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Dissertation/Thesis Abstract

Person, Place, and Prevention in Primary Care: A Multilevel Analysis of Variation in the Delivery of Mental Health, Substance-Use Disorder, and Obesity Services
by Hoyt, Alex, Ph.D., Brandeis University, The Heller School for Social Policy and Management, 2012, 248; 3508689
Abstract (Summary)

This research focused on six services delivered in the primary care setting that would be characterized as "effective care"—(1) inquiring about alcohol/drug use and (2) anxiety/depression, (3) intervening for behavioral health problems (substance use disorders, depression, and anxiety), (4) obesity (BMI greater than 29), (5) smokers, and (6) referring for mammography. Using data from Healthcare for Communities as well as several other sources, a multilevel observational design with time-order effects was used to accomplish three aims: First, describe the rates of service delivery in a national sample; Second, develop multivariate models testing the influence of individual-level demographics, health and risk behavior status, and health care utilization; and Third, using multilevel analysis, test the influence of community-level characteristics including socioeconomics and demographics, prevalence, health system capacity, and managed care market characteristics.

It was found that the rate of alcohol/drug inquiry was 24.6%, anxiety/depression inquiry was 18.8%, and behavioral health intervention was 20.1%. The rate of intervention for obesity was 68% and smoking was 67.5%, while the proportion of women with an up-to-date mammogram was 76.4%. Not only were the rates of behavioral health services lower than the somatic service (mammography), the geographic variation was much greater. Disparities were present in fully specified multivariate models suggesting that the rate of services in these groups may be related to providers' perceptions more than individual patients' actual health needs. In multilevel models, alcohol/drug inquiry, anxiety/depression inquiry, and obesity intervention were positively associated with the local supply of specialty resources, and negatively associated with a ratio of specialists to primary care physicians. Additionally, the proportion of primary care physicians using information technology for preventive service reminders had a positive association with alcohol/drug and anxiety/depression inquiry.

These findings have several policy implications. First, this research provides support for the implementation of information technology to assist in the delivery of clinical preventive services. Second, students in the health care professionals may benefit from training that builds their confidence in asking about behavior health and counseling for behavior change. Third, incentives to practicing primary care providers to screen and counsel patients may need to be enhanced.

Indexing (document details)
Advisor: Tompkins, Christopher
Commitee: Friedmann, Peter, Horgan, Constance, Parks-Thomas, Cindy
School: Brandeis University, The Heller School for Social Policy and Management
Department: The Heller School for Social Policy and Management
School Location: United States -- Massachusetts
Source: DAI-A 73/09(E), Dissertation Abstracts International
Subjects: Mental health, Public policy, Health care management
Keywords: Alcohol abuse, Depression, Geographic variation, Mental health services, Obesity, Prevention, Primary care, Smoking cessation
Publication Number: 3508689
ISBN: 978-1-267-34492-2
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