Illusory generalizability of clinical prediction models.

It is widely hoped that statistical models can improve decision-making related to medical treatments. Because of the cost and scarcity of medical outcomes data, this hope is typically based on investigators observing a model's success in one or two datasets or clinical contexts. We scrutinized this optimism by examining how well a machine learning model performed across several independent clinical trials of antipsychotic medication for schizophrenia. Models predicted patient outcomes with high accuracy within the trial in which the model was developed but performed no better than chance when applied out-of-sample. Pooling data across trials to predict outcomes in the trial left out did not improve predictions. These results suggest that models predicting treatment outcomes in schizophrenia are highly context-dependent and may have limited generalizability.

Factors Associated With Inpatient Hospice Utilization Among Hospitalized Decedents With Comfort Measures Only Status.

Background: Patients with serious illness may elect to transition their care to comfort measures only (CMO) while in the hospital. Although studies have shown that routine hospice care is underutilized, the rate of general inpatient hospice (GIP) use among CMO patients during their terminal admission remains unclear. Objectives: We sought to (1) examine the rate of GIP utilization and (2) identify factors associated with its use among hospitalized CMO decedents. Methods: CMO decedents in two academic, tertiary care hospitals in the United States who died between October 1, 2020 and October 31, 2021, were subgrouped based on their primary medical service (GIP vs. non-GIP) at the time of inpatient death. Data abstracted from the electronic health record included demographics, primary diagnosis codes, Rothman Index (RI), time of CMO order, ordering clinician type, time of death, and length of stay (LOS). Multivariable logistic regression analysis was performed, adjusting for relevant covariates. Results: Of 1475 CMO decedents, only 321 (n = 22%) patients received GIP. On multivariable analysis, CMO patients who died in an ICU were five times less likely (odds ratio [OR] = 0.18, confidence interval [95% CI] 0.11-0.29) to receive GIP. Every 10-point increase in RI raised the likelihood of receiving GIP by 59% (OR = 1.59, 95% CI 1.39-1.80). Conclusions: Most CMO decedents died in the hospital without GIP. Compared with GIP decedents, non-GIP decedents were less acutely ill. There was no difference in total LOS between the two groups. CMO decedents were much less likely to receive GIP in an ICU. The RI may help clinicians identify CMO patients who would benefit from GIP earlier in their terminal admission.

Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers.

OBJECTIVE: Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap. METHODS: Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378). RESULTS: Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia. CONCLUSIONS: VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.

Provision of Non-English Language Services in U.S. Mental Health Facilities.

OBJECTIVE: This study aimed to examine the proportion of U.S. mental health facilities that provide non-English language services. METHODS: Using data from the 2018 National Mental Health Services Survey, the authors examined differences between mental health facilities that provided non-English language services and those that did not across 23 organizational characteristics. Further analyses compared facilities by their method of language service provision. RESULTS: Of 7,503 facilities, 5,186 (69.1%) provided non-English language services. These facilities were more likely than others to have high patient volume, be publicly owned, and be located in the 10 states with the highest percentage of residents with limited English proficiency. Among facilities with language services, 592 (11.4%) relied on multilingual staff, 2,532 (48.8%) relied on external on-call interpreters, and 2,062 (39.8%) relied on both. CONCLUSIONS: Most mental health facilities provide non-English language services, and those that do tend to be large public organizations located in areas of greatest need.

PTSD and the War of Words.

Trauma-related symptoms among veterans of military engagement have been documented at least since the time of the ancient Greeks.1 Since the third edition of the Diagnostic and Statistical Manual in 1980, this condition has been known as posttraumatic stress disorder, but the name has changed repeatedly over the past century, including shell shock, war neurosis, and soldier's heart. Using over 14 million articles in the digital archives of the New York Times, Associated Press, and Reuters, we quantify historical changes in trauma-related terminology over the past century. These data suggest that posttraumatic stress disorder has historically peaked in public awareness after the end of US military engagements, but denoted by a different name each time-a phenomenon that could impede clinical and scientific progress.