Are psychiatrists' characteristics related to how they care for depression in the medically ill? Results from a national case-vignette survey

Readmission rates of South Korean psychiatric inpatients by inpatient volumes per psychiatrist

BACKGROUND

Readmission rates of psychiatric inpatients are higher in South Korea than other Organization for Economic Co-operation and Development (OECD) countries. In addition, the solution for readmission control is deficient based on the characteristics of the South Korean National Health Insurance (NHI) system. Therefore, it is necessary to identify ways to reduce psychiatric inpatient readmissions. This study investigated the relationship between inpatient volume per psychiatrist and the readmission rate of psychiatric inpatients in South Korea.

METHOD

We used NHI claim data (N = 37,796) from 53 hospitals to analyze readmission within 30 days for five diagnosis (organic mental disorders, mental and behavioral disorders due to psychoactive substance use, schizophrenia, mood disorders, neurotic disorders, and stress-related and somatoform disorders) between 2010 and 2013. We performed χ2 and analysis of variance tests to investigate associations between patient and hospital-level variables and readmission within 30 days. Finally, generalized estimating equation (GEE) models were analyzed to examine possible associations with readmission.

RESULTS

Readmissions within 30 days accounted for 1,598 (4.5 %) claims. Multilevel analysis demonstrated that inpatient volume per psychiatrist were inversely related with readmission within 30 days (low odds ratio [OR]: 0.38, 95 % confidence interval [CI]: 0.28-0.51; mid-low OR: 0.48, 95 % CI: 0.36-0.63; mid-high OR: 0.55, 95 % CI: 0.44-0.69; Q4 = ref). The subgroup analysis by diagnosis revealed that both "schizophrenia, schizotypal, and delusional disorders" and "mood disorders" had inverse relationships with readmission risk for all volume groups.

CONCLUSIONS

We observed an inverse association between inpatient volume per psychiatrist and the 30-day readmission rate of psychiatric inpatients, suggesting that it could be a useful quality indicator in mental health care.

The outcomes of psychiatric inpatients by proportion of experienced psychiatrists and nurse staffing in hospital: New findings on improving the quality of mental health care in South Korea

Readmission rates for mental health care are higher in South Korea than other Organization for Economic Development (OECD) countries. Therefore, it is worthwhile to continue investigating how to reduce readmissions. Taking a novel approach, we determined the relationship between psychiatrist experience and mental health care readmission rates. We used National Health Insurance claim data (N=21,315) from 81 hospitals to analyze readmissions within 30 days of discharge for "mood disorders" or "schizophrenia, schizotypal and delusional disorders" during 2010-2013. In this study, multilevel models that included both patient and hospital-level variables were analyzed to examine associations with readmission. Readmissions within 30 days of discharge accounted for 1079 (5.1%) claims. Multilevel analysis demonstrated that the proportion of experienced psychiatrists at a hospital was inversely associated with risk of readmission (OR: 0.79, 95% CI: 0.74-0.84 per 10% increase in experienced psychiatrists). Readmission rates for psychiatric disorders within 30 days of discharge were lower in hospitals with a higher number of nurses (OR: 0.95, 95% CI: 0.94-0.96 per 10 nurses). In conclusion, health policymakers and hospital managers should make an effort to reduce readmissions for psychiatric disorders and other diseases by considering the role that physician experience plays and nurse staffing.

Competence of birth attendants at providing emergency obstetric care under India's JSY conditional cash transfer program for institutional delivery: an assessment using case vignettes in Madhya Pradesh province

BACKGROUND

Access to emergency obstetric care by competent staff can reduce maternal mortality. India has launched the Janani Suraksha Yojana (JSY) conditional cash transfer program to promote institutional births. During implementation of the JSY, India witnessed a steep increase in the proportion of institutional deliveries-from 40% in 2004 to 73% in 2012. However, maternal mortality reduction follows a secular trend. Competent management of complications, when women deliver in facilities under the JSY, is essential for reduction in maternal mortality and therefore to a successful program outcome. We investigate, using clinical vignettes, whether birth attendants at institutions under the program are competent at providing appropriate care for obstetric complications.

METHODS

A facility based cross-sectional study was conducted in three districts of Madhya Pradesh (MP) province. Written case vignettes for two obstetric complications, hemorrhage and eclampsia, were administered to 233 birth attendant nurses at 73 JSY facilities. Their competence at (a) initial assessment, (b) diagnosis, and (c) making decisions on appropriate first-line care for these complications was scored.

RESULTS

The mean emergency obstetric care (EmOC) competence score was 5.4 (median = 5) on a total score of 20, and 75% of participants scored below 35% of the maximum score. The overall score, although poor, was marginally higher in respondents with Skilled Birth Attendant (SBA) training, those with general nursing and midwifery qualifications, those at higher facility levels, and those conducting >30 deliveries a month. In all, 14% of respondents were competent at assessment, 58% were competent at making a correct clinical diagnosis, and 20% were competent at providing first-line care.

CONCLUSIONS

Birth attendants in the JSY facilities have low competence at EmOC provision. Hence, births in the JSY program cannot be considered to have access to competent EmOC. Urgent efforts are required to effectively increase the competence of birth attendants at managing obstetric complications in order to translate large gains in coverage of institutional delivery services under JSY into reductions in maternal mortality in Madhya Pradesh, India.

What are tests for? The implications of stuttering steps along the US patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.

Decision rules for GHB (γ-hydroxybutyric acid) detoxification: a vignette study

BACKGROUND

GHB dependent patients can suffer from a severe and sometimes life-threatening withdrawal syndrome. Therefore, most of the patients are treated within inpatient settings. However, some prefers an outpatient approach to treatment. The aim of this study was to develop decision rules for addiction physicians to determine whether an outpatient or inpatient setting should be chosen for a safe GHB detoxification.

METHODS

A prospective vignette study was performed. Forty addiction medicine specialists from various treatment settings and residents of the Addiction Medicine postgraduate Master training were asked to contribute vignettes of GHB dependent patients. A focus group of 15 psychiatrists and addiction medicine specialists was asked to recommend an outpatient or inpatient setting for GHB detoxification treatment per vignette. Finally, five addiction medicine specialists, experts in GHB dependence treatment in the Netherlands, assessed the bio-psychosocial reasons for the choices of the focus group and formulated the recommended criteria.

RESULTS

Based on the bio-psychosocial state of twenty vignette patients, addiction physicians and psychiatrists established the criteria and conditions recommended for the indication of an outpatient GHB detoxification. Intensity of addiction (GHB dose ≤32 g/d and frequency of abuse ≤2 h) was stated as the primary criterion in determining the setting as well as the complexity of the psychiatric comorbid disorders. The importance of a stable support system was emphasised.

CONCLUSION

The vignette study resulted in a set of criteria with which addiction medicine specialists can make a weighted decision as to an outpatient or inpatient setting for GHB detoxification.

Predicting the length of hospital stay of psychiatry patients using signal detection analysis

In Japan, the length of hospital stay (LOS) at psychiatric institutions often exceeds a year, and factors related to such stays have been identified. However, we do not know how multiple patient, hospital, and physician factors interact to determine LOS. Patient data were collected from a psychiatric hospital in Osaka, Japan. We developed subgroups, which were determined by interactions related to LOS using signal detection theory. In acute or emergency wards, five factors related to LOS were identified, and subjects were categorized into six subgroups. The indices obtained by the five factors ranged 2.49-3.47 for odds ratio, 0.47-0.84 for sensitivity, 0.40-0.76 for specificity, and 0.52-0.71 for positive predictive value. In general wards, five factors related to LOS were identified, and subjects were categorized into six subgroups. The indices obtained by the five factors ranged 3.02-5.36 for odds ratio, 0.58-0.86 for sensitivity, 0.37-0.68 for specificity, and 0.85-0.92 for positive predictive value. Psychiatrists who have been practicing longer in acute or emergency wards appear to have significantly longer stay of patients, and older or more severe patients tend to be in need of longer inpatient care. Our results provide findings that may be helpful in decreasing LOS at psychiatric hospitals.

The Evidence and Rationale for Maintenance of Licensure

Fulfilling a statutory responsibility to protect the public within their jurisdictions, state medical boards have been working with the Federation of State Medical Boards (FSMB) and collaborating organizations to thoughtfully explore pathways and procedures by which Maintenance of Licensure (MOL) may be implemented for physicians in the years ahead. As a better understanding emerges of the types of continuing medical education (CME) and continuous professional development (CPD) activities physicians already engage in, and the resources that may be necessary for state boards to meaningfully implement MOL, questions have sometimes arisen about the value of these activities in contributing to quality health care and improved patient outcomes. Though MOL has not yet been formally implemented, there is a growing body of compelling evidence and rationale for the educational activities that could meet a state board's requirements for MOL. This article summarizes the recent literature on the subject, including CME and CPD, and recent policy statements of organizations and thought leaders from the house of medicine.

Psychiatrist characteristics related to patient outcome in Japan

We evaluated psychiatric care in terms of the relationship between patient outcome (length of stay, Global Assessment of Functioning (GAF) at discharge, GAF difference, and GAF change per day) and psychiatrist characteristics (gender and years in psychiatric practice) in patients with schizophrenia, schizotypal, or delusional disorders (ICD-10 codes F20-F29) and in those with mood disorders (ICD-10 codes F30-F39). The sample consisted of inpatients discharged from an institute in Japan between April 2007 and March 2008. Multivariate analyses were performed to identify patient and psychiatrist characteristics related to outcome. We found that psychiatrist characteristics, such as gender and years in practice, were associated with GAF-related outcomes in patients in the F20-F29 and F30-F39 code groups (P < 0.05, P < 0.001, respectively). Patient characteristics and clinical factors such as GAF at admission, ward type, arrival by ambulance, admission type, seclusion, restraint, diagnosis, and patient age, were associated with outcome in both diagnostic groups. These findings show that gender and years in psychiatric practice had a significant effect on psychiatric patient outcome. Further studies in multiple institutes using a follow-up design are necessary to verify these findings.

Practitioner perceptions of attenuated psychosis syndrome

The "Attenuated Psychosis Syndrome" (APS, sometimes referred to as the "schizophrenia prodrome") is characterized by subthreshold psychotic-like symptoms and functional decline, and is often associated with significant disability. These symptoms may cause impairment and are of further interest due to their predictive relation to schizophrenia and other psychotic disorders. These symptoms currently are not represented in the diagnostic system for mental health, and it is unclear how they are conceptualized by relevant professionals. The current study surveyed a national sample (n=303) of clinical psychologists, psychiatrists, and general practitioners regarding their clinical appraisal of APS. Practitioners were asked to respond to vignettes representing three conditions: psychosis, subthreshold psychosis (indicating 'attenuated' psychosis symptoms), and no psychotic symptoms. Practitioners' responses suggested that APS is viewed consistently with a DSM-IV-TR defined mental disorder and that most clinicians may diagnose this condition as a full threshold psychotic disorder. Findings tentatively suggest that the inclusion of an attenuated psychosis symptoms category in the forthcoming DSM-5 may be helpful in improving diagnostic reliability and facilitating best practice among community practitioners.

Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists

OBJECTIVE

We surveyed child and adolescent psychiatrists (CAPs) to characterize how they diagnose bipolar disorder (BPD) in children.

METHODS

We approached by mail and then telephone 100 CAPs randomly sampled from five regions of the main professional organization of American CAPs; 53 CAPs were reached and agreed to participate. We asked about their training and practice setting, and asked them to name 10 symptoms indicative of BPD. We conducted descriptive analyses to determine how CAPs ranked symptoms, whether reports were consistent with Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria, and whether alternative symptom models might guide their decision making.

RESULTS

CAPs considered lability, grandiosity, family history of BPD, aggression, and expansive or euphoric mood as the most important factors in diagnosing BPD. Only 21 (39.6%) CAPs reported sufficient symptoms to meet DSM criteria for BPD (DSM-Yes status). DSM-Yes status was associated with participants' region, less expertise (< or =10 years practicing child and adolescent psychiatry), and lower levels of self-reported confidence in their ability to diagnose BPD.

CONCLUSIONS

CAPs vary in the symptoms they use to diagnose BPD, with most using a mixture of DSM and non-DSM symptoms. Expertise and confidence may lessen one's reliance on DSM criteria. Further studies are needed to understand CAPs' diagnostic decisions about BD and to develop interventions to support accurate diagnostic decision making and improve patient care.

Physician clinical information technology and health care disparities

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Virtual standardized patients: an interactive method to examine variation in depression care among primary care physicians

BACKGROUND: Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581-90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested. AIM AND METHOD: The primary aim of this methods-focused paper was to review the extent to which our study method - an interactive CD-ROM patient vignette methodology - was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data? FINDINGS: Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology - combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol - generated valid explanations for variations in primary care physician practice patterns related to depression care.

Patient and physician predictors of post-fracture osteoporosis management

BACKGROUND

Undertreatment of osteoporosis after hip or wrist fracture has been well documented, but the reasons for current patterns of care are poorly understood.

OBJECTIVE

We tested the role of physician and patient characteristics in predicting undertreatment when osteoporosis management was clearly indicated after a hip or wrist fracture in women over age 65.

METHODS

We assembled a cohort of 9,698 female Medicare beneficiaries aged > or = 65 years who experienced hip or wrist fracture between 2000 and 2004 and their prescribing physicians.

MEASUREMENTS

The dominant prescriber was identified as the physician prescribing at least 50% of patient prescriptions in the year after the fracture. Multivariate logistic regression estimated the role of physician and patient characteristics on osteoporosis management after hip or wrist fracture.

RESULTS

Patients older than 90 and black patients were less likely to be treated for osteoporosis relative to patients aged 65-69 and white patients. Female providers were more likely to manage osteoporosis. Models including patient characteristics discriminated well between managed and unmanaged patients (C statistic 0.81), while adding physician predictors to the model provided no additional discriminatory ability (C statistic 0.81).

CONCLUSIONS

Our findings highlight that osteoporosis management rates are similar across providers, but vary considerably by patient types.

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes

OBJECTIVES

To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions.

METHODS

Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression.

RESULTS

For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions.

CONCLUSIONS

Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.

Measuring clinical practice

The goals of this paper are to review techniques for measuring clinical practice within healthcare professions and to discuss possible applications of these techniques to primary care optometry. A review of the literature suggests a lack of systematic research investigating standards of clinical practice within optometry. It is argued that evidence-based research to determine the content of typical optometric eye examinations would be valuable for several reasons: to evaluate the service provided to the public by the profession; setting priorities and assessing the outcomes of continuous education and training; to influence governmental and professional policy decisions; National Health Service General Ophthalmic Services issues; the equitable management of clinicolegal matters and consumer complaints; setting appropriate professional guidelines and developing undergraduate training. Evidence-based studies within other healthcare professions have evaluated the content of clinical consultations. The literature reviewed reveals three main approaches: (1) abstraction of medical records, (2) use of clinical vignettes and (3) use of standardized patients (SPs) who present unannounced to clinics. In this review, we compare and contrast the use of these different methods in assessing the content of clinical consultations. It is clear from the literature reviewed that the use of SPs is the 'gold standard' methodology. Clinical vignettes can also provide useful data, especially if computerized.

Variables that influence diagnosis and treatment of the eating disorders within primary care settings: a vignette study

OBJECTIVE

This study examined the influence of clinical and nonclinical features of case presentation on the diagnosis and treatment of eating disorders in primary care.

METHOD

Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated. Outcome variables included the primary diagnosis and the treatment course selected for each case.

RESULTS

Female cases were more likely to receive an eating disorder diagnosis, even when their symptoms were identical to those of males. Nonclinical demographic variables also influenced treatment decisions. Weight status and physical comorbidity had a limited influence on treatment pathways.

CONCLUSION

Nonclinical features of case presentations are used when making eating disorder diagnoses and in selecting treatment. Decision-making in primary care does not reflect recommendations from clinical guidance, and this disparity might increase the risk of complications in the care of sub-groups of eating-disordered patients.

An automated scoring algorithm for computerized clinical vignettes: Evaluating physician performance against explicit quality criteria

OBJECTIVE

To evaluate the accuracy of an automated algorithm for scoring physicians' responses to open-ended clinical vignettes against explicit, evidence-based quality criteria.

METHODS

One hundred sixteen physicians completed a total of 915 computerized clinical vignettes at 4 sites. Each vignette simulated an outpatient primary care visit for one of 8 different clinical cases. The automated algorithm scored disease-specific quality criterion as done or not done by recognizing the presence or absence of predefined patterns in the physician's text response to the vignette. Scores generated by the automated algorithm for each criterion were compared to scores generated by trained human abstractors. Vignette responses were divided into development and test sets. Percentage agreement between automated and manual scores was computed separately for the development and test sets. Sensitivity and specificity were calculated. Costs of automated and manual scoring were compared.

RESULTS

Accuracy of the algorithm exceeds 90% for both the development and test sets, and is high for care items that were deemed either necessary or unnecessary, across diverse clinical cases, and for all domains of the outpatient clinical encounter. The sensitivity of the automated scoring algorithm is 89.0%, and specificity is 93.5%. Automated scoring is approximately 84% less expensive than manual scoring.

CONCLUSION

Automated scoring of computerized vignettes appears feasible and accurate. Computerized vignettes incorporating accurate automated scoring offer the promise of a highly standardized but relatively inexpensive measurement tool for a wide range of quality assessments within and across health systems.

The use of direct clinician observation and vignettes for health services quality evaluation in developing countries

This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality.

How does clients' method of payment influence psychologists' diagnostic decisions?

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious client intended to pay via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues.