Aileen B. Rothbard, ScD
Data Driven Decision Analysis
A large part of Dr. Rothbard’s research efforts over the years has involved the acquiring, combining and constructing of a substantial database on behavioral health treatment and support services for clients receiving care in the public mental health system. These data have been used to analyze and model service utilization, cost, and outcomes for many studies employing decision support tools. Using operations research approaches, she has employed Data Envelopment Analysis (DEA) to determine which programs are performing on the frontier of best practice. She has also used an innovative queuing network application, funded by NIMH, to do residential planning in mental health that deals with problems of system congestion between hospital discharge and community placement and some preliminary work on a user-friendly interface that will enable MH agencies to determine the number and level of inpatient, residential, and outpatient resources they need to optimize their system. In a more patient oriented study approach, she was involved in implementing an e-prescribing system for five large Community Mental Health Centers (CMHCs) and developing an automated feedback report on patients who had missed refilling their psychotropic prescriptions. In addition, Dr. Rothbard was involved in study on a therapist feedback system in a CMHC agency that provided clinicians with information on the progress of their patients and suggestions on how to improve those outcome when they were below a set of benchmark levels constructed from a large sample. Several other studies used Geographic Information System (GIS) techniques to identify variability in service access across different sites; identification of a seriously mentally ill population at greatest risk for HIV using a mental health status tool (Colorado Symptom Index (CSI); and a prediction model that generated the rate of individuals with chronic mental illness using definitions proposed by NIMH and other State/Agency authorities.
Cost Comparison and Cost Offset
Studies related to implementation of new mental health programs and changes in organizational structure and management of mental health systems have been an important focus of Dr. Rothbard’s research. Policy people want to know if the new programs are cost effective. These studies have involved the costs of discharging long term state hospital clients into the community, the effect of managed Behavioral Health care on cost reductions and more recently whether Patient Medical Homes, as defined by the ACA, can help reduce care costs through more integrated patient care strategies for those with co-morbid chronic physical and mental health disorders. Additionally, many of her studies have focused on the cost of care of patients with mental health and HIV; those in recovery oriented versus traditional partial hospital programs, and cost effectiveness of supplemental services for substance abuse clients. The cost studies have shown mixed results. Given that new programs are often more costly initially, outcomes have to be exceedingly robust, which is generally not the case. They also take time to ramp up which means they are not operating at full capacity which compromises cost efficiency. However, comparing the traditional programs with the newer ones at a later time period is practically difficult as older programs are phased out. Costs are often skewed, especially with small intervention program sizes, making it is hard to draw valid conclusions. Better methodologies and study designs need to be developed in this important area of comparative cost analysis. Dr. Rothbard’s current research is examining the cost effectiveness of new models of patient care such as medical care homes which integrate behavioral and physical treatment using different approaches.
As part of examining mental health services as they relate to innovative program interventions and policy changes, it has been evident that racial disparities are prevalent in all forms of health care. Many of Dr. Rothbard’s studies have identified racial differences in mental health (MH) penetration rates, intensity of care, quality of care, and geographic patterns of care for people enrolled in a large Medicaid (MA) program have provided clear evidence of significant differences despite insurance parity and similar benefits. Rates of outpatient MH services have consistently been found to be significantly lower in African Americans compared to other racial groups, except Asians. They are also found to have the lowest rates of intensity or engagement in outpatient therapy when compared to other racial groups and less likely to receive a combination of therapy plus medication for depression. A ten year trend analysis of the MA population through 2013 showed that rates of use have increased for all groups but the differential has not decreased. Agencies providing services to the MA population in higher income, White areas were found to have higher quality of care indicators than those in low income, African American areas; i.e., higher percentage of patients on atypical antipsychotic prescriptions (47% vs. 33%) and higher percentage using intensive case management (ICM) Finally, a geographic (GIS) analysis showed that White clients were much more likely to select a program with a higher percentage of similar clients, even when they had to travel longer distances. This suggests that racial concordance may play a role in selection of a mental health facility. All of these studies indicate a complex combination of client and provider factors that result in less and poorer treatment for African Americans
Community Integration for at risk persons with Mental Health disorders
Dr. Rothbard’s early research and publications focused on policy changes in the public mental health system associated with deinstitutionalization and the consequences on the care of the seriously mental ill population in the community setting. Sje looked at the patterns of care for individuals following their discharge from the state mental hospitals and examined the effects of deinstitutionalization on a large cohort of individuals leaving a sizeable State Mental Hospital over three years and again ten years later. She has continued to investigate the effectiveness of new programs in the community for this population such as supported housing and recovery models of care. Dr. Rothbard also has studied the treatment of their chronic health conditions to determine the extent of access and quality of care in community settings. The findings from her work with respect to the status of the mentally ill and their quality of life support the fact that it is better but not sufficiently well, as Richard Frank has concluded. Fragmentation between inpatient and outpatient services continues to be a problem and there is inadequate funding, housing capacity, and social service supports to allow these individuals to live more satisfactorily in the community. Co-morbid substance use adds to the cycle of homelessness and early mortality. Nonetheless, there is a consensus that those with chronic mental health disorders are happier in this environment than in institutions and can manage sufficiently in the community with proper supports.
Pharmaceutical Studies on Trends, Disparities and Adherence Patterns
The use of medication to treat the symptoms of behavioral health disorders is of great importance in both maintenance and improvement of outcomes. The type of medication, appropriateness, adherence and effectiveness are all issues of importance in the treatment of behavioral health disorders. Psychotropic medications are used widely, but not necessarily appropriately or equally. Dr. Rothbard’s early studies examined the use of newer atypical antipsychotics by class of medication, by patient characteristics such as racial and by organizational and cost factors related to managed care versus fee for service. She also investigated the use of medications with co-morbid populations, like those with HIV and mentally illness to determine if these individuals were less likely to be treated with appropriate drugs. Additionally, she looked at prescription patterns following the implementation of an automated prescription system which gave feedback to psychiatric prescribers on inappropriate use of antipsychotics and antidepressants. Recently, Dr. Rothbard’s research is examining feedback to prescribers of opioids and benzodiazepines employing the use of prescriber report cards to change inappropriate behavior. The studies have shown that Blacks are less likely to use any psychotropic medication and the newer psychotropic medications and stay on them a shorter period of time. Feedback reports based on electronic prescribing at outpatient clinics were slightly effective and results from our opioid and benzodiazepine report cards to prescribers await the results of an RCT trial and secondary data analysis of a comparison group, Issues of adherence tend to be problematic with individuals with behavioral health and physical problems but adherence to medication is equal or less than those with physical health disorders that have no behavioral health problems. Interestingly, those with the most serious mental illness are more adherent perhaps because of frequent contact with the provider network.