Capturing diagnosis-timing in ICD-coded hospital data: recommendations from the WHO ICD-11 topic advisory group on quality and safety.

PURPOSE: To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data. METHODS: As part of the World Health Organization International Classification of Diseases-11th Revision initiative, the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting. RESULTS: The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators. CONCLUSIONS: As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.

International variation in the definition of 'main condition' in ICD-coded health data.

Hospital-based medical records are abstracted to create International Classification of Disease (ICD) coded discharge health data in many countries. The 'main condition' is not defined in a consistent manner internationally. Some countries employ a 'reason for admission' rule as the basis for the main condition, while other countries employ a 'resource use' rule. A few countries have recently transitioned from one of these approaches to the other. The definition of 'main condition' in such ICD data matters when it is used to define a disease cohort to assign diagnosis-related groups and to perform risk adjustment. We propose a method of harmonizing the international definition to enable researchers and international organizations using ICD-coded health data to aggregate or compare hospital care and outcomes across countries in a consistent manner. Inter-observer reliability of alternative harmonization approaches should be evaluated before finalizing the definition and adopting it worldwide.

Barriers to mental health treatment: results from the National Comorbidity Survey Replication.

BACKGROUND: The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population. METHOD: Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment. RESULTS: Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions. CONCLUSIONS: Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

Report of the Graduate Medical Education National Advisory Committee and health manpower development.

The federally chartered Graduate Medical Education National Advisory Committee projected a shortage of approximately 12,000 general and child psychiatrists by 1990. The committee's methods of analysis and recommendations have been criticized on grounds ranging from the accuracy of its data to the appropriateness of federal involvement in free-market issues. Yet the GMENAC report appears to have contributed to a recent reversal of psychiatric recruitment trends, and psychiatrists should be aware of its further implications for clinical and academic psychiatry. We analyzed the GMENAC process as one element among many that will determine future health care personnel development trends.

The 'anatomy' of research funding of mental illness and addictive disorders.

To assess the level and sources of research funding for mental illness and substance abuse fields, we undertook a systematic survey of public and private funding entities. Applying standard definitions, we found that research support in these fields totaled approximately $859 million in fiscal 1988. This level of research support for mental illness and substance abuse is extremely limited and disproportionate to the overall costs to society by these disorders. Mental disorders and substance abuse accounted for $66.8 billion in health care costs in 1988; in the same year, research on these disorders represented only 4.7% of all health research support nationwide. The three institutes of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) (namely, the National Institute of Mental Health [NIMH], the National Institute of Drug Abuse [NIDA], and the National Institute on Alcoholism and Alcohol Abuse [NIAAA]) support 64% of all mental illness and substance abuse research; other federal agencies add little more than 7.5%, with the Department of Veterans Affairs the largest at 2%. The pharmaceutical and hospital industries account for another 17% of all support; state funding is 8%, which is particularly surprising in light of the states responsibility for the chronically mentally ill. While there has been recent significant growth in the research budgets of the NIMH, the NIDA, and the NIAAA, other sectors have not grown commensurately, leaving the field vulnerable to the funding vicissitudes of these institutes. Greater coalition building and advocacy are necessary to expand the breadth and depth of research resources for the field.(ABSTRACT TRUNCATED AT 250 WORDS)

Research activities of full-time faculty in academic departments of psychiatry.

Using data collected by a 1989 American Psychiatric Association survey of full-time, salaried faculty in departments of psychiatry at US medical schools, we examined the number of faculty engaged in research, their levels of involvement in research, distribution, sources of funding, fields and topics studied, and training. Using a three-level measure of research involvement, we categorized 39.1% of the respondents as "researchers," 36% as "limited commitment researchers," and 25.1% as not involved in research. In a pattern similar to that observed for research funding in other studies, half of the researchers were concentrated in the top 15 of the 116 responding departments. Level of research involvement varied by degree type (joint-program MD/PhDs were most involved), sources of funding, fields, and topics. Among faculty with MDs, having had research experiences in medical school or postdoctoral research training was associated with a higher level of research involvement. The findings underscore the need to expand and improve postdoctoral research training--especially for MDs--and programs to recruit college and medical students into psychiatric research.

Peering into the 'black box'. Measuring outcomes of managed care.

Research on the impact of managed care on access, quality, outcomes, and costs of mental health and substance abuse services has been limited because of the lack of generalizability of studies, the "black box" focus of much of the research, the dynamic changes in mental health and substance abuse managed care, and the proprietary nature of the health care industry. This article provides a framework for understanding the organizational, financial, and procedural features of health plans and the effect of these features on the characteristics and flow of patients through health plans and the selection and utilization of treatments. The diverse research priorities of key stakeholders, i.e., public and private purchasers, managed care organizations, providers, and patients and their families, are described along with a broader societal agenda for delineating the outcomes of health care plans. Critical research and methodologic issues in studying the effects of managed care are outlined, including issues related to identifying and selecting appropriate outcome measures and developing appropriate methods for risk adjustment to adequately control for patient selection bias. This article asserts that government, purchasers, health care plans, providers, consumers, and researchers must collaboratively develop resources and research approaches to fully evaluate the effects of managed care. To realize this objective, auspices with reasonable objectivity are needed along with access to necessary data within the black box of health care systems, a cadre of trained investigators, and sufficient research funding, including the development of an all payers fund to support clinical and health services research.

Psychiatric consultations in short-term general hospitals.

We investigated the use of psychiatric consultations in short-term general hospitals using a national sample of 327 hospitals and examining the hospital experience of approximately 263,000 patients discharged from these hospitals. We found that the demographic characteristics of patients receiving psychiatric consultations in the national sample were roughly similar to those reported for patients receiving consultations in earlier, single-hospital studies. Rates of consultation were considerably lower, however: 0.9%, compared with a median rate of 3.3% reported in the literature. We also found that patients receiving psychiatric consultations used more hospital resources than other patients.

Career, research involvement, and research fellowship plans of potential psychiatrists.

For this investigation, we used Association of American Medical Colleges survey data to compare the career, research involvement, and research fellowship plans of 532 senior medical students in 1985 intending to specialize in psychiatry with plans of 10,516 students designating other specialty preferences, and discriminant analyses to identify factors associated with psychiatry students' career, research, and fellowship plans. Although a higher percentage of the psychiatry students planned academic or research careers than did their classmates in the other specialties (34.6% vs 27.8%), a lower percentage expected to take a research fellowship (15.4% vs 20.7%). In the multivariate analysis, medical school experience variables such as research, publication, and exposure to a research-oriented environment all were associated with plans for a career in academic medicine or research, exclusive or significant research involvement, and plans to complete a research fellowship.

Sex differences in rank attainment and research activities among academic psychiatrists.

Data from a survey distributed to all full-time faculty in academic departments of psychiatry were used to examine possible sex differences in research activities and rank attainment among psychiatrists. A total of 1923 psychiatrists responded, 1564 men (81.3%) and 359 women (18.7%). Continuous dependent variables were analyzed by using analyses of covariance with the year graduated from medical school as a covariate. For categorical dependent variables, the sample was divided into four 10-year cohorts based on the year graduated from medical school, and differences between men and women were analyzed with chi 2 tests. Over the entire sample, men were more likely than women to have had research training, to have ever been principal investigators on peer-reviewed grants, to mentor research trainees, to be currently involved in research activities, and to meet defined criteria as a "researcher." Many gender differences remained significant after controlling for seniority and research training. In every cohort, the men had attained higher academic rank than the women. In general, differences in research activity and productivity were most marked in the youngest cohort. To ensure a rich talent pool for psychiatric research, efforts must be made to recruit and support researchers from among the increased number of women in psychiatry.

Antidepressant prescribing practices of outpatient psychiatrists.

BACKGROUND: The authors examined recent changes in the number and proportion of patients prescribed antidepressants by psychiatrists in outpatient private practice and characterized antidepressant prescription patterns by patient age, sex, race, payment source, and clinical diagnosis. METHODS: The authors analyzed physician-reported data from the 1985 and 1993-1994 National Ambulatory Medical Care Survey, focusing on visits to physicians specializing in psychiatry. Logistic regressions were used to examine associations between survey year and antidepressant prescription, adjusting for the presence of other variables. RESULTS: The proportion of outpatient psychiatric visits in which an antidepressant was prescribed increased from 23.1% (95% confidence interval [CI], 19.7%-26.5%) in 1985 to 48.6% (95% CI, 47.5%-49.7%) in 1993-1994. After controlling for several patient variables, psychiatric patients were approximately 2.3 (95% CI, 1.8-2.9) times more likely to receive an antidepressant in 1993-1994 than in 1985. In 1993-1994, selective serotonin reuptake inhibitors accounted for approximately half of the psychiatric visits with an antidepressant prescription. Increases in the rate of antidepressant prescription were particularly evident for children and young adults; whites; new patients; and patients with adjustment disorders, personality disorders, depression not otherwise specified or dysthymia, and some anxiety disorders. CONCLUSIONS: During the late 1980s and early 1990s, there was a significant increase in the prescription of antidepressants by office-based psychiatrists. This increase was greatest for patients with less severe psychiatric disorders.

Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network.

Despite extensive studies on the epidemiology of mental disorders and advances in the treatment of these conditions, there is a paucity of detailed information concerning the characteristics of psychiatric patients and how treatments are administered in routine psychiatric practice. This 1997 observational study collected detailed information from 417 psychiatrists on the demographic, diagnostic, clinical, and treatment characteristics of a systematic sample of 1228 patients. Six hundred thirty-seven patients (51.9%) were women and the mean patient age was 41.9 years. The most common diagnostic category (53.7%) was mood disorders, followed by schizophrenia/psychotic disorders (14.6%), anxiety disorders (9.3%), and disorders of childhood (7.7%). Six hundred seventy-one patients (54.6%) had at least one comorbid Axis I condition and almost half (49.8%) had a history of psychiatric hospitalization. Patients received a mean of 2.0 psychotherapeutic medications, most commonly antidepressants (62.3%). Findings demonstrate that psychiatrists in routine practice treat a patient population with severe, complex conditions.

Use of benzodiazepines in the community.

BACKGROUND: Although benzodiazepines are the most commonly prescribed psychotropic medications in the United States, considerable controversy surrounds their proper role in medical practice. METHODS: Data from the household section of the 1987 National Medical Expenditure Survey were analyzed to estimate the prevalence and general characteristics of adults who purchased benzodiazepines in 1987. RESULTS: An estimated 6.2% (10.9 million) of the adult population purchased benzodiazepines in 1987. In nearly half (47.0%) of the purchases, the use of benzodiazepines perceived by the patient did not correspond to a labeled or literature-supported unlabeled use. Multivariate analysis disclosed that benzodiazepine use was predicted by sociodemographic factors (white race, female gender, age older than 64 years, and unemployed work status), pharmacologic factors (use of an antidepressant), mental health factors (high levels of anxiety), and general health factors (poor general health, cardiac disease, arteriosclerosis, health-related work impairment, and trouble walking one block). CONCLUSIONS: These data indicate that benzodiazepine use is less prevalent than previously reported and suggest that there has been a recent decline in use. A marked discrepancy exists between why people perceive they purchase benzodiazepines and the recognized uses of these medications.

Linking general health and mental health systems of care: conceptual models of implementation.

Recent political and scientific developments have contributed to a growing recognition of the need to move mental health into the mainstream of general health service delivery. It is important to systematically approach the development of a range of conceptual models that could link these two systems. The author defines such linkage relationships in terms of three basic elements: contractual, functional, and educational. He describes six models and presents specific examples of each. He suggests the factors that should be examined to select the most effective model for a given context and presents future research needs in the field.

Outpatient psychotherapy in the United States, I: Volume, costs, and user characteristics.

OBJECTIVE: This article provides an overview of the volume, composition, and costs of outpatient psychotherapy in the United States. METHOD: Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the volume and distribution of psychotherapy visits by provider specialty, setting, source of expenditure, and reason for visit. An examination was made of the demographic characteristics, health status, and mental health utilization profile of psychotherapy users. RESULTS: In 1987, Americans made 79.5 million outpatient psychotherapy visits at a total cost of $4.2 billion. Most of these visits were to mental health specialists (more than 80%) and were reported to be for the treatment of mental health conditions (63.5%). However, psychotherapy was not provided in a substantial proportion of the visits to mental health specialists (21.1%) or the visits to treat mental conditions (29.8%). Separated and divorced persons, females, whites persons aged 35 to 49 years, and those with more than 15 years of education had a greater likelihood of using psychotherapy. Psychotherapy use was also greater among persons in poor general health and those reporting health-related functional impairments. General medical costs of psychotherapy users exceeded those of nonusers. CONCLUSIONS: Psychotherapy accounts for approximately 8% of outpatient medical care costs. Users of psychotherapy appear to be more distressed than is commonly assumed: they report poorer general health, higher general medical costs, and more functional impairment than nonusers. Although mental health specialists commonly provide psychotherapy to treat mental disorders, all mental health care is not psychotherapy.

Outpatient psychotherapy in the United States, II: Patterns of utilization.

OBJECTIVE: The purpose of this article is to characterize the use of psychotherapy based on episode duration. METHOD: Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the demographic characteristics, provider and reason for visit distribution, mental and physical health status, and expenditures associated with very short-term (one to two sessions), short-term (three to 10 sessions), intermediate-term (11 to 20 sessions), and long-term (> 20 sessions) psychotherapy. RESULTS: Long-term psychotherapy accounted for 15.7% of psychotherapy users and 62.9% of total psychotherapy expenditures. Age above 65 years, black race, and less than 12 years of education decreased the likelihood of receiving long-term psychotherapy. Whereas long-term psychotherapy episodes tended to be provided by the specialty sector (65.7%) for specific mental conditions (53.8%), very short-term episodes were predominantly provided by the general medical sector (72.2%) for general medical or unspecified conditions (68.3%). Psychotropic medication use and, to less extent, psychiatric hospitalization tended to be more common among longer- as opposed to shorter-term users. CONCLUSIONS: Long-term and short-term psychotherapy tend to be provided by different health care professionals for the treatment of different types of health conditions. To help ensure the future of third-party payment for long-term psychotherapy, research is needed to better define the conditions under which long-term psychotherapy achieves benefits that equal or surpass those of other medical services or procedures of similar cost.

Outpatient mental health care in nonhospital settings: distribution of patients across provider groups.

OBJECTIVE: A national overview of outpatient mental health care in nonhospital settings is provided, focusing on the distribution of patients among psychiatrists, psychologists, general medical physicians, and other health professionals. METHOD: Data from the household section of the 1987 National Medical Expenditure Survey were analyzed to determine the volume and characteristics of patients receiving mental health care from these four professional groups. RESULTS: In 1987 an estimated 4.1% of noninstitutionalized Americans (9.0 million) made 84 million outpatient mental health visits to nonhospital settings. Psychiatrists provided significantly more visits than psychologists for schizophrenia, bipolar disorder, substance abuse, and depression, but significantly fewer visits for anxiety disorders and symptoms such as "nervousness." General medical physicians provided the most visits for adjustment disorders and substance abuse, while the other professionals provided the most visits for childhood mental disorders and mental retardation. CONCLUSIONS: In 1987 important differences existed between the outpatients who received mental health care from psychologists, psychiatrists, general medical physicians, and other health professionals.

Challenges to academic psychiatry.

Economic constraints, effects of retrenchments in federal health policy, and increased competition for resources are challenging all sectors of academic medicine. Departments of psychiatry are at particular risk during this era for reasons including the lack of a sound research and research training base in many psychiatry departments; the small number of students entering the field and implications therein for the availability of residency slots in psychiatry; and patterns of allocating resources within academic medical centers which, combined with biases in reimbursement policy toward cognitively based specialties, threaten the economic strength of psychiatric departments. A conceptual model based on marketing principles is proposed to aid in identifying and capitalizing on the unique strengths of the field.

The cost-effectiveness of psychotherapy: a plan for research.

The authors assess gaps in the current knowledge base on psychotherapy research and the cost-effectiveness of psychotherapy. Despite the considerable and increasingly sophisticated body of research on the efficacy of psychotherapy, there is an alarming paucity of studies focusing on the cost-effectiveness of psychotherapy. This problem is particularly evident in the absence of studies exploring nonclinical effects of treatment and the broader range of domains in which intervention may have an impact. Initiation of research on the cost-effectiveness of psychotherapy is important for ensuring good clinical practice and data-based policy formulation. What is needed is greater specificity regarding the populations and problems for which psychotherapy can provide the greatest benefits, identification of the variables, measures, and methodological approaches that are most useful in yielding these important data, and comprehensive quantification of the costs and effects of psychotherapy.

Pharmacotherapy in outpatient psychiatric practice.

OBJECTIVE: This article examines some of the factors that influence the extent to which psychiatrists provide pharmacotherapy to their outpatients. METHOD: Data from the 1988-1989 APA Professional Activities Survey are used to define the characteristics of psychiatrists who prescribe medications to a high, medium, and low proportion of their outpatients in treatment. Outpatient assessments, evaluations, or consultations were excluded from this analysis. Correlations between psychiatric practice characteristics and rates of pharmacotherapy are examined. RESULTS: One-third of psychiatrists prescribed medications to less than 46.7% of their outpatients, one-third prescribed medications to between 46.7% and 84.6%, and one-third prescribed medications to over 84.6% of their outpatients. The psychiatrists in the last group included a proportionately higher number of young psychiatrists, men, nonwhites, those without psychoanalytic or child psychiatry training, those with larger caseloads, and those who worked in the public sector. These psychiatrists also treated a disproportionately large number of patients with schizophrenia and related psychotic disorders. In a multivariate model, clinical, practice, and educational variables, but not demographic variables, were found to correlate with the extent of pharmacotherapy provided. CONCLUSIONS: Psychiatrists vary widely in the extent to which they are involved in prescribing psychotropic medications. The diagnostic composition of their caseload, their work setting, and their educational background, but not their demographic characteristics, appear to influence the extent of their involvement.