Understanding Mechanisms of Mental Health Care Disparities

描述（由申请人提供）：本提案有两个主要目标：1)制定一个精神卫生保健差距指数，用于各州精神卫生保健报告卡；2)使用网络交互式地图传播指数的结果，并从国家决策者那里获得关于报告和结果的初步反馈。有必要制定一个以州为基础的精神卫生保健差距指数，以一种简明、易于使用的工具来评估和跟踪差距，从而改进从研究到政策的转化。然而，在将多个差距衡量指标简化为一个数字方面存在困难，包括确定差距指标的最佳权重以及确定各州在缩小差距方面取得成功的阈值的选择。我们首先使用来自政策制定者、倡导者和临床医生的定性访谈的信息来引出最突出的结构和变量，以纳入指数。在此基础上，运用现代检验理论方法（验证性因子分析和潜变量模型）构建了一个综合心理卫生保健启动、支出和质量差异六个指标的指数，并对该指数的内部效度和外部效度进行了优化。我们使用贝叶斯小区域估计和分层建模来克服小样本量和嵌套数据，使用2004-2009年医疗支出小组调查的限制和公共使用数据。为了确保广泛传播和使用，我们使用交互式地图来呈现结果，该地图允许展示和操作州级差异指数组成数据。将征求各州决策者的反馈意见，以更好地了解他们对报告和指数结果的反应，以及他们对其所在州精神卫生保健差异气候背后机制的解释。

DESCRIPTION (provided by applicant): There are two main objectives of this proposal: 1) to develop a mental health care disparities index to be used in state mental health care report cards; and 2) to disseminate the results of the index using web-enabled interactive maps and receive initial feedback on the presentation and results from state policymakers. There is a need for developing a state-based mental health care disparities index to improve translation from research to policy with a concise, readily useable tool for assessing and tracking disparities. However, difficulties arise in reducing multiple disparities measures into a single number, including identifying the optimal weighting of disparities indicators and the choice of thresholds determining states' success in reducing disparities. We first use information from qualitative interviews of policymakers, advocates and clinicians to elicit the most salient constructs and variables to be included in the index. We then develop an index using modern test theory methods (confirmatory factor analysis and latent variable modeling) that combines six indicators of mental health care initiation, expenditure, and quality disparities while optimizing the internal and external validity of the index. We use Bayesian small area estimation and hierarchical modeling to overcome small sample sizes and nested data using restricted and public use data from the 2004-2009 Medical Expenditure Panel Survey. To ensure wide dissemination and use, we present results using interactive maps that allow for the presentation and manipulation of state-level disparities index component data. Feedback from state policymakers will be elicited to better understand their reactions to the presentation and the results of the index and their interpretation of the mechanisms underlying the mental health care disparities climate in their state. PUBLIC HEALTH RELEVANCE: In this project, we develop a disparities index to create a state-by-state mental health care disparities report card. We aim to develop an index/report card that is salient and has face validity for policymakers and advocates, while being backed by rigorous quantitative and qualitative methods. The methods used to develop the report card are small area estimation and modern test theory methods enhanced by key informant interviews. For the second part of the proposed project, we focus on the dissemination of the index/report card, using a web-enabled geographic information systems setup to present information in an easily accessible and interactive manner. The results and presentation of the index/report card will be shown to state mental health directors for feedback and to inform future directions in the development of the index and in understanding policy mechanisms underlying mental health care disparities.