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TEL 01-146 – HSR&D Study

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TEL 01-146
Telephone Care as a Substitute for Routine Psychiatric Medication Management
Amy E Wallace MD MPH
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: October 2003 - September 2009

BACKGROUND/RATIONALE:
Telemedicine uses communications technologies to provide health care when distance separates participants. Applied to general medical care practice, telemedicine is associated with improved continuity of care, cost-effectiveness, and improved service quality. To date, evaluations of telepsychiatry have focused on video technology. The telephone is a more readily available and less expensive communication technology that has not been evaluated as a method of health services delivery in the medication management of stable psychiatric outpatients.

OBJECTIVE(S):
The objectives of this study are to answer the following questions: 1) Does substituting brief, scheduled, clinician-initiated telephone calls (telephone care) for routine psychiatric medication management visits reduce overall healthcare utilization? And, 2) is substituting brief, scheduled, clinician-initiated telephone calls (telephone care) for routine psychiatric medication management visits as effective as routine care?

METHODS:
We enrolled 324 psychiatrically stable subjects who carried a diagnosis of major depression, post-traumatic stress disorder (PTSD), and/or non-PTSD anxiety disorder. We used a balanced randomization strategy to assign subjects to routine care or telephone care for a two-year period within each provider panel. Patients randomized to receive routine care were scheduled to see their psychiatric medication provider at the recommended interval. Patients randomized to receive telephone care were scheduled to see their provider at twice the recommended clinic visit interval, and two ten-minute telephone contacts are scheduled at a specific time at standard 0.67 and 1.3 times the multiple of the recommended interval.

At two years, we used ten data sources to compare two primary outcomes (total VHA health services utilization and mental health component scores from the SF-12-V) as well as VHA costs, imputed non-VHA costs, patient and provider satisfaction, medication compliance, and diagnosis specific outcomes.

FINDINGS/RESULTS:
A total of 324 subjects were enrolled in the study across two sites (White River Junction, VT and Manchester, NH). Control and intervention subjects did not differ demographically, or with respect to baseline health care utilization, clinical severity, or health status.
Analyses comparing treatment and control groups yielded no differences in serious adverse event rates across treatment groups. Though non-serious adverse event rates were not statistically different across groups, non-psychiatric adverse events (non-psychiatric emergency room visits and hospitalizations) trended toward being higher for the control group (p = 0.075). Three patients died during the study period: one due to a motor vehicle accident and two due to complications of pre-existing medical conditions.
Administrative data analysis is pending. Patient report data suggested no differences in utilization of mental health or non-mental health services within the VA; however, subjects in the intervention arm used fewer non-VA mental health services during the study period (p = 0.01).

IMPACT:
The research will contribute to efficiency of health care provision and quality effectiveness within VA by determining the potential cost-savings associated with telephone management of stable psychiatric patients. Our findings should be of interest to VHA management and strategic planners, VHA policymakers, and taxpayers and insurers.

PUBLICATIONS:

Journal Articles

  1. Morden NE, Mistler LA, Weeks WB, Bartels SJ. Health care for patients with serious mental illness: family medicine's role. Journal of the American Board of Family Medicine. 2009 Mar 1; 22(2):187-95.
  2. Pomerantz A, Cole BH, Watts BV, Weeks WB. Improving efficiency and access to mental health care: combining integrated care and advanced access. General hospital psychiatry. 2008 Nov 1; 30(6):546-51.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Access, Deployment Related, PTSD, Telemedicine
MeSH Terms: Depression, Telemedicine

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