Dawn Wiest

Trigger–outcome and risk-factor analyses in substance use disorder (SUD) care are sensitive to modeling choices: alternative trigger definitions, adjustment sets, study periods, and lag windows can yield different risk contrasts. We introduce risk-envelope trigger–outcome analysis, a robustness-first framework that reports adjusted risk differences (ARDs) across a prespecified family of clinically plausible specifications rather than relying on a single analytic route. The goal is screening and prioritization, not point-identified causal inference. We apply the framework to a regional SUD patient-quarter panel from 2017Q1 through 2022Q4 that is linked to tract/county context indicators. The analysis identifies stable diagnosis-side signals, especially suicidal ideation followed by next-quarter SubA (polysubstance use excluding alcohol and nicotine) evidence, while showing that some clinically plausible pairs are specification-sensitive. Short-term recurrence, specification-adjusted transition checks, and SubA–opioid cross-transitions provide operational markers for follow-up, and multiplicity-controlled context screening identifies community indicators that co-move with documented SUD evidence. Risk-envelope analysis provides a transparent basis for SUD trigger screening under observational and specification uncertainty.

Randomized evaluations of complex care management programs have yielded mixed evidence of effectiveness in improving health outcomes. An approach to care for individuals with concurrent medical and social needs, complex care is distinct from other care management approaches for its interdisciplinary team-based models, prioritization of patients’ self-defined goals, and emphasis on cross-sector partnerships to improve care transitions across multiple settings.^1,2 These programs tend to focus on high-cost, high-needs populations,^3-5 and their value is often framed as cost savings achieved through reductions in avoidable hospitalizations and emergency department use.^6,7 Several randomized clinical trials have shown positive effects with complex care programs in reducing costs,^8,9 hospitalizations,^8,10-12 or emergency department visits,¹⁰ while others have produced null results for similar outcomes.^8-10,13-16

Objectives: The purpose of our study was to assess the relationship between intervention dosage and hospital utilization outcomes among patients with complex health and social needs enrolled in a care management program. We highlight the importance of measuring patient engagement and intervention dosage in program evaluation. Study Design: We performed a secondary analysis of data collected between 2014 and 2018 as part of a randomized controlled trial of the Camden Coalition’s signature care management intervention. Our analytical sample consisted of 393 patients. Methods: We calculated a time-invariant cumulative dosage rank based on the number of hours spent by care teams working with or on behalf of patients and then divided patients into low- and high-dosage groups. We applied propensity score reweighting to compare hospital utilization outcomes between patients in these 2 groups. Results: Compared with patients in the low-dosage group, those in the high-dosage group had a lower readmission rate at 30 (21.6% vs 36.6%; ,P, < .001) and 90 (41.7% vs 55.2%; ,P, = .003) days post enrollment. The difference between the 2 groups at 180 days post enrollment was not statistically significant (57.5% vs 64.9%; ,P, = .150). Conclusions: Our study elucidates a gap in how care management programs for patients with complex health and social needs are evaluated. Although the study shows an association between intervention dosage and care management outcomes, patients’ medical complexity and social circumstances are among the factors that can attenuate the dose-response relationship over time.

In the United States and abroad, health systems have begun to address housing insecurity through programs that adhere to the Housing First model. The model provides permanent supportive housing without disqualification due to current mental health problems or substance use, along with optional case management services. This study used qualitative methods to explore how housing stability affected chronic disease management and social and community relationships among individuals with complex health and social needs and patterns of high hospital utilisation who were housed as part of a scattered‐site Housing First program in a mid‐size city in the northeastern United States. 26 individual, semi‐structured interviews were conducted with Housing First clients in their homes or day program sites between March and July 2017. Interviews were digitally recorded and transcripts were analysed using a qualitative descriptive methodology until thematic saturation was reached. Findings suggest that housing provided the physical location to manage the logistical aspects of care for these clients, and an environment where they were better able to focus on their health and wellness. Study participants reported less frequent use of emergency services and more regular interaction with primary care providers. Additionally, case managers' role in connecting clients to behavioural health services removed barriers to care that clients had previously faced. Housing also facilitated reconnection with family and friends whose relationships with participants had become strained or distant. Changes to physical and social communities sometimes resulted in experiences of stigmatisation and exclusion, especially for clients who moved to areas with less racial and socioeconomic diversity, but participation in the program promoted an increased sense of safety and security for many clients.

A small percentage of patients relies extensively on hospital-based care and account for a disproportionately high share of health care spending in the United States. Evidence shows that behavioral health conditions are common among these individuals, but understanding of their behavioral health needs is limited. This study aimed to understand the behavioral health characteristics and needs of patients with high hospital utilization patterns in Camden, New Jersey. The sample consisted of patients in a care management intervention for individuals with patterns of high hospital utilization who were referred for behavioral health assessments (N = 195). A clinical psychologist conducted the assessments, which informed a multiaxial evaluation with diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders and a Mental Status Examination, to facilitate accurate diagnosis. Demographic characteristics, housing instability, exposure to trauma, and health care service utilization data were also collected through self-report and chart reviews. Ninety percent of patients were diagnosed with a psychiatric and/or active substance use disorder. Depression was the most common psychiatric disorder and alcohol use was the most common substance use disorder. However, only 10% of patients with an active substance use disorder were in treatment, and only 17% of patients with a mental health diagnosis were receiving mental health treatment. Nearly all (91%) patients reported having a primary care provider at the time of assessment and most had seen their primary care provider within three months of their last hospital discharge. Non-medical barriers to health and wellness, specifically housing instability and exposure to trauma, were also common (35 and 61% of patients, respectively) among patients. Findings highlight the importance of identifying and treating patients with behavioral health needs in the primary care setting. Developing connections with community agencies who provide behavioral health and substance use treatment can enhance primary care providers’ efforts to address their patients’ non-medical barriers to treatment, as can embedding behavioral health providers within primary care offices. The study also underscores the need for trauma-informed care in primary care settings.

Hospital readmissions are costly indicators of the quality of patient care.^1,2 In 2012, 7% of the US population had a hospital stay, for a total cost of $381 billion,³ and an estimated 1 in 12 adults is readmitted within 30 days, adding $16 billion to health care costs annually.⁴ To address costs and improve care quality, the Patient Protection and Affordable Care Act established the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reduction Program. Launched in October 2012, this program ties payments for all Medicare admissions to hospitals’ readmission rates, creating motivation for hospitals to reduce avoidable readmissions.² An estimated one-quarter of all 30-day hospital readmissions are preventable, and many of these can be traced to inadequate postdischarge follow-up.⁵ Timely postdischarge follow-up with a primary care provider (ie, a physician, nurse practitioner, clinical nurse specialist, or physician assistant as allowed under state law) can improve care transitions and reduce readmission risk through medication reconciliation, discharge plan review, and patient education.^6,7

Depression is a leading cause of disability worldwide, and many internists diagnose and treat depression. This study aimed to examine the impact of a practice improvement intervention on screening and managing patients with depression in primary care. This pre–post study design included a physician practice survey designed to capture what the physicians believed they were doing in practice, a chart audit tool to capture what physicians were actually doing in practice, and an intervention that included an evidence-based educational program, online toolkit, and practice improvement coaching conference calls that promoted group learning. Following completion of the intervention, participants increasingly used the Patient Health Questionnaire-9 to detect, diagnose, and gauge treatment success for depression and reported increased use of guidelines and team-based care. Although barriers to improving depression care exist, this study suggests that evidence-based quality improvement programs can positively affect practice.

Into the 1990s, Arab countries witnessed a rise in the number of terrorist attacks perpetrated by Islamist militants against governments, foreign targets, and citizens. In response to terrorism, governments throughout the Middle East and North Africa suppressed the civil and political rights of all citizens. This clampdown on civil society transpired on the heels of political reforms in several countries and coincided with the increasing integration of these states into international treaty regimes, signaling a willingness to comply with world standards on human rights. Engaging the literatures on terrorism, world polity, and social movements, I first analyze the relationship between political regime type and movement mobilization. Next I examine the impact of transnational terrorism on human rights mobilization. I use network analysis to show that, contrary to expectations of world polity theory and the boomerang hypothesis, activists' ties to the transnational rights network thinned over the same time period (1980-2000) that these states became more integrated into international society through treaty ratification and memberships in intergovernmental organizations. The findings indicate that while the globalization of human rights has empowered human rights movements in nondemocratic societies, state power continues to set limits on mobilizing capacities.

Since the late 1980s, governments have focused intensely on formalizing political and economic relationships within regions. There has also been a concurrent rise in transnational, regional level organizing among social movement activists globally, suggesting the regionalization of `global civil society.' However, opportunities for participation in transnational associations vary widely across countries. In this article, we examine the influence of international (both global and regional) institutional contexts, citizen participation in international society, and national level factors on varying levels of participation in regional transnational social movement organizations (TSMOs). We use negative binomial regression to examine relationships among these factors at three time points: 1980, 1990, and 2000. We find that in the early time period, citizen network connections to international society facilitated the formation of and participation in regionally organized TSMOs. Over time, however, regional and global institutional contexts were more predictive of participation in regional TSMOs than were international network ties. Our analysis also uncovered how qualitatively different forms of regionalism translated into significantly different levels of TSMO regionalization. In Europe, where the regional institutional structure is more elaborated than elsewhere in the world, the number of regional TSMOs in which citizens participated greatly outpaced that found elsewhere. Irrespective of international, institutional factors, however, state-level features remained crucial to explaining the development of regional TSMO sectors and the variable levels of participation in them. Citizens in states with restrictions on political rights and civil liberties had significantly lower participation in these organizations in 1990 and 2000. Even so, over time, citizens in states with more ties to global and regional multilateral processes found more ways to overcome this disadvantage and strengthen their participation in regional, transnational civil society.