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.

A framework for measuring quality and promoting accountability across silos: the case of mental disorders and co-occurring conditions.

BACKGROUND: Quality measures can be effective tools for improving delivery of care and patient outcomes. Co-occurring conditions (COCs), including general medical conditions and substance use disorders, are the rule rather than the exception in patients with serious mental health disorders and lead to substantial morbidity and mortality burden. COCs among persons with mental health disorders are often treated by separate systems ("silos") in the US healthcare system, making it difficult to establish expectations for performance, assign accountability for measure results and ultimately improve quality of care for this group. OBJECTIVES: A framework for measuring quality of care for COCs is proposed by reviewing the current state of quality for COCs and examples of quality measures based on the Donabedian model. METHODS AND FRAMEWORK: The framework will also be applied to better define which providers are accountable for quality improvement, to ultimately ensure that quality measures have an impact on improving care for COCs.

Depression in primary care: linking clinical and systems strategies.

Depression is a serious, often chronic disease that can be managed effectively with a chronic care model in primary care settings. Depressed persons are likely to be seen by a primary care physician, but their condition often goes unrecognized and untreated. There are effective treatment models that consist of efficacious psychotherapeutic and pharmacological interventions, use of evidence-based guidelines for primary care treatment of depression, development of explicit plans and protocols, reorganization of practice, longitudinal follow-up, patient self-management, decision-making support, access to community resources and leadership commitment. Moving these models into everyday practice requires overcoming both clinical and system barriers. Barriers consist of issues surrounding patients, providers, practices, plans, and purchasers. An understanding of these barriers at each level helps to provide a framework for the changes required to overcome them. The Robert Wood Johnson Foundation National Program on Depression in Primary Care will seek to apply simultaneously both clinical and system strategies in a new five-year initiative to overcome these barriers.

The societal costs of chronic major depression.

Major depression is a widespread, often chronic disorder affecting the individual, his or her family, and society as a whole. It incurs tremendous social and financial costs in the form of impaired relationships, lost productivity, and lost wages. Although chronic major depression is eminently treatable, it continues to be undertreated and underrecognized. This is particularly true in primary care settings, where physicians are usually the first to encounter chronic depression but are seldom trained to distinguish depression from other medical illnesses with similar symptoms. In addition, because of the stigma attached to depression, patients often characterize their symptoms as part of a physical illness or fail to report them to a clinician at all. This article discusses the epidemiology of depression, its impact and burden on society, and its special character (including diagnosis and treatment) as a chronic illness.

Comparing the national economic burden of five chronic conditions.

Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and hypertension. Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses. Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs. The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.

Large medical databases, population-based research, and patient confidentiality.

OBJECTIVE: This article is a discussion of the use of large clinical databases in population-based research on psychiatric disorders. METHOD: The authors review uses of large clinical databases in research on the etiology, impact, and treatment of psychiatric disorders. They also describe existing privacy safeguards applicable to use of medical records data in research. RESULTS: The growth of large medical databases has prompted increasing concern about the confidentiality of patient records. Efforts to restrict access to computerized medical data, however, may preclude use of such data in important and legitimate research. Prior research using large medical databases has made important contributions across a broad range of topics, including epidemiology, genetics, treatment effectiveness, and health policy. Continued population-based research will be essential in order to preserve the accessibility and quality of treatment for people with psychiatric disorders. CONCLUSIONS: Public domain research should be distinguished from proprietary or commercial uses of health information, and existing privacy safeguards should be vigorously applied. In our efforts to protect patient privacy, however, we should take care not to endorse or reinforce prejudices against psychiatric treatment and people who suffer from psychiatric disorders. Neither should we ignore important opportunities to improve quality of care and influence public policy through population-based research.

Psychiatric care of patients with depression and comorbid substance use disorders.

BACKGROUND: The goal of this study was to describe the sociodemographic and clinical characteristics and routine psychiatric care of depressed patients with or without substance use disorders (SUDs) and to assess the association between the presence of comorbid SUD and the psychiatric management of patients with depression. METHOD: Each of a sample of 531 psychiatrists participating in the Practice Research Network (PRN) of the American Psychiatric Institute for Research and Education was asked to provide information about 3 randomly chosen patients. Data were collected using a self-administered questionnaire, which generated detailed diagnostic and clinical data on 1228 psychiatric patients. Weighted data were analyzed using the SUDAAN software package. Multivariate logistic regression was used to compare depressed patients with and without SUD. RESULTS: A total of 595 patients (48.4%) were diagnosed with depression (DSM-IV criteria). The prevalence of SUD (excluding nicotine dependence) in this group was 18.1%. The group with SUD had a significantly larger proportion of males, young adults, patients seen in public general hospitals, and non-managed care public plans. No significant group differences were found for primary payer, locus of care, length of treatment, type of current or past treatment, and prescription of medications. Only 2.2% of SUD patients were prescribed with an anti-SUD medication (i.e., disulfiram and naltrexone). CONCLUSION: Concomitant SUDs have little effect on the routine psychiatric care of depressed patients. Efforts should be made to improve the identification and management of depressed patients with SUD.

Understanding disability in mental and general medical conditions.

OBJECTIVE: This study characterized the prevalence, characteristics, and impact of mental and general medical disabilities in the United States. METHOD: The 1994-1995 National Health Interview Survey of Disability was the largest disability survey ever conducted in the United States. A national sample was screened for disability, defined as limitation or inability to participate in a major life activity. Analyses compared cohorts who attributed their disability to physical, mental, or combined conditions. RESULTS: Of 106,573 adults, 1.1% reported functional disability from mental conditions, 4.8% from general medical conditions, and 1.2% from combined mental and general medical conditions. Disabilities attributed to a mental condition were predominantly associated with social and cognitive difficulties, those attributed to general medical conditions with physical limitations, and combined disabilities with deficits spanning multiple domains. In multivariate models, comorbid medical and mental conditions were associated with a twofold increase in odds of unemployment and a two-thirds increase in odds of support on disability payments compared to respondents with a single form of disability. More than half the nonworking disabled reported that economic, social, and job-based barriers contributed to their inability to work. One-fourth of working disabled people reported discrimination on the basis of their disability during the past 5 years. CONCLUSIONS: An estimated three million Americans (one-third of disabled people) reported that a mental condition contributes to their disability. Mental, general medical, and combined conditions are associated with unique patterns of functional impairment. Social and economic factors and job discrimination may exacerbate the functional impairments resulting from clinical syndromes.

Recent patterns and predictors of antipsychotic medication regimens used to treat schizophrenia and other psychotic disorders.

Up-to-date data are needed on the types of treatments used by psychiatrists and the reasons for use of particular treatments. Using 1997 American Psychiatric Association (APA) Practice Research Network (PRN) Study data on patients with schizophrenia and other psychotic disorders, we identified the characteristics of antipsychotic medications (APMs) currently being prescribed and factors associated with the use of particular regimens. In this study population, use of the newer APMs, including risperidone, olanzapine, and clozapine, has increased rapidly and now accounts for over one-half of all APM use. Other intriguing findings include the fact that one-sixth of patients with schizophrenia and other psychotic disorders are concurrently treated with two or more APMs. Factors associated with being prescribed one of the newer APMs risperidone or olanzapine include being elderly, having more education, being white, having psychiatric comorbidity, and making fewer recent visits to a psychiatrist. The APA PRN Study data are an important new resource for mental health services researchers.

Referrals to psychiatrists. Assessing the communication interface between psychiatry and primary care.

The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N = 542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists' level of satisfaction was related to the quantity and quality of information provided by referring physicians.

Alcohol abuse and dependence in a national sample of psychiatric patients.

OBJECTIVE: To examine clinical characteristics and services being provided to Alcohol Abuse/Dependent (AAD) patients in current psychiatric practice. METHOD: In a national sample of psychiatrists (N = 417), each provided data on three preselected patients (N = 1,245; 51.8% women) that included demographics, DSM-IV diagnoses, treatment setting and health-plan measures. Logistic regression was used to compare patients with and without an AAD diagnosis. RESULTS: Only 12% of patients (n = 151) had an AAD diagnosis. AAD patient care was more frequently subject to utilization review and restriction or specification of medications to be prescribed (formulary). Psychiatrists also perceived greater restrictions on AAD patient care (e.g., requirements to use specific practice guidelines or treatment algorithms). CONCLUSIONS: Findings suggest that health care systems are subjecting treatment patients with AAD to greater scrutiny and may be limiting the extent and nature of care provided to these patients. The low prevalence of AAD among patients being seen by psychiatrists also warrants further attention. Study findings highlight the utility of practice-based research in addiction psychiatry.

Managed care and fee discounts in psychiatry: new evidence.

This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.