Trends in Medicare Part B Spending on Discarded Drugs, 2017-2020.

This cross-sectional study quantifies trends in discarded drug spending since the onset of mandated reporting.

The oversight of autonomous artificial intelligence: lessons from nurse practitioners as physician extenders.

The development of autonomous artificial intelligence (A-AI) products in health care raises novel regulatory challenges, including how to ensure their safety and efficacy in real-world settings. Supplementing a device-centered regulatory scheme with a regulatory scheme that considers A-AI products as a 'physician extender' may improve the real-world monitoring of these technologies and produce other benefits, such as increased access to the services offered by these products. In this article, we review the three approaches to the oversight of nurse practitioners, one type of physician extender, in the USA and extrapolate these approaches to produce a framework for the oversight of A-AI products. Under the framework, the US Food and Drug Administration would evaluate A-AI products and determine whether they are allowed to operate independently of physician oversight; required to operate under some physician oversight via a 'collaborative protocol' model; or required to operate under direct physician oversight via a 'supervisory protocol' model.

Predictors of frequent emergency department use among patients with psychiatric illness.

OBJECTIVE: To identify the patient characteristics associated with frequent emergency department (ED) use and develop a tool to predict risk for returning in the next month. METHOD: Prospective cohort study of 863 adults with psychiatric illness presenting to one of four general hospital EDs. ED visits and relevant clinical information in the year before and one month after the index visit were abstracted. RESULTS: One hundred sixty-seven of the patients (19%) were considered frequent users. Characteristics associated with frequent user status were homelessness, cocaine-positive toxicology screen, Medicare insurance, a personality disorder and hepatobiliary disease (all P<.05). Patients scoring in the highest risk category had nearly five times the odds of returning to the ED in the month subsequent to the index visit. CONCLUSIONS: Psychiatric patients with frequent ED use are a heterogeneous group, but there are specific target conditions which, if confirmed, may facilitate reduced ED use and be replaced by more appropriate treatment.

Race/ethnicity and other social determinants of psychological well-being and functioning in mental health clinics.

Significant racial and ethnic differences exist in the receipt of psychiatric care and help-seeking. We examined the relationship between race/ethnicity and psychological well-being and functioning in psychiatric outpatients. We analyzed intake data for 8,697 adult patients in psychiatry clinics in New England between 2008 and 2010. Patients rated psychological wellbeing using the Schwartz Outcome Scale (SOS-10); clinicians rated the Global Assessment of Functioning (GAF). In an analysis of variance with covariates, race/ethnicity exhibited a small but statistically significant association with GAF (F(4,8481)=17.902, p<.001) and SOS-10 scores (F(4,8165)=7.271, p<.001). However, after adjustment for physical health and socioeconomic variables, these differences became insignificant or were reversed. Our findings suggest that the relationship between race/ethnicity and mental health may be confounded by other socioeconomic or health differences and may be small compared with the effect of those variables. Future studies on race and psychological well-being should take social determinants of health into consideration.

Interprofessional differences in disposition decisions: results from a standardized web-based patient assessment.

OBJECTIVE: This study examined differences in disposition decisions among mental health professionals using a standardized Web-based simulation. METHODS: Using a Web-based simulation that described, across users, the same complex psychiatric patient, credentialed clinicians in a psychiatry department conducted a violence risk assessment and selected a level of follow-up care. RESULTS: Of 410 clinicians who completed the simulation, 60% of psychiatrists were more likely than other types of clinicians to select higher levels of care (inpatient or emergency services) for the standardized virtual patient (odds ratio=2.67, 95% confidence interval=1.67-4.25), even after adjustment for other factors. Virtual actions taken, such as contracting with the patient for safety and discussing hospitalization, elucidated these training differences. CONCLUSIONS: Training backgrounds were important determinants of clinicians' actions and the dispositions they recommended for a psychiatric patient at high risk of self-harm and harm to others in the educational setting and may suggest the need for further training to standardize and optimize care.

Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness.

STUDY OBJECTIVE: To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS: This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS: The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION: Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Bottlenecks in the emergency department: the psychiatric clinicians' perspective.

OBJECTIVE: To ask psychiatric clinicians for their perspectives on the rate-limiting steps (RLS) in patient care in the Emergency Department (ED) and to compare them to the patient's actual length of stay. METHOD: Prospective cohort study of clinicians' perspectives on the RLS among 1092 adult ED patients. Medical records were abstracted for ED time and other data. RESULTS: Clinicians identified five RLS: limited availability of staff, limited availability of beds after discharge, need for clinical stability, need for additional history and patient's financial issues. The last RLS was the only one not associated with increased wait times in the ED. There were significant differences in the patterns of RLS by trainee status and hospital. For example, significantly higher proportions of trainees reported that RLS in patient care were due to the need for clinical stability and additional history and lack of bed availability. In contrast, non-trainee clinicians were more likely to cite problems with the availability of ED staff as an RLS. CONCLUSIONS: Most of the RLS in patient care identified by clinicians were associated with actual increases in ED wait time for their patients. Next steps include asking clinicians for possible solutions to the delays their patients experience.

Measuring outcomes in adult outpatient psychiatry.

Despite growing pressure for accountability, mental health professionals continue to debate the value of routinely measuring treatment outcomes. This paper sought to move the outcomes measurement debate forward by reviewing some of the current limitations in outcomes methodology and by providing initial strategies to address them. Using these strategies, we evaluated outcomes for a large diagnostically diverse group of adult outpatients receiving treatment as usual (TAU) within an academic medical centre. Initial self-report and clinician-rated assessments were obtained from 5546 patients, and follow-up data were obtained from 1572 (28%) patients. Using the subset of patients with the follow-up data, we determined treatment effect sizes, rates of reliable improvement (and deterioration) and rates of clinically significant improvement for all patients and for specific diagnostic groups (depression, anxiety, substance abuse, mood disorders not otherwise specified, bipolar and psychotic conditions). TAU outcomes for depression and anxiety were also compared with benchmarks derived from the randomized controlled trial literature. Lastly, the impact of patient or sample characteristics on outcome was explored. Overall, these findings generally support the benefit of TAU over no treatment while also highlighting both the utility and limitations inherent in the current approaches to evaluating treatment outcomes. Suggestions for improving outcomes measurement are provided.

Antipsychotic polytherapy on an inpatient psychiatric unit: how does clinical practice coincide with Joint Commission guidelines?

OBJECTIVE: A recently developed quality measure set for inpatient psychiatric care includes measurement of antipsychotic polytherapy at discharge. Our objective was to use detailed chart reviews to assess the use of antipsychotic polytherapy and place this use in the context of these measures. METHODS: Patients (N=75) discharged on multiple antipsychotics and a comparable set (N=114) of comparison patients (a randomly selected set of all admitted inpatients) were identified from consecutive admissions to a psychiatric inpatient unit. Medical records were reviewed to ascertain the clinical rationale for antipsychotic polytherapy and assess differences in characteristics between these groups. RESULTS: Patients discharged on antipsychotic polytherapy were more likely to have public insurance, longer lengths of stay, psychotic illness, more prior admissions, and state-funded services for persons with chronic mental illness. We identified subgroups of patients based on the clinical rationale for the antipsychotic co-prescription (refractory illness, regimen unchanged from admission and use of antipsychotic for nonpsychosis symptoms). Some, but not all, such rationales appeared to be clinically justified. CONCLUSIONS: The majority of patients discharged on antipsychotic polytherapy had justifiable clinical rationales that were concordant with the new quality measures. However, two additional subsets were identified, one where quality improvement efforts may be warranted and another where revision of existing quality measure definitions should be considered. Given the implications of public reporting of quality measures, further study and refinement of these measures are required to provide meaningful information to all concerned stakeholders.

Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: a prospective study.

STUDY OBJECTIVE: We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. METHODS: This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. RESULTS: The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. CONCLUSION: ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

Aberrant frontoparietal function during recognition memory in schizophrenia: a multimodal neuroimaging investigation.

Prefrontal-parietal networks are essential to many cognitive processes, including the ability to differentiate new from previously presented items. As patients with schizophrenia exhibit structural abnormalities in these areas along with well documented decrements in recognition memory, we hypothesized that these patients would demonstrate memory-related abnormalities in prefrontal and parietal physiology as measured by both functional magnetic resonance imaging and magnetoencephalography (MEG). Medicated outpatients with schizophrenia (n = 18) and age-matched healthy control subjects (n = 18) performed an old-new recognition memory task while physiological data were obtained. Whereas controls exhibited strong, bilateral activation of prefrontal and posterior parietal regions during successful identification of old versus new items, patients exhibited greatly attenuated activation of the right prefrontal and parietal cortices. However, within the patient group, there was strong correlation between memory performance and activation of these right-sided regions as well as a tight correlation between old-new effect-related activations in frontal and parietal regions, a pattern not seen in control subjects. Using MEG, control subjects-but not patients-exhibited a sequential pattern of old > new activity in the left posterior parietal cortex and then right prefrontal cortex; however, patients uniquely exhibited old > new activity in right temporal cortex. Collectively, these findings point to markedly different distributions of regional specialization necessary to complete the old-new item recognition task in patients versus controls. Inefficient utilization of prefrontal-parietal networks, with compensatory activation in temporal regions, may thus contribute to deficient old-new item recognition in schizophrenia.

MTHFR 677C --> T genotype disrupts prefrontal function in schizophrenia through an interaction with COMT 158Val --> Met.

Understanding how risk genes cumulatively impair brain function in schizophrenia could provide critical insights into its pathophysiology. Working memory impairment in schizophrenia has been associated with abnormal dopamine signaling in the prefrontal cortex, which is likely under complex genetic control. The catechol-O-methyltransferase (COMT) 158Val --> Met polymorphism (rs4680), which affects the availability of prefrontal dopamine signaling, consistently stratifies prefrontal activation during working memory performance. However, the low-dopamine COMT 158Val allele does not confer increased risk for schizophrenia, and its effects on prefrontal function are not specific to the disorder. In the setting of other genetic variants influencing prefrontal dopamine signaling, COMT 158Val --> Met genotype may exert disease-specific effects. A second polymorphism, methylenetetrahydrofolate reductase (MTHFR) 677C --> T (rs1801133), has been associated with overall schizophrenia risk and executive function impairment in patients, and may influence dopamine signaling through mechanisms upstream of COMT effects. We found that the hypofunctional 677T variant was associated with decreased working memory load-dependent activation in the prefrontal and insular cortices in 79 schizophrenia patients, but not in 75 demographically matched healthy controls. Further, significant MTHFR x COMT genotype interactions were observed, which differed by diagnostic group: Reduced prefrontal activation was associated with the 677T and 158Val alleles in patients, but with 677C/C and 158Met/Met genotype in controls. These findings are consistent with epistatic effects of the COMT and MTHFR polymorphisms on prefrontal dopamine signaling, and suggest that in schizophrenia patients, the MTHFR 677T allele exacerbates prefrontal dopamine deficiency. The findings also suggest the importance of weighing COMT effects on prefrontal function within the context of MTHFR genotype.

No evidence for a differential deficit of reality monitoring in schizophrenia: a meta-analysis of the associative memory literature.

INTRODUCTION: Patients with schizophrenia exhibit deficits in memory performance, particularly when required to bind together disparate items (associative memory). Yet the literature on associative memory is decidedly mixed, with some studies showing large deficits and other showing none. METHODS: The aims of this meta-analysis were to determine an overall effect size for the associative memory deficit in patients with schizophrenia and to examine two potential moderating variables related to this impairment: the nature of the memory being tested (pair vs. source recognition) and the inclusion or exclusion of novel items as part of the recognition test. RESULTS: We found that the mean effect sizes were large for pair recognition (r=.50) and medium for source recognition (r=.29), with a significant difference between the two recognition types. Contrary to a priori hypotheses, there were no differences in the effect sizes across the various types of source memory (i.e., internal, external, or reality monitoring). There was, however, a significant difference in the effect sizes between those studies that included novel items as part of the memory test (r=.26) and those that did not (r=.44). CONCLUSION: These findings suggest that the associative memory deficit in schizophrenia is not specific to self/other distinctions, but is rather a more global effect seen across testing conditions. In addition, memory tests that do not include new items appear to maximise this effect, perhaps by removing a potential response outlet for subjects who lack confidence in the accuracy of their memory performance.

Reach of benchmark psychiatric trial results to community-based providers: a case study of CATIE.

OBJECTIVE: To evaluate the familiarity of front-line clinicians with findings from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), the influence of didactic continuing medical education on provider knowledge about key details of CATIE, and how location-related factors affect rates of pre-event knowledge and intraevent learning about CATIE. METHOD: Data derived from the Massachusetts General Hospital Psychiatry Academy (MGH-PA) semester II live symposia provided in different cities nationally between September and December 2006 were analyzed to evaluate providers' self-assessment of their knowledge about CATIE. In addition, participants were also asked a preactivity and postactivity question to assess learning of material presented during the live event psychosis lecture. Descriptive statistics were utilized to characterize participants' self-assessment of knowledge about CATIE, while parametric and nonparametric statistical tests were used to evaluate the degree of observed learning and the effect of lecture location on the results. RESULTS: 3333 participants (mean attendance: N = 278 per event) attended 1 of the 12 MGH-PA live symposia. Of the subsample of providers who treat schizophrenia, 51% indicated that either they had never heard of CATIE or they were not familiar enough with its results to change their practice. Overall, the proportion of correct answers on the postactivity question was 65%, compared with 24% prior to the lecture (chi(2) = 48.68, df = 1, p < .001). Degree of learning did not differ among symposium locations. CONCLUSION: In this sample, the CATIE study had very limited dissemination to, and impact on, a geographically and occupationally diverse sample of mental health practitioners. Robust learning of a key methodologic detail of this trial was evidenced across symposium locations.

Effects of transdermal nicotine on episodic memory in non-smokers with and without schizophrenia.

RATIONALE: Nicotinic agonists may improve attention and memory in humans and may ameliorate some cognitive deficits associated with neuropsychiatric disorders such as schizophrenia. MATERIALS AND METHODS: We investigated the effects of a single dose of nicotine on episodic memory performance in 10 adults with schizophrenia and 12 healthy controls. Participants were nonsmokers in order to avoid confounding effects of nicotine withdrawal and reinstatement on memory. At each of two study visits, participants performed a test of episodic memory before and 4 h after application of a 14-mg transdermal nicotine (or identical placebo) patch in counterbalanced order. RESULTS: Compared with placebo, nicotine treatment was associated with more rapid and accurate recognition of novel items. There was a trend for a treatment by diagnosis interaction, such that the effect of nicotine to reduce false alarms was stronger in the schizophrenia than the control group. There was no effect of nicotine on accuracy or reaction time for identification of previously viewed items. CONCLUSIONS: These data suggest that nicotine improves novelty detection in non-smokers, an effect that may be more pronounced in non-smokers with schizophrenia. Because memory deficits are associated with functional impairment in schizophrenia and because impaired novelty detection has been linked to the positive symptoms of schizophrenia, study of the effects of chronic nicotinic agonist treatment on novelty detection may be warranted.

Auditory stimulus repetition effects on cortical hemoglobin oxygenation: a near-infrared spectroscopy investigation.

The cortical response to repeated sensory stimuli plateaus (or declines) as repetition frequencies increase beyond 2-8 Hz. This study examined the underlying changes in cortical oxygenated and deoxygenated hemoglobin associated with this phenomenon using near-infrared spectroscopy. The optical signal was measured from 11 healthy volunteers listening to noise-burst trains presented at 2, 10, and 35 Hz. In a bilateral region consistent with the posterior superior temporal gyrus there was an inverse relationship between deoxyhemoglobin concentration change and stimulus frequency: greatest at 2 Hz, intermediate at 10 Hz, and smallest at 35 Hz. These findings provide preliminary support for a relationship between the perceptual characteristics of auditory stimuli and modulation of cortical oxygenation as measured via an emerging neuromonitoring technique.