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Compendium of Research Related to Mental Health (continued)


Health care utilization and expenditures by Vietnam veterans. American Public Health Association Annual Meeting, 1991.
Authors: Beauregard K and Potter D.

Description: This paper examines health care utilization and expenditures for veterans who served during the Vietnam War era. Data are from the household survey of NMES. Information on approximately 1,100 Vietnam War era veterans is used to present national estimates of health care utilization and expenditures for inpatient hospital stays, hospital outpatient and emergency room visits, mental health care, and ambulatory care visits. Also examined are patterns of use of the Veterans Administration's health care system. Estimates are characterized by demographic, socioeconomic, and health status indicators comparing veterans to a cohort of nonveterans.

Determinants of ambulatory mental health services use for school-age children and adolescents. Health Services Research Oct. 1996; 31(4), pp. 409-427.
Authors: Cunningham P and Freiman M.

Description: This study used the 1987 NMES to analyze a comprehensive multivariate model of the use of mental-health-related ambulatory care services by children ages 6-17. It was found that children with poor mental health in high-income families were more than three times as likely to have a mental-health-related visit as children with poor mental health in low-income families. The number of mental-health-related visits and the likelihood of seeing a mental health specialist also increased along with family income. Mental health use by other family members was strongly associated with use by children. The study concludes that the socioeconomic status of children is an important factor in explaining unmet need for mental health services.

Interactions between use of and insurance for specialty ambulatory mental health services. Presented at the Seventh Biennial Research Conference on the Economics of Mental Health; Sept. 1994; Bethesda, MD. Discussion paper, June 1996
Author: Freiman M.

Description: Data from the 1987 NMES were used to analyze some aspects of the interaction between the coinsurance rate for ambulatory mental health care and the probability of use of such care. Some evidence for selection effects was found, in that when an instrument is estimated for the coinsurance rate for ambulatory mental health services, this instrument is found to perform better than the actual insurance rate in a demand equation for these services. The results for the instrumental equation also suggest that the selection bias often discussed with regard to mental health insurance and service use may involve both supply and demand side effects in the labor market. The implications of these results for estimating the effects of broad changes in coverage are discussed.

Use of health care for the treatment of mental problems among racial/ethnic subpopulations. Medical Care Research and Review Mar. 1997; 54(1), pp. 80-100.
Authors: Freiman M and Cunningham P.

Description: This paper uses the 1987 NMES to analyze the degree to which interactions among race, ethnicity, and other characteristics of a person and his or her local area are important in determining the probability of any mental health care use. Separate equations are estimated for "blacks and Hispanics" and "whites and other groups." Simulations are then performed where the probabilities of use are estimated for individuals in one racial/ethnic group using coefficients estimated for another racial/ethnic group. These simulations show that the probability of use for blacks and Hispanics would be similar to whites if they were subject to the same behavioral patterns (regression coefficients) as whites, and vice versa. The results indicate the limitations of simply using dummy variables to represent race/ethnicity and the value of learning more about how the health care system interacts with persons of different racial/ethnic backgrounds. Policies that directly affect the location, characteristics, and behavior of health care providers, as well as the behavior of consumers, may be as relevant to achieving equality of use or access as incremental changes in health coverage.

The demand for health care for the treatment of mental problems among the elderly. In: Advances in Health Economics and Health Services Research. Volume 14. Greenwich, CT: JAI Press; 1993.
Authors: Freiman M, Cunningham P, and Cornelius L.

Description: Much of the research on the demand for mental health care has focused on ambulatory care visits. This focus would not appear to be entirely appropriate for the elderly, as ambulatory visits are neither the most prevalent form of treatment nor the most expensive. In general, the mental health use the researchers found among the elderly was characterized by its low intensity for those with any such use. The most common type of mental health treatment among the noninstitutionalized elderly in the 1987 NMES was prescription drugs. This use of medicines is substantially more prevalent among the elderly than other age groups. It was found that being newly widowed was a strong predictor of mental health treatment during the year. For such a situation, a limited-term prescription for a mild tranquilizer and/or hypnotic may be sufficient and appropriate. However, widowhood occurred for only 2.4 percent of the sample, so its potential to explain prescription drug treatment is limited. The frequency with which prescription medicines were found to be the sole form of treatment for a mental problem raises the question of whether at least some portion of these problems might better be treated with more intensive ambulatory care or other treatments.

Psychotropic medication use among the elderly. Presented at the NAMH Research Conference on Mental Health Services Research; Sept. 1995; Bethesda, MD. Discussion paper, August 1996.
Authors: Freiman M and Norquist G.

Description: Using the 1987 NMES, it was found that over four million elderly persons residing in the community used psychotropic medicines for a mental condition in 1987. Such use is substantially greater among the elderly than other age groups. These elderly psychotropic drug users utilize the health care system for a wider range of conditions and illnesses, use a larger number of nonpsychotropic medicines, and are more likely to have difficulties in basic locomotion and movement than elderly persons who are not taking psychotropic drugs. A notable feature of this drug use is the almost total absence of involvement with the specialty mental health sector. These results provide a useful baseline that raises some potential concerns, and against which results from later periods can be evaluated. The results also suggest that the high level of use of psychotropic drugs for mental conditions among the elderly, who often have other substantial health problems and limitations of functioning, and who make almost no use of the specialty mental health treatment sector, remains a cause for concern.

Determinants of ambulatory treatment mode for mental illness. Health Economics July 2000; 9(5), pp. 423-434.
Authors: Freiman M and Zuvekas S.

Description: A reduced-form bivariate probit model was used to jointly analyze the choice for ambulatory treatment from the specialty mental health sector and/or the use of psychotropic drugs. Significant differences in treatment choices by education, gender, and race/ethnicity were found. Women were more likely than men to use specialty mental health services and more likely to use psychotropic medications. Biases and misperceptions on the part of the patients must be considered when interpreting these differences, as well as traditional patient preferences. The results are further discussed in this article as they relate to other findings and policies.

Health insurance, health reform, and outpatient mental health treatment: Who benefits? Inquiry Summer 1999; 36, pp. 127-146.
Author: Zuvekas S.

Description: This research examined the impact of proposed health policy changes on the use of outpatient mental health treatment among adults with different mental health needs using data from the 1987 NMES and the National Institute of Mental Health's Epidemiologic Catchment Area Study. It was found that health insurance substantially increases the use of treatment by those with severe mental disorders, but that increased health insurance coverage alone cannot meet the treatment needs of this group. It was also found that those in better mental health account for a significant proportion of additional expenditures when insurance coverage is expanded. The investigator concludes that policies intended to increase access to mental health treatment must carefully consider the potential costs of substantial increased use by those not targeted by these policies.

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The influence of parental separation on smoking initiation in adolescents. Journal of Health and Social Behaviors Mar 2002; 43(1), pp. 56-71.
Author: Kirby J.

Description: In this study, it is suggested that parental separation is one possible risk factor for smoking initiation. To examine this, a nationally representative sample of American adolescents was interviewed at two points in time. Two questions were addressed: Is there a relationship between parental separation and the likelihood that an adolescent will initiate smoking? If there is a relationship, through what factors does parental separation operate to influence the initiation of smoking in adolescents? The findings suggest that parental separation increases the likelihood that adolescents will start smoking. It does so in part by raising depressive symptoms and rebelliousness in adolescents. Despite the significance of these indirect effects, however, the bulk of the effect of parental separation on smoking initiation is direct.

Carve outs and related models of contracting for specialty care: Framework and highlights of a workshop. American Journal of Managed Care, Jun 1998; 4 Suppl, pp. SP11-21.
Authors: Friedman B, Devers K, Hellinger F, et al.

Description: This article provides an overview of papers presented at a workshop sponsored by AHCPR in January 1998. The papers, published in this special issue of the American Journal of Managed Care, focus on one set of strategies: the use of carve-outs and related models of contracting for specialty care. The defining common feature of these contracts is that they engage providers and management entities different from those otherwise available to care for the same patients within a health plan. The other common feature of these arrangements is that they receive significant attention in the marketplace and almost no attention from research. The purpose of the workshop and this special issue of the American Journal of Managed Care was to identify what is known and not known about these arrangements and develop an agenda for future research.

Developing integrated mental health service delivery systems. Living in the community with disability: A cross-group perspective. 1998. V. Mor and S. Allen, editors. New York: Springer Publications.
Authors: Robinson G and Brach C.

Description: This book chapter discusses three methods for integrating mental health services for persons with severe mental illness living in the community: case management, capitation, and central authorities.

Maternal psychological distress: the role of children's health. Women and Health 1996; 24(1), pp. 59-75.
Authors: Hahn B and Schone B.

Description: This article examines the factors associated with psychological distress in women, combining clinical-based studies, which have focused on children's health and mother's distress, with sociological studies of the impact of social and economic factors on women's distress. Using data from NMES, this research examines the association between children's health and mother's distress, as well as whether that relationship is mediated by socioeconomic, demographic, and social network factors. Results of the study demonstrate that acute and chronic conditions have different effects on maternal distress and that marital stress affects the relationship between children's health and maternal distress by increasing the impact of some variables and decreasing the effect of others. These findings suggest that children's health has an important effect on symptoms of maternal distress; the results also suggest that the role of children's health must be considered in the context of other economic and social factors.

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Evidence-Based Practice Reports

Under the Evidence-based Practice Program at AHRQ, 12 5-year contracts have been awarded to institutions in the United States and Canada to serve as Evidence-based Practice Centers (EPCs). The EPCs review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities. Public and private-sector organizations may use the reports and assessments as the basis for their own clinical guidelines and other quality improvement activities. All evidence reports produced by AHRQ are available online.

Following is a list of completed evidence reports related to mental health.

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Jadad AR, Boyle M, Cunningham C, et al. Treatment of Attention-Deficit/Hyperactivity Disorder. Evidence Report/Technology Assessment Number 11. (Prepared by McMaster University, Hamilton, Ontario, Canada under Contract No. 290-97-0017.) AHRQ Pub. No. 00-E005. Rockville, MD: Agency for Healthcare Research and Quality. Nov. 1999.

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Mulrow CD, Williams JW, Trivedi M, et al. Treatment of Depression: Newer Pharmacotherapies. Evidence Report/Technology Assessment Number 7. (Prepared by the San Antonio Evidence-based Practice Center based at the University of Texas Health Science Center at San Antonio under Contract No. 290-97-0012.) AHCPR Pub. No. 99-E014. Rockville, MD: Agency for Health Care Policy and Research. Feb. 1999.

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Alcohol Dependence

West SL, Garbutt JC, Carey TS, et al. Pharmacotherapy for Alcohol Dependence. Evidence Report/Technology Assessment Number 3. (Prepared by the Research Triangle Institute, Research Triangle Park, NC under Contract No. 290-97-0011) AHCPR Pub. No. 99-E004. Agency for Health Care Policy and Research. Jan. 1999.

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Clinical Guidelines

AHRQ-supported clinical practice guidelines are in the public domain within the United States and may be used and reproduced without special permission. HSTAT (Health Services/Technology Assessment Text), a free electronic service, provides computer access to the full text of clinical practice guideline products and can be accessed at The HSTAT site includes AHRQ-supported guidelines, quick reference guides, and consumer guides in both English and Spanish on common clinical conditions. Following are descriptions of mental-health-related guidelines developed by AHRQ.

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Treating Tobacco Use and Dependence

Chair of the Guideline Panel: Michael C. Fiore, M.D., M.P.H., University of Wisconsin Center for Tobacco Research and Intervention This Public Health Service clinical practice guideline, developed by a private-sector panel of experts convened by a consortium of Federal and nonfederal partners, was issued in June 2000. AHRQ was among the partners. The guideline was developed to assist all health care providers, especially those with direct patient contact, to help tobacco users quit.

These materials are available at and through the AHRQ Web site ( Tobacco guideline materials are available through the AHRQ Publications Clearinghouse.

This Public Health Service tobacco guideline supersedes an earlier AHRQ-sponsored guideline on smoking cessation.

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Depression in Primary Care

Chair of the Guideline Panel: A. John Rush, M.D., University of Texas Southwestern Medical Center.

These clinical practice guidelines were developed to assist primary care providers, including physicians, nurse practitioners, mental health nurse specialists, physician assistants, social workers, and others in the diagnosis of depressive conditions and the treatment of major depressive disorders. The guidelines were published in 1993 and were based primarily on research done in psychiatric settings. They included a clinical practice guideline, a quick reference guide for clinicians, and a patient guide. These guideline products are no longer current and are provided for archival purposes only at Several individuals who participated in the development of the original guidelines have reviewed studies published between 1992 and 1998 on treatment of depression in primary care settings.

For more information, see "Treating Major Depression in Primary Care Practice: An Update of the Agency for Health Care Policy and Research Practice Guidelines," by Herbert C. Schulberg, Wayne Katon, Gregory E. Simon, and A. John Rush in the December 1998 Archives of General Psychiatry 55, pp. 1121-1127. CD-ROM disks featuring the depression guidelines, including the quick reference guide and patient booklets, are available at all 600 Federal Depository Libraries located throughout the country and at many medical libraries in hospitals, universities, and managed care organizations.

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Early Identification of Alzheimer's and Related Dementias

Co-Chairs of the Guideline Panel: Paul T. Costa, Jr., Ph.D., National Institute on Aging, and T. Franklin Williams, M.D., FACP, University of Rochester Medical Center.

These guidelines were developed to aid clinicians, patients, and family members in the recognition, diagnosis, and treatment of Alzheimer's disease and related dementias. They included a clinical practice guideline, a quick reference guide for clinicians, and a patient and family guide. These guideline products are no longer current and are provided for archival purposes only at:

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National Guideline Clearinghouse™

The National Guideline Clearinghouse™ (NGC) is a comprehensive database of evidence-based clinical practice guidelines and related documents. This database is produced by AHRQ, in partnership with the American Medical Association and the American Association of Health Plans. The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.

Key components of the NGC include:

  • Structured abstracts (summaries) about the guideline and its development.
  • A utility for comparing attributes of two or more guidelines in a side-by-side comparison.
  • Syntheses of guidelines covering similar topics, highlighting areas of similarity and difference.
  • Links to full-text guidelines, where available, and/or ordering information for print copies.
  • An electronic forum, NGC-L, for exchanging information on clinical practice guidelines, their development, implementation, and use.
  • Annotated bibliographies on guideline development methodology, implementation, and use.

Currently, 100 mental-health-related guidelines are housed in the NGC. They are broken down into the following related subconcepts:

  • Adjustment disorders—3 guidelines.
  • Anxiety disorders—9 guidelines.
  • Delirium, dementia, amnestic, cognitive disorders—23 guidelines.
  • Dissociative disorders—1 guideline.
  • Eating disorders—4 guidelines.
  • Factitious disorders—1 guideline.
  • Impulse control disorders—1 guideline.
  • Mental disorders diagnosed in childhood—24 guidelines.
  • Mood disorders—19 guidelines.
  • Neurotic disorders—1 guideline.
  • Personality disorders—2 guidelines.
  • Schizophrenia and disorders with psychotic features—6 guidelines.
  • Sexual and gender disorders—4 guidelines.
  • Sleep disorders—12 guidelines.
  • Somatoform disorders—1 guideline.
  • Substance-related disorders—26 guidelines.

The Web address for the NGC is:

It can also be accessed through the AHRQ Web site.

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User Liaison Program

The User Liaison Program (ULP), established in 1978, contributes to AHRQ's mission by timely synthesis and dissemination of research findings to State policymakers and researchers. ULP's flagship products are small policy-thematic workshops and skill-building workshops, as well as workshops designed for specific States on request. The program also produces teleconferences and written products such as issue summaries, Web-based materials, and distance learning programs. In addition to providing information and tools to make informed health policy decisions, ULP serves as a bridge between State and local health policymakers and the health services research community, by bringing back to AHRQ the research questions being asked by key policymakers. Following are brief descriptions of workshops related to mental health.

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Depression: Implications for State and Local Health Care Programs

This workshop was designed for State and local health officials from the executive and legislative branches responsible for designing, implementing, and managing programs and policies that influence the delivery of health services, particularly services related to depression. The workshop was held in Washington, DC, July 10-12, 2000.

At the completion of this workshop, participants were expected to be better able to:

  • Understand the impact of depression and how it is addressed within the current health care system.
  • Put into operation an evidence-based framework to consider health care system strategies to improve the diagnosis and treatment of the condition.
  • Assess the latest health services research findings to identify promising approaches to meeting the needs of patients with depression.
  • Analyze promising strategies and initiatives implemented by public and private organizations to better serve people suffering from depression.

The workshop has been archived. Go to:

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Improving the Outcomes of State Health and Human Service Initiatives: Integrating Mental Health and Substance Abuse Strategies

This seminar offered State executive and legislative officials and senior-level State policymakers information to develop a better understanding of the individual insurance market and the impact that implemented reforms have had to date. It was held in Albuquerque, New Mexico, July 19-21, 1999.

The workshop objectives were developed to provide participants with:

  • Important research about the nature of the mental health/substance abuse (MH/SA) problems that exist within program populations.
  • Information on key trends and developments in the finance and delivery of MH/SA services.
  • The opportunity to examine the cutting-edge efforts of States that are promoting better outcomes from program initiatives by incorporating MH/SA strategies.
  • An examination of issues and opportunities regarding evaluation and impact of MH/SA-related strategies and interventions.
  • A forum for discussing challenging issues within their own States and for sharing insights and lessons learned among participants.

The seminar has been archived. Go to:

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Reducing Violence: Issues, Options, and Opportunities for State Governments

This workshop was designed for State and local officials and others responsible for initiating and supporting violence prevention policies and programs. The workshop was held in Albuquerque, NM, on February 7-9, 2000.

At the completion of this workshop, participants were expected to be better able to:

  • Assess research findings on violence reduction strategies.
  • Put into operation a research-based framework to help guide the design of effective violence prevention strategies.
  • Identify and use a range of strategies and policies regarding school and youth violence, intimate partner violence, suicide, and child/elder abuse.
  • Determine methods that States and localities can use to collect and analyze data for design, monitoring, and evaluation of violence prevention initiatives.
  • Recognize and take advantage of opportunities to play a leadership role in developing effective violence prevention initiatives in their communities.

The workshop has been archived. Go to:

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Other Activities

U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF), an independent panel of private-sector experts in primary care and prevention, was convened by the U.S. Public Health Service to rigorously evaluate clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations, and chemoprophylaxis. The Task Force's pioneering efforts culminated in the 1989 Guide to Clinical Preventive Services. A second edition of the guide, published in 1996, included assessments of more than 200 services offered in primary care settings for adults, pregnant women, and children. Now a third USPSTF is updating assessments and recommendations and addressing new topics.

The mission of the Task Force is to:

  • Evaluate the benefits of individual services.
  • Create age-, gender-, and risk-based recommendations about services that should routinely be incorporated into primary medical care.
  • Identify a research agenda for clinical preventive care.

Additional mental-health-related topics are in progress. They include:

  • Screening: Dementia, family violence.
  • Counseling: Avoiding problem drinking, prevention of suicide risk, prevention of youth violence.

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Foundation for Accountability Abstracts

AHRQ funded a series of scientific papers to support the performance measurement efforts of the Foundation for Accountability (FACCT). The authors of these papers reviewed the science base and provided recommendations on measures. FACCT had identified the topics covered in this series—population-level measurement areas such as satisfaction and a number of clinical conditions—as first priorities. The following mental-health related report is available.

Measuring Health Care Quality: Major Depressive Disorder—This discussion paper analyzes assessment tools for major depressive disorder (MDD) along the following dimensions:

  • Diagnostic status, remission, and relapse.
  • Severity of illness.
  • Patient functioning and quality of life.
  • Disease management.
  • Family social support and family burden.
  • Patient satisfaction.
  • Disease progression.

The authors make recommendations concerning effective measures to use, measurement strategy, and risk adjustment. They then describe a number of quality measurement (accountability) systems. The authors conclude that measurement tools for MDD are readily available and can be used in conducting accountability systems.

This discussion paper was written by G. Richard Smith, Cindy L. Mosley, and Brenda M. Booth, of the Center for Outcomes Research and Effectiveness, University of Arkansas for Medical Sciences. A print copy is available for free from the AHRQ Publications Clearinghouse, AHCPR Publication No. 96-N023.

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HIV Cost and Services Utilization Study

The HIV Cost and Services Utilization Study (HCSUS) was the first major research effort to collect information on a nationally representative sample of people in care for HIV infection. HCSUS examines costs of care, utilization of a wide array of services, access to care, quality of care, quality of life, unmet needs for medical and nonmedical services, social support, satisfaction with medical care, and knowledge of HIV therapies. HCSUS is funded through a cooperative agreement between AHRQ, several other Federal agencies, and RAND. HCSUS is addressing a broad array of issues relevant to public policy formulation and health services research including:

  1. Cost, use, and quality of care.
  2. Access to care.
  3. Unmet needs for care.
  4. Quality of life.
  5. Social support.
  6. Knowledge of HIV.
  7. Clinical outcomes.
  8. Mental health.
  9. The relationship of these variables to provider type and patient characteristics.

Findings: A national sample of 2,864 HIV-infected adults receiving medical care were enrolled in HCSUS. The study showed that revealing their HIV-positive status triggered physical assaults on about 45 percent of the HIV-infected people who were attacked by someone close to them. Overall, 21 percent of women, 12 percent of men who reported having sex with men, and 8 percent of heterosexual men reported physical harm after their HIV diagnosis.

Women who identified themselves as gay, lesbian, or bisexual reported partner or other relationship violence nearly as often as women who self-identified as heterosexual (24 vs. 20 percent). Yet women living with a male vs. female sexual partner were almost three times more likely to report violence after their HIV diagnosis (25 vs. 9 percent). Also, women whose CD4 cell counts were at least 500 reported nearly 75 percent more violence than women with lower cell counts, suggesting that revealing HIV status may have triggered the violence. National surveys of U.S. women aged 19-29 years in poor families indicate that 6 percent have been assaulted, which is less than one-third the rate reported by the HIV-infected women surveyed by HCSUS.

Men at higher risk of being assaulted were those who reported having sex with men, were 40 years of age or younger, were Hispanic, self-identified as gay or bisexual, had no financial assets, had a female partner, were homeless, or reported a history of drug dependence. Men with a high school education or less had nearly three times the odds of being harmed as more educated men.

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AHRQ Domestic Violence Scholar-in-Residence

Jeffrey Coben, M.D., Associate Professor of Emergency Medicine, Surgery, and Public Health at the Hahnemann School of Medicine, Medical College of Pennsylvania, and Director, Center for Violence and Injury Control at Allegheny General Hospital, West Penn Allegheny Health System, was the AHRQ Domestic Violence Scholar-in-Residence from September 2000 to July 2001. This program was co-supported by the Family Violence Prevention Fund.

Dr. Coben worked with AHRQ's Center for Outcomes and Effectiveness Research on several projects that will provide scientific information on the cost, quality, outcomes, and effectiveness of domestic violence screening and interventions available to domestic violence victims in health care settings. The Donabedian model to measure quality of health care looks at the structure, process, and outcomes of the program. AHRQ attempts to achieve its mission through health services research, a field that investigates the structures, processes, and effect of health care services. The Scholar in Residence examined health care services as they relate to domestic violence, particularly the structure and process aspects. The goal is to better define these issues.

Findings: A toolkit designed to permit a formal assessment of a hospital's performance in implementing a program to deal with intimate partner violence (IPV) is near completion. The instrument contained in this toolkit was developed based on input from a panel of 19 experts, including IPV researchers, advocates, and program planners. The Delphi process of consensus development was used, and the panelists were instructed to concentrate on structural and process measures of program performance.

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Page last reviewed January 2003
Internet Citation: Compendium of Research Related to Mental Health (continued). January 2003. Agency for Healthcare Research and Quality, Rockville, MD.