PRP040: Bayesian Analysis of a Medical Legal Partnership's Effect on Mental Health and Utilization: A Randomized Controlled Trial
Winston Liaw, MD, MPH; Robert Suchting, PhD; Thomas Northrup, PhD; Angela Stotts, PhD; Abigail Hernandez, BS
Abstract
Context: Despite calls to address social determinants of health, family physicians lack resources to deal with social needs, including health-harming legal needs (HHLNs). One promising resource is the medical-legal partnership (MLP), which embeds legal screening and referral in clinics, but more evidence is needed prior to broader implementation. Objective: The objective is to examine whether an MLP reduces stress, depression, and medical overutilization. Study Design: Randomized controlled trial. Setting: Urban, primary care clinic in Houston. Population studied: Low-income individuals, aged 18 or older, who are English or Spanish speaking with positive screens for HHLNs. Intervention: Randomization to an MLP referral or 6-month waitlist. Outcome Measures: The primary outcome was perceived stress (Perceived Stress Scale (PSS); 0-40 range). Secondary outcomes were depression (Center for Epidemiologic Studies Depression Scale (CES-D); 0-60 range with 16 or higher being consistent with a depressive disorder diagnosis), and self-reported emergency department, urgent care, and hospital visits. Assessments occur at 3, 6, and 9 months, and we report 3 month data. Generalized linear modeling was used to fit each outcome at 3-months as a function of MLP group, controlling for baseline. Bayesian statistical inference with weakly informative priors and a 75% posterior probability (PP) threshold was used to identify noteworthy differences. For this interim analysis, groups remained blinded. Results: N=160 were randomized to intervention (80) and control (80) groups. After removing assessments with missing values and non-responders, the follow up rates ranged from 73.8% to 86.3% for Group 1 and 72.5% to 90.0% for Group 2, across the outcomes. Analyses did not find meaningful group differences on the PSS (PP = 50.6%). Being in Group 2 was associated with 44% lower odds of having a CES-D score of 16 or higher (PP = 84.3%) and being hospitalized at 0.5 the rate of Group 1 (PP = 85.5%). The PP for other outcomes (urgent care, and emergency department) did not reach the 75% threshold. Conclusion: Group 2 was associated with lower hospital visits and depression scores. The six and nine month assessments are ongoing and will determine whether these differences persist and new differences emerge.
Gillian Bartlett
gillian.bartlett@missouri.health.edu 11/21/2020I look forward to hearing more of these promising results. Very interesting approach.