Oversight on the borderline: Quality improvement and pragmatic research.

Pragmatic research that compares interventions to improve the organization and delivery of health care may overlap, in both goals and methods, with quality improvement activities. When activities have attributes of both research and quality improvement, confusion often arises about what ethical oversight is, or should be, required. For routine quality improvement, in which the delivery of health care is modified in minor ways that create only minimal risks, oversight by local clinical or administrative leaders utilizing institutional policies may be sufficient. However, additional consideration should be given to activities that go beyond routine, local quality improvement to first determine whether such non-routine activities constitute research or quality improvement and, in either case, to ensure that independent oversight will occur. This should promote rigor, transparency, and protection of patients' and clinicians' rights, well-being, and privacy in all such activities. Specifically, we recommend that (1) health care organizations should have systematic policies and processes for designating activities as routine quality improvement, non-routine quality improvement, or quality improvement research and determining what oversight each will receive. (2) Health care organizations should have formal and explicit oversight processes for non-routine quality improvement activities that may include input from institutional quality improvement experts, health services researchers, administrators, clinicians, patient representatives, and those experienced in the ethics review of health care activities. (3) Quality improvement research requires review by an institutional review board; for such review to be effective, institutional review boards should develop particular expertise in assessing quality improvement research. (4) Stakeholders should be included in the review of non-routine quality improvement and quality improvement-related research proposals. Only by doing so will we optimally leverage both pragmatic research on health care delivery and local implementation through quality improvement as complementary activities for improving health.

Diagnostic inconsistency: a marker of service utilization in bipolar disorder.

Community outcomes for the treatment of bipolar disorder remain poor, including frequent hospitalization. Recent small-scale studies suggest that hospitalization may be tied to poor recognition and medication management. This paper examines the health care charges associated with poor recognition of mania. Service utilization was analyzed for 3,856 individuals with bipolar disorder in a managed care plan. Only 8.2% of patients were diagnosed with bipolar disorder, however they accounted for 45% of inpatient charges. Among patients with bipolar disorder, cases where diagnoses were changed to unipolar depression were hospitalized more quickly. Interventions are suggested to increase consistent recognition of manic history.

Association of utilization management and treatment plan modifications among practicing U.S. psychiatrists.

OBJECTIVE: This study examined the relationship between utilization management techniques and psychiatrists' treatment plan modifications. METHOD: Nationally representative data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network were used to examine the demographic and clinical characteristics of patients whose care was subjected to utilization management and to assess the association between utilization management and psychiatrists' treatment plan modifications. RESULTS: Approximately half of all patients had treatment that was subject to utilization management (52.6%). For the patients whose treatment was not subject to utilization management, 15.5% had their treatment plan changed compared to the 31.5% who were subject to utilization management. Overall, after adjustment for differences in patients, settings, and psychiatrist characteristics, the patients subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not subject to utilization management. These patients were 3.7 times more likely to have their type of treatment changed and 2.3 times more likely to have their frequency or number of visits changed. Psychiatrists in individual practice settings and those with nonsalaried income sources were more likely to modify treatment decisions for their patients when subject to utilization management. CONCLUSIONS: The presence of utilization management is highly associated with changes in psychiatrists' treatment decisions. When compared to evidence-based treatment recommendations, these changes seem likely to result in less than optimal care.

Risk factors for psychosocial dysfunction among enrollees in the State Children's Health Insurance Program.

OBJECTIVE: The authors studied enrollees in the State Children's Health Insurance Program (SCHIP) (Title XXI) to characterize risk factors for psychosocial dysfunction among children of the working poor. METHODS: Medical and psychosocial variables were included in a survey completed by 393 parents of children enrolled in SCHIP. Regression analysis was used to examine the relationship between these variables and scores on the Pediatric Symptom Checklist, a measure of psychosocial dysfunction among children. RESULTS: Stepwise multiple regression showed that parental dysphoria, parental history of psychiatric or substance use problems, childhood chronic medical illness, and exposure to traumatic events each contributed independently to variance in psychosocial dysfunction in this population, explaining 34 percent of total variance. CONCLUSIONS: Despite strong progress in implementing SCHIP at the state level, the behavioral health care needs of children of the working poor have not been well defined. This study identified risk factors that can be easily found in the patient's medical record or detected during an interview by the primary care physician. Thus screening to identify children at risk of psychosocial dysfunction is warranted among SCHIP enrollees.