes for both the care recipient and the caregiver are of high priority. This is where smart home technology comes in but, at present, design falls short. We should consider what caregivers need to succeed.

What do Caregivers Require of Smart Home Technology?

Fortunately, we do know what caregivers want from smart home technology.

Technology that is easy to use has a lot of appeal. Surveyed caregivers endorse having very little time to learn and manage complicated technology in addition to their other caregiving duties. They want products that are intuitive and have built in customer support. Community resources to help with implementation and management are also desirable.

While ease of use is attractive, safety is caregivers’ main priority when choosing which products to implement in their loved one’s home. Available research shows that caregivers want technology that prevents injury and illness. Even better is if the technology also improves or addresses medication compliance, hygiene, or sleep quality. It might sound like a no-brainer, but caregivers juggle myriad concerns when supporting an aging loved one and not having to worry as much about safety is a relief.

An example of technology focused on safety is a wandering detection system for adults with Alzheimer’s disease. The system is active during sleeping hours and alerts the caregiver if the individual with Alzheimer’s wanders about or exits the house. As a result of employing the detection system, caregivers reported better quality sleep for themselves and improvements in depression and anxiety.

When smart home technology is easy to use and enhances safety, a new dimension of the caregiving dynamic emerges: independence. Overwhelmingly, studies show that caregivers want to use technology that supports independence for their aging loved one. This, as a result, returns some independence back to the caregivers. They then have more time and energy to make their own health care appointments, rest, or participate in social engagements they otherwise might miss.

When it comes to balancing the need for interpersonal connection though, caregivers and aging adults have seemingly conflicting desires.

For caregivers, connection is achieved by employing technology that augments their hands-on, in-person care, but doesn’t replace it. In part, this is because caregivers understand and value the social connection and humanity involved in in-person care for both them and their loved one. Many caregivers also feel a familial duty to provide care that can’t be replaced by a robot.

For care recipients though, they want technology to help them with daily tasks in ways that alleviate some of their caregivers’ burden. In using devices that help both caregivers and care recipients complete tasks more easily, older adults feel like their relationship with their caregiver is stronger and less impacted by the natural strain that comes with the physical, emotional, and psychological stress of care.

In short, both caregivers and aging adults seek profound connection, channeled through different priorities. Caregivers don’t want to feel replaced, and care recipients want connection to be strengthened by technology that makes life easier for both them and their caregivers.

Caregivers want uncomplicated technology to help them deliver care to their aging loved ones, supporting their safety, independence, and social connection. Older adults want technology that meets those same demands, as well as supports their autonomy, dignity, and privacy. Technology that can honor both stakeholders will be the ultimate success story for aging in place.

The post We Need Caregivers’ Voices When Designing Effective Smart Home Technology first appeared on The Incidental Economist.

Artificial Sweeteners and Cancer

When we released a recent episode about the artificial sweetener erythritol, many of you brought up questions about recent news on other artificial sweeteners – sucralose and aspartame – so we went to take a look, and that’s the topic of this week’s Healthcare Triage.

 



The post Artificial Sweeteners and Cancer first appeared on The Incidental Economist.

Telehealth Use and Availability in VHA Outpatient Mental Health Care

In response to the COVID-19 pandemic, health systems and providers nationwide accelerated their adoption of telehealth as a substitute for care that had previously occurred in-person. Already an early adopter of virtual care, the Veterans Health Administration (VHA) was well-positioned to rapidly expand telehealth services, especially for outpatient mental health care. While both the availability and the use of telehealth have substantially increased and been sustained over pre-pandemic levels, many Veterans continue to prefer seeing a provider in-person. This suggests that telehealth complements but should not replace in-person care.

The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief examining telehealth utilization within VHA, including visit volume by care modality, telehealth provision by provider, and usage among Veterans. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post Telehealth Use and Availability in VHA Outpatient Mental Health Care first appeared on The Incidental Economist.

4 Ways Clinicians Can Address the Non-Physical Side Effects of Serious Illness

Illness and treatment can have significant physical side effects, like nausea and infertility. But there are also serious non-physical side effects: Patients lose time, money, and independence. I was invited to write about this by the Center to Advance Palliative Care, touching on what clinicians can do to help patients.

In other words, serious illness has serious side effects, both physical and non-physical. While these concepts or discussions may be novel, the impact of serious illness on a patient’s life is not. While acknowledging these non-physical side effects of treatment is the first step, the next is doing something about them. All the side effects listed above are why palliative care is so important. Palliative care focuses on quality of life and relieving both symptoms and stress related to serious illness. These kinds of discussions are the perfect entry point for clinicians to talk about non-physical side effects.

Read the full article here.

Research for this piece was supported by Arnold Ventures.

The post 4 Ways Clinicians Can Address the Non-Physical Side Effects of Serious Illness first appeared on The Incidental Economist.