persons with serious mental illness
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Persons with Serious Mental Illness. Michael B. Blank, PhD Center for Mental Health Policy and Services Research University of Pennsylvania HIV Screening and Access to Care Institute of Medicine of the National Academies April 15 th 2010. External Support. - PowerPoint PPT PresentationTRANSCRIPT
Persons with Serious Persons with Serious Mental IllnessMental Illness
Michael B. Blank, PhDMichael B. Blank, PhD
Center for Mental Health Policy and Services ResearchCenter for Mental Health Policy and Services Research
University of PennsylvaniaUniversity of Pennsylvania
HIV Screening and Access to CareHIV Screening and Access to Care
Institute of Medicine of the National AcademiesInstitute of Medicine of the National AcademiesApril 15April 15thth 2010 2010
External SupportExternal Support
R01 NR088514-01 (PI - Blank)R01 NR088514-01 (PI - Blank) NINR NINR Nursing Intervention for HIV Regimen Adherence among SMINursing Intervention for HIV Regimen Adherence among SMI R01 DA015627-01A1 (PI - Blank) NIDAR01 DA015627-01A1 (PI - Blank) NIDAHIV Prevention Program among Substance Abusing SMIHIV Prevention Program among Substance Abusing SMI P30-AI45008 (PI – Hoxie) NIAIDP30-AI45008 (PI – Hoxie) NIAIDCenter for AIDS Research (CFAR)Center for AIDS Research (CFAR)
U18PS000704 (PI - Blank) CDCU18PS000704 (PI - Blank) CDCMulti-Site Rapid HIV Testing in Urban Community Mental Health Multi-Site Rapid HIV Testing in Urban Community Mental Health SettingsSettings
Today’s Talk
Present epidemiology of HIV and SMI in Philadelphia
Describe findings from discarded blood and estimate rates of undetected illness at HUP
Present differential outcomes of HIV infections from Medicaid Claims
Describe differential costs of treatment for comorbid persons from Medicaid Claims
Cross of 1994-6 Medicaid Claims & PDPH AIDS Cross of 1994-6 Medicaid Claims & PDPH AIDS Surveillance RegistrySurveillance Registry
- +
- 51357 688 52045
(90.22%) (1.21%) (91.42%)
+ 1176 3706 4882
(2.07%) (6.51%) (8.58%)
52533 4394 56927
(92.28%) (7.72%) (100%)
Med
icai
d C
laim
s
Dependent Covariates P < Exp(B)
HIV Positive
Sex (Male) .000 4.27
Age (18 yrs.) .000 .98
Black .000 1.67
Hispanic .000 1.53
Asian .000 .06
Time on Welfare .000 1.25
Schizophrenia .000 2.13
Affective Disorder .000 4.68
Constant .000 .00
Claims combined with AIDS Registry
Logistic Regression of Positive HIV/AIDS Diagnosis
(N=391,454)
Dependent Covariates P < Exp(B)
HIV Positive
Sex (Male) .000 4.27
Age (18 yrs.) .000 .98
Black .000 1.67
Hispanic .000 1.53
Asian .000 .06
Time on Welfare .000 1.25
Schizophrenia .000 2.13
Affective Disorder .000 4.68
Constant .000 .00
Claims combined with AIDS Registry
Logistic Regression of Positive HIV/AIDS Diagnosis
(N=391,454)
Dependent Covariates P < Exp(B)
Sex w/ MSMSex (Male) *.000 57.58Age (18 yrs.) *.000 .95Black *.001 .72Hispanic *.000 .24Schizophrenia .889 1.03Affective Disorder .310 .86Both Disorders .753 .89Constant *.000 .08
Logistic Regression – Modes of Transmission
(N=4,092)
Dependent Covariates P < Exp(B)
IDUSex (Male) .101 .89Age (18 yrs.) *.003 1.01Black .565 1.05Hispanic *.012 1.32Schizophrenia .449 1.13Affective Disorder *.033 1.27Both Disorders .953 1.02Constant .106 .78
Logistic Regression – Modes of Transmission
(N=4,092)
Dependent Covariates P < Exp(B)
Sex w/ MSM & IDU
Sex (Male) *.000 16.50
Age (18 yrs.) *.001 .97
Black .168 .79
Hispanic *.035 .59
Schizophrenia *.023 1.97
Affective Disorder .256 1.30
Both Disorders .303 .54
Constant *.000 .02
Logistic Regression – Modes of Transmission
(N=4,092)
Dependent Covariates P < Exp(B)Heterosexual Males Age (18 yrs.) *.003 1.03
Black *.005 2.15
Hispanic *.014 2.20
Schizophrenia .145 1.69
Affective Disorder .168 1.44
Both Disorders .716 1.24
Constant *.000 .01
Logistic Regression – Modes of Transmission
(N=4,092)
Dependent Covariates P < Exp(B)Heterosexual Females Age (18 yrs.) *.005 .98
Black *.000 2.97
Hispanic *.000 4.65
Schizophrenia .140 1.57
Affective Disorder .778 .94
Both Disorders .119 .38
Constant *.000 .29
Logistic Regression – Modes of Transmission
(N=4,092)
Costs to Medicaid in 2003Costs to Medicaid in 2003
Opportunistic Infection RatesOpportunistic Infection Rates
Examine adverse events for 405,969 Examine adverse events for 405,969 persons with co-occurring HIV, mental persons with co-occurring HIV, mental illness and controlsillness and controls
Calculate rates of opportunistic infections Calculate rates of opportunistic infections over an 11 year periodover an 11 year period
Identify types of opportunistic infections that Identify types of opportunistic infections that differentially affect HIV+ persons with differentially affect HIV+ persons with mental illnessmental illness
1
2
3
4
5
6
7
8
9
CONTROLS SMI ONLY HIV ONLY SMI/HIV
Rat
e
Relative Risk of Opportunistic Infections Roughly Equal for those with HIV only and HIV/SMI
Respiratory infectionsPneumonia organism Influenza
Candidiasis
Pneumonia bacterial
1
2
3
4
5
6
7
8
9
10
11
CONTROLS SMI ONLY HIV ONLY SMI/HIV
Rat
eRelative Risk of Opportunistic Infections
Markedly Higher for HIV/SMI than HIV only
Hepatic CirrhosisHerpes simplex
Tuberculosis
Hepatitis C
Hepatitis B
Hepatitis A
1
11
21
31
41
51
61
71
81
91
101
CONTROLS SMI ONLY HIV ONLY SMI/HIV
Rat
e
Relative Risk of AIDS-defining Opportunistic InfectionsMarkedly Higher for HIV only than HIV/SMI
Pneumocystosis
Mycobacteriosis
Cryptococcosis
Cytomegalovirus
Toxoplasmosis
ConclusionsConclusions
Persons with co-morbid HIV and SMI have Persons with co-morbid HIV and SMI have much higher rates of OI than any other groupmuch higher rates of OI than any other group
Three clusters of OIs are identifiable and Three clusters of OIs are identifiable and have different patterns for HIV/SMIhave different patterns for HIV/SMI
AIDS-defining OIs are lower for HIV/SMI, AIDS-defining OIs are lower for HIV/SMI, perhaps reflecting greater mortality before perhaps reflecting greater mortality before reaching very low levels of immune reaching very low levels of immune functioningfunctioning
Discarded Blood StudyDiscarded Blood Study
This study identified previously undetected This study identified previously undetected infectious disease among persons with infectious disease among persons with serious mental illness. serious mental illness.
Observational-naturalistic methods were Observational-naturalistic methods were used to simulate universal screening among used to simulate universal screening among 588 adult psychiatric patients588 adult psychiatric patients
Laboratory results showed that 10% of Laboratory results showed that 10% of patients had HIV, 32% had Hepatitis Bpatients had HIV, 32% had Hepatitis B
Table 1Rates of metabolic and infectious diseases among 588 adults with serious mental illness admitted to psychiatric inpatient units Method of detectiona
Abstracted Clinical data Laboratory test data
Variablea Total N
N % N %
Hepatitis BHepatitis CHigh glucose levelsb
461546588
75981
21114
14611740
32217
High total cholesterol levelsHigh triglyceride levelsHIV
568572388
14331
218
12410339
221810
a Abstracted clinical data was gathered from a review of admission history, physical examinations, physician-ordered laboratory results, standardized nursing assessment forms and discharge summaries, and electronic records of all inpatient and outpatient services rendered in the year before admission. Laboratory testing involved physician-ordered laboratory blood tests and laboratory blood tests conducted for the purposes of this study (simulated universal screening).
b The number of positive laboratory test results for diabetes is less than the number based on history, which suggests that metabolic conditions were well controlled at the time of admission or that patients may have given a false positive history.
Rothbard, et al. Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients. Psychiatric Services, April 2009 Vol. 60 Mo4 p536
Recommendations
Make rapid HIV testing routinely available in Community Mental Health Settings
Screen for Blood-borne Infections routinely in inpatient settings
Integrate teaching condom skills, HIV risk reduction, and positive sexuality curricula into ongoing treatment
Consider the use of Peer Specialists to deliver HIV prevention messages
Integrate medication adherence interventions into ongoing care for HIV+ persons with mental illness
AcknowledgmentsAcknowledgments
Linda AikenLinda Aiken Tiffany Brown Tiffany Brown James CoyneJames Coyne Martin FishbeinMartin Fishbein Robert GrossRobert Gross Trevor HadleyTrevor Hadley Nancy HanrahanNancy Hanrahan Janet HinesJanet Hines Ann Kutney LeeAnn Kutney Lee
David MetzgerDavid Metzger Aileen RothbardAileen Rothbard Phyllis SolomonPhyllis Solomon Julie TennilleJulie Tennille Tom Ten HaveTom Ten Have Evan WuEvan Wu City of Philadelphia City of Philadelphia
Department of Public HealthDepartment of Public Health City of Philadelphia City of Philadelphia
Community Behavioral HealthCommunity Behavioral Health