Behavioral Health Issue Behavioral Health Issue Screening and Use of Health Screening and Use of Health

ServicesServices

Deena J. Chisolm, PhDDeena J. Chisolm, PhDColumbus Children’s Research Institute &Columbus Children’s Research Institute &

The Ohio State UniversityThe Ohio State University

The TARAA Research TeamThe TARAA Research Team

• Kelly J. Kelleher, MD, MPH – Principal InvestigatorKelly J. Kelleher, MD, MPH – Principal Investigator• William Gardner, PhD - Co-InvestigatorWilliam Gardner, PhD - Co-Investigator• Jack Stevens, PhD - Co-InvestigatorJack Stevens, PhD - Co-Investigator• Deena J. Chisolm, PhD - Supplemental Co-InvestigatorDeena J. Chisolm, PhD - Supplemental Co-Investigator• Lindsay BuchananLindsay Buchanan• Teresa Julian, CNP, PhDTeresa Julian, CNP, PhD• Jennifer McGeehan, MPHJennifer McGeehan, MPH

• Funded by NIDA grant #R01MH078629-01 Funded by NIDA grant #R01MH078629-01

BackgroundBackground

• Routine screening for behavioral health issues in Routine screening for behavioral health issues in primary care is recommended by the AAP.primary care is recommended by the AAP.

• Standardized screening is not regularly done Standardized screening is not regularly done because of:because of:– Limited time in the clinical encounterLimited time in the clinical encounter– Limited resources and increased cost for referral and careLimited resources and increased cost for referral and care

• Computerized self-interviews can help with the first Computerized self-interviews can help with the first limitation and yield information superior to that in limitation and yield information superior to that in face-to-face interviews for sensitive topics.face-to-face interviews for sensitive topics.

Trial of Automated Risk Trial of Automated Risk Assessment in AdolescentsAssessment in Adolescents

• Goal: To improve recognition and treatment of Goal: To improve recognition and treatment of behavioral health problems in adolescents in behavioral health problems in adolescents in primary care through:primary care through:– Risk screening in the primary care waiting room Risk screening in the primary care waiting room

using wireless web-tabletsusing wireless web-tablets– Immediate provision of scored screening results to Immediate provision of scored screening results to

clinicians (3 day delay as a control condition) clinicians (3 day delay as a control condition) – Motivational Interview follow-up calls for substance Motivational Interview follow-up calls for substance

users (phase II)users (phase II)

• Setting nine urban primary care clinicsSetting nine urban primary care clinics

Preliminary ResultsPreliminary Results

• 95% were satisfied with their experience and 95% were satisfied with their experience and satisfaction did not vary by race, payor, satisfaction did not vary by race, payor, computer experience, or risk status.computer experience, or risk status.

• Clinicians in the immediate results group Clinicians in the immediate results group were more likely to recognize behavioral were more likely to recognize behavioral health issues than those who received health issues than those who received delayed results.delayed results.

Research QuestionResearch Question

• Do youth who screen positive for behavioral Do youth who screen positive for behavioral health issues in primary care use more health issues in primary care use more services in the following 6 months than those services in the following 6 months than those who screen negative?who screen negative?

MethodsMethodsIndependent VariablesIndependent Variables

• Mutually exclusive behavioral health issue categories:Mutually exclusive behavioral health issue categories:– NoneNone– depression – score of >=25 on the CES-DCdepression – score of >=25 on the CES-DC– suicidal thoughts – serious thought of ending life past 30 days suicidal thoughts – serious thought of ending life past 30 days

(PHQ-A) (PHQ-A) – violence risk – physical fighting or carrying a weapon (YRBS)violence risk – physical fighting or carrying a weapon (YRBS)– substance use – alcohol, marijuana, or inhalants (CASI-A)substance use – alcohol, marijuana, or inhalants (CASI-A)– multiple risksmultiple risks

• Potential Confounders: age, gender, service use in Potential Confounders: age, gender, service use in previous six months, payorprevious six months, payor

MethodsMethodsOutcome VariablesOutcome Variables

• Used data warehouse to gather all visits six Used data warehouse to gather all visits six months before and six months after screening.months before and six months after screening.

• Service Use VariablesService Use Variables– Any visitAny visit– Mental Health related visit – any visit with a Mental Health related visit – any visit with a

diagnosis code included in Clinical Classification diagnosis code included in Clinical Classification Software (CCS) Codes 66-74Software (CCS) Codes 66-74

MethodsMethodsAnalysisAnalysis

• Relationships between behavioral health Relationships between behavioral health issues and probability of use were tested issues and probability of use were tested using chi-squared and logistic regression.using chi-squared and logistic regression.

• Multivariate relationship between behavioral Multivariate relationship between behavioral health issues and number of visits were health issues and number of visits were tested using negative binomial regression.tested using negative binomial regression.

Sample CharacteristicsSample Characteristics

• 1,524 youth ages 11-201,524 youth ages 11-20

• 72% under age 1672% under age 16

• 57% female57% female

• 65% non-white65% non-white

• 76% covered by Medicaid76% covered by Medicaid

Positive ScreensPositive Screens

24%

7%3% 2%

22%

42%

0%

10%

20%

30%

40%

50%

Pro

po

rtio

n o

f Y

ou

th

Re

po

rtin

g

Violence(n=363)

Depression(n=107)

Substance(n=50)

SuicidalThts (n=31)

Multiple(n=341)

None(n=632)

Probability of Service Use Within 6 MonthsProbability of Service Use Within 6 MonthsBy Risk CategoryBy Risk Category

0%

10%

20%

30%

40%

50%

60%

70%

Perc

en

t o

f yo

uth

wit

h

vis

its

No Risk Suicidal Thts. Depression Substance Violence Multiple

Any Use MH Use

Adjusted Odds Ratios for Service Use Adjusted Odds Ratios for Service Use (reference=no risk)(reference=no risk)

Behavioral Health Behavioral Health IssueIssue

Any Use*Any Use* Mental Health*Mental Health*

Suicidal ThoughtsSuicidal Thoughts 2.93 (1.22-6.98)2.93 (1.22-6.98) 3.83 (1.38-10.58)3.83 (1.38-10.58)

DepressionDepression 1.06 (0.66-1.69)1.06 (0.66-1.69) 2.76 (1.43-5.35)2.76 (1.43-5.35)

SubstanceSubstance 1.02 (0.51-1.04)1.02 (0.51-1.04) 0.53 (0.07-4.02)0.53 (0.07-4.02)

ViolenceViolence 1.18 (0.88-1.59)1.18 (0.88-1.59) 1.61 (1.01-2.57)1.61 (1.01-2.57)

MultipleMultiple 1.01 (0.75-1.37)1.01 (0.75-1.37) 1.79 (1.12-2.87)1.79 (1.12-2.87)

*Odds ratios adjusted for gender, age group, prior use, and study arm

Six Month Visit rate per 100 YouthSix Month Visit rate per 100 YouthBehavioral Behavioral

Health IssueHealth IssueAny VisitAny Visit

RateRate

Mental Health VisitMental Health Visit

RateRateNoneNone 131.6131.6 21.521.5

Suicidal ThoughtsSuicidal Thoughts 138.7138.7 38.738.7

DepressionDepression 205.6*205.6* 39.2*39.2*

SubstanceSubstance 142.0142.0 8.08.0

ViolenceViolence 153.4153.4 34.7*34.7*

MultipleMultiple 162.8162.8 42.5*42.5*

*Difference in visit counts (reference=none) tested using negative binomial regression controlling for age group, gender, use in previous 6 months, and study arm

ConclusionsConclusions

• Self-reported behavioral health issues factors are Self-reported behavioral health issues factors are common in adolescents seen in primary care.common in adolescents seen in primary care.

• Youth who screen positive for depression, violence, or Youth who screen positive for depression, violence, or multiple risks have higher mental health service use multiple risks have higher mental health service use after screening than those with no behavioral issues.after screening than those with no behavioral issues.

• Mental health services use in those who screen Mental health services use in those who screen positive for depression are still below optimal.positive for depression are still below optimal.

ImplicationsImplications

• Primary care screening programs may Primary care screening programs may increase treatment for behavioral problems increase treatment for behavioral problems while creating limited additional burden in the while creating limited additional burden in the health care system.health care system.

• Systems should consider developing case Systems should consider developing case management approaches for youth with management approaches for youth with identified behavioral health problems to identified behavioral health problems to ensure appropriate use of services.ensure appropriate use of services.

Thank You

Questions?