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.

The breathing hand: obstetric brachial plexopathy reinnervation from thoracic roots?

It has been found that in cases of obstetric brachial plexopathy, injured phrenic nerve or C3/4/5 roots may sprout into the adjacent injured upper and middle trunks of the brachial plexus. This aberrant regeneration produces co-contraction of the diaphragm and proximal upper limb muscles. This phenomenon, referred to as respiratory synkinesis or "the breathing arm", may not be limited to the upper cervical roots. We present two cases, identified through electromyographic investigations, of respiratory synkinesis selectively affecting intrinsic hand muscles, and propose that upper thoracic roots and their intercostal nerves may also produce respiratory synkinesis, resulting in a "breathing hand." This novel brand of synkinesis indicates that obstetric brachial plexus neuropathies can have quite proximal nerve injury in all trunks. The findings in our patients may not be entirely unique. The time required to develop distal muscle synkinesis and the subtle nature of our findings may suggest that with time and the assistance of EMG the breathing hand may be more common. When considering brachial plexus surgery, the significance of respiratory synkinesis should not be overlooked as its presence indicates injury at a root or proximal trunk level and may come from either nerves destined for the diaphragm or for the intercostal muscles.

Risk adjustment alternatives in paying for behavioral health care under Medicaid.

OBJECTIVE: To compare the performance of various risk adjustment models in behavioral health applications such as setting mental health and substance abuse (MH/SA) capitation payments or overall capitation payments for populations including MH/SA users. DATA SOURCES/STUDY DESIGN: The 1991-93 administrative data from the Michigan Medicaid program were used. We compared mean absolute prediction error for several risk adjustment models and simulated the profits and losses that behavioral health care carve outs and integrated health plans would experience under risk adjustment if they enrolled beneficiaries with a history of MH/SA problems. Models included basic demographic adjustment, Adjusted Diagnostic Groups, Hierarchical Condition Categories, and specifications designed for behavioral health. PRINCIPAL FINDINGS: Differences in predictive ability among risk adjustment models were small and generally insignificant. Specifications based on relatively few MH/SA diagnostic categories did as well as or better than models controlling for additional variables such as medical diagnoses at predicting MH/SA expenditures among adults. Simulation analyses revealed that among both adults and minors considerable scope remained for behavioral health care carve outs to make profits or losses after risk adjustment based on differential enrollment of severely ill patients. Similarly, integrated health plans have strong financial incentives to avoid MH/SA users even after adjustment. CONCLUSIONS: Current risk adjustment methodologies do not eliminate the financial incentives for integrated health plans and behavioral health care carve-out plans to avoid high-utilizing patients with psychiatric disorders.

Use of consumer ratings for quality improvement in behavioral health insurance plans.

BACKGROUND: The Consumer Assessment of Behavioral Healthcare Services (CABHS) survey collects consumers' reports about their health care plans and treatment. The use of the CABHS to identify opportunities for improvement, with specific attention to how organizations have used the survey information for quality improvement, is described. METHODS: In 1998 and 1999, data were collected from five groups of adult patients in commercial health plans and five groups of adult patients in public assistance health plans with services received through four organizations (one of three managed behavioral health care organizations or a health system). Patients who received behavioral health care services during the previous year were mailed the CABHS survey. Non-respondents were contacted by telephone to complete the survey. RESULTS: Response rates ranged from 49% to 65% for commercial patient groups and from 36% to 51% for public assistance patients. Promptly getting treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services, received the least positive responses, whereas questions about communication received the most positive responses. In addition, questions about access- and plan-related aspects of quality showed the most interplan variability. Three of the organizations in this study focused quality improvement efforts on access to treatment. DISCUSSION: Surveys such as the CABHS can identify aspects of the plan and treatment that are improvement priorities. Use of these data is likely to extend beyond the behavioral health plan to consumers, purchasers, regulators, and policymakers, particularly because the National Committee for Quality Assurance is encouraging behavioral health plans to use a similar survey for accreditation purposes.

The role of profit status under imperfect information: evidence from the treatment patterns of elderly medicare beneficiaries hospitalized for psychiatric diagnoses.

Medicare claims for elderly admitted for psychiatric care were used to estimate the impact of hospital profit status on costs, length of stay (LOS), and rehospitalizations. No evidence was found that not-for-profits (NFPs) treated sicker patients or had fewer rehospitalizations. For-profits (FPs) actually treated poorer patients. Longer LOS and lower daily costs of NFPs were attributable to their other characteristics, e.g. medical school affiliation. Instrumental variables (IV) estimates suggested that NFP general hospitals actually have lower adjusted costs. These findings fail to support concerns that FP growth leads to declining access and quality or contentions that NFPs are less efficient.

Developing a quality management system for behavioral health care: the Cambridge Health Alliance Experience.

The rapid pace of change in the health care system presents tremendous challenges for clinicians and managers charged with the delivery of mental health and substance abuse services. Declining reimbursement, new incentive structures, and increasing competition are placing unprecedented pressure on providers to deliver care efficiently. Regulatory scrutiny, consumer dissatisfaction, and a growing awareness of gaps between actual and ideal practice have led to intensifying pressure to improve quality. Yet system change has also presented new opportunities for managing cost and quality of care. Consolidation of facilities and practices into integrated networks, developments in information systems technology, and the emergence of models to facilitate change have led to the rise of "quality management," a framework for assessing and improving clinical, operational, and financial performance within a health care organization. This article reviews some of the precipitating factors and theoretical structures underlying quality management and then, through a case study of one organization's experience, describes the implementation of a quality management program in a behavioral health care delivery system. The case study emphasizes how theoretical frameworks were operationalized and how organizational structure and process were shaped to address challenges well known in quality management, such as authority, accountability, and follow-through. A multiphase model of quality management program development is formulated and used to provide context for this program's development.

Quality measures for mental health care: results from a national inventory.

The National Inventory of Mental Health Quality Measures was funded by the Agency for Healthcare Research and Quality to (1) inventory process measures for assessing the quality of mental health care; (2) identify clinical, administrative, and quality domains where measures have been developed; and (3) identify areas where further research and development is needed. Among the 86 measures identified, most evaluated treatment of major mental disorders, for example, schizophrenia (24 percent) and major depression (21 percent). A small proportion focused on children (8 percent) or the elderly (9 percent). Domains of quality included treatment appropriateness (65 percent), continuity (26 percent), access (26 percent), coordination (13 percent), detection (12 percent), and prevention (6 percent). Few measures were evaluated for reliability (12 percent) or validity (3 percent). Measures imposing a lower burden were more likely to be in use (chi 2 = 4.41, p = .036). Further measures are needed to assess care for several priority clinical and demographic groups. Research should focus on measure validity, reliability, and implementation costs. In order to foster quality improvement activities and use of common measures and specifications for mental health care, the inventory of quality measures will be made available at www.challiance.org/cqaimh.

Carcinoma of unknown primary site: phase II trials with docetaxel plus cisplatin or carboplatin.

PURPOSE: To evaluate the toxicity, response rate and short-term survival associated with the chemotherapy combinations of docetaxel plus cisplatin or carboplatin when used for the treatment of patients with metastatic carcinoma of unknown primary site. PATIENTS AND METHODS: Twenty-six patients were treated with docetaxel 75 mg/m2 i.v. and cisplatin 75 mg/m2 i.v. given every three weeks (study A) and subsequently, 47 patients were treated with docetaxel 65 mg/m2 and carboplatin (AUC dose = 6) every three weeks (study B). Stable or responding patients received a maximum of eight courses of therapy. Patients who were known to be in treatable subset groups were excluded from these trials. The majority of patients had two or more sites of metastasis; about 45% had adenocarcinoma and 50% poorly differentiated carcinoma. RESULTS: In study A, 6 of 23 (26%) assessable patients had a major response to therapy. The median survival was eight months and one-year survival 42%. Seven patients were removed from the study early for grade 3 or 4 nausea and vomiting. In study B, 9 of 40 assessable patients (22%) had a major response to therapy. Median survival was eight months and one-year survival 29%. Toxicity associated with this regimen was predominantly myelosuppression. Comparisons of the two sequential trials showed no differences in response rates or survivals (P = 0.75). CONCLUSIONS: Docetaxel and cisplatin (study A) is an active combination in carcinoma of unknown primary site, but associated with substantial gastrointestinal toxicity. A combination of docetaxel plus carboplatin (study B) is better tolerated and produced a similar response rate, median survival and one-year survival. Comparative phase III trials will be necessary to unequivically prove a survival advantage for any form of therapy in these patients. However, the survival for patients with carcinoma of unknown primary site receiving docetaxel-based chemotherapy is comparable to the survivals for several other groups of advanced cancer patients, such as non-small cell lung cancer, receiving various types of chemotherapy.

Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use.

OBJECTIVE: This study assessed the extent to which patients treated with electroconvulsive therapy (ECT) had diagnoses for which ECT is an efficacious treatment according to evidence-based standards. METHODS: ECT use among all beneficiaries of a large New England insurance company in 1994 and 1995 was examined using a retrospective cohort design. Associations between provider characteristics and ECT use for diagnoses outside the standards were determined using logistic regression analysis. RESULTS: A total of 996 individuals among approximately 1.2 million beneficiaries were treated with ECT. They received a total of 1,532 ECT courses. For 86.5 percent of the courses, the diagnosis was within evidence-based indications; for 13.5 percent, the diagnosis was outside the indications. In more than half of the 13.5 percent of cases, conditions were depressive disorders for which no studies have been conducted or disorders that likely had associated depressive symptoms. Patients receiving ECT for diagnoses outside evidence-based indications were more likely to have been treated by psychiatrists who graduated from medical school between 1940 and 1960 and between 1961 and 1980 than by those who graduated between 1981 and 1990. These patients were also less likely to have been treated by psychiatrists who received their medical education outside the U.S. CONCLUSIONS: Diagnoses of patients treated with ECT were mostly within evidence-based indications. The results provide reassurance to those concerned that ECT may be used indiscriminately. If confirmed by further research, the finding that psychiatrists trained in earlier eras were more likely to use ECT for diagnoses outside evidence-based indications may offer an opportunity for targeted quality improvement.

Differences between generalists and mental health specialists in the psychiatric treatment of Medicare beneficiaries.

OBJECTIVE: To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. DATA SOURCES: Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association. STUDY DESIGN: Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors. PRINCIPAL FINDINGS: Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. CONCLUSIONS: Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for care provided in the specialty sector. Our study suggests that the treatment patterns in the specialty sector may be preferred by some patients; further, earlier findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable population may be inappropriate. The need for further research on outcomes is indicated.

Health utilities in Alzheimer's disease: a cross-sectional study of patients and caregivers.

OBJECTIVES: Although the broad impacts of Alzheimer's disease (AD) are increasingly recognized, little work has focused on the overall health-related quality of life experienced by Alzheimer's disease patients and their caregivers. The study had two main objectives: (1) to test the feasibility of measuring health utilities in Alzheimer's disease with a generic preference-weighted instrument using proxy respondents and (2) to assess the utility scores of Alzheimer's disease patients (and their caregivers) in different disease stages and care setting. METHODS: A cross-sectional study of 679 Alzheimer's disease patient/caregiver pairs was conducted at 13 sites in the United States: four academic medical centers, four managed care plans, two assisted living facilities, and three nursing homes. The Health Utilities Index Mark II (HUI:2) questionnaire was administered to caregivers of patients who responded both as proxies for patients and for themselves. Responses to the questionnaire were converted into a global utility score, between 0 and 1, using the HUI:2 multi-attribute utility function. RESULTS: Global utility scores varied considerably across patients' Alzheimer's disease stage: for the six stages assessed (questionable, mild, moderate, severe, profound, and terminal), mean utility scores were 0.73, 0.69, 0.53, 0.38, 0.27, and 0.14, respectively. In multiple regression analyses, Alzheimer's disease stage was a negative and significant predictor of utility scores for patients; setting did not exert an independent effect. Utility scores for the caregivers were insensitive to patients' Alzheimer's disease stage and setting. CONCLUSIONS: Patients' Alzheimer's disease stage had a substantial influence on health utilities, as measured by the HUI:2. More research is needed to assess the validity of using proxy respondents.

Cost-effectiveness of donepezil in the treatment of mild or moderate Alzheimer's disease.

OBJECTIVE: To demonstrate the use of cost-effectiveness analysis to assess the economic impact of donepezil in the treatment of mild or moderate AD. BACKGROUND: Cost-effectiveness analyses show the relationship between resources used (costs) and health benefits achieved (effects) for an intervention compared with an alternative strategy. METHODS: We developed a model to estimate the incremental cost-effectiveness of donepezil compared with no treatment. We determined costs per quality-adjusted life-years gained, a measurement that enhances the comparability of diverse studies. The model projects the progression of AD patients into more severe disease stages and into nursing homes. Data from a randomized clinical trial of donepezil were used to assess the drug's impact on the 6-week probabilities of progression. Data on the costs and health-related quality of life associated with different disease stages and settings were taken from published estimates and our companion cross-sectional study, respectively. RESULTS: Donepezil costs are partially offset by a reduction in the costs of care due to enhancement in cognitive functioning and the delay to more costly disease stages and settings. The magnitude of this cost offset and of the effect of donepezil on health-related quality of life depends on the model's assumptions about the duration of the drug effect, where controlled data are lacking. If the drug effect exceeds 2 years, the model predicts that for mild AD the drug would pay for itself in terms of cost offsets. CONCLUSIONS: The results of the cost-effectiveness model presented here suggest that donepezil may be cost-effective but additional controlled data on long-term drug efficacy are needed.

Electrophysiologic findings in amyloid myopathy.

Myopathy is an uncommon manifestation of systemic amyloidosis. A retrospective chart review of 17 patients seen between 1975 and 1997 with biopsy-proven amyloid myopathy was performed to characterize the electrophysiologic features. Nerve conduction study abnormalities occurred in 14 of 17 patients (82%). The most common abnormality was a low peroneal and/or tibial compound muscle action potential amplitude (n = 9). Mild abnormalities also occurred in seven other nerves. Repetitive stimulation at 2 Hz in 10 nerves was normal. Electromyography demonstrated fibrillation potentials in 69% of muscles, most frequently in the gluteus medius (90%) and paraspinals (87%). The fibrillation potentials were sparse in 60%. Short-duration, low-amplitude motor unit potentials (MUPs) were found in 72% of the muscles examined, were mild in 81%, and were more common in proximal muscles. Long-duration MUPs were found in 19% of muscles and a mixed population of MUPs in 4%. These findings are similar to those of common chronic, inflammatory myopathies.

Neurological manifestations of Erdheim-Chester disease.

Erdheim-Chester disease is a rare sporadic systemic histiocytic disease of unknown aetiology that affects multiple organ systems. The case records of all patients with Erdheim-Chester disease who had been seen at the Mayo Clinic between 1975 and 1996 were reviewed to assess the neurological manifestations of the disease. Two of 10 patients had neurological involvement. A 42 year old woman developed central diabetes insipidus and a progressive cerebellar syndrome. Brain MRI showed a lesion in the left pons with patchy gadolinium enhancement and T2 weighted signal abnormalities extending into both cerebellar peduncles and the medulla. Biopsy of the brainstem mass showed a xanthogranulomatous lesion. The second patient was a 53 year old man with retroperitoneal fibrosis secondary to xanthogranulomatous infiltration. Although he had no neurological symptoms and a normal neurological examination, MRI of the head showed multiple uniformly enhancing extra-axial masses along the dura of both convexities and the falx, and a mass in the left orbital apex. Both patients had the characteristic radiographic and bone scan findings of Erdheim-Chester disease. Review of the literature disclosed a wide variety of neurological manifestations in Erdheim-Chester disease. The most frequent CNS manifestations are diabetes insipidus, cerebellar syndromes, orbital lesions, and extra-axial masses involving the dura.

Inpatient psychiatric treatment of elderly Medicare beneficiaries.

OBJECTIVE: The clinical characteristics and treatment patterns of elderly Medicare beneficiaries hospitalized for psychiatric disorders were examined. METHODS: Administrative data on all elderly Medicare beneficiaries in the United States hospitalized in a nonfederal hospital for a primary psychiatric disorder in 1990-1991 were used to calculate descriptive statistics on case-mix by age group, hospital type (psychiatric hospital, general hospital psychiatric unit, or general hospital nonpsychiatric unit), and primary diagnosis. Length of stay, costs, and discharge destination by hospital type and primary diagnosis were also determined. RESULTS: A total of .6 percent of elderly Medicare beneficiaries were hospitalized for a psychiatric disorder in 1990, accounting for more than 240,000 admissions and $1 billion in Medicare payments. The most common reasons for hospitalization were major depressive disorder (28.1 percent), dementia and other organic disorders (26.8 percent), and substance-related disorders (12.6 percent). Organic disorders were particularly prevalent among the oldest old, accounting for more than half of psychiatric admissions among those 85 and older. A total of 43 percent of the psychiatric admissions were to general hospital nonpsychiatric units, 38 percent to general hospital psychiatric units, and only 19 percent to psychiatric hospitals. Within each diagnostic category, patients admitted to general hospital nonpsychiatric units had the shortest average lengths of stay and the lowest average costs. Among beneficiaries with organic, affective, and psychotic disorders other than schizophrenia, those admitted to general hospitals had shorter lengths of stay, higher rates of discharge to nursing homes, and lower rates of discharge to self-care than those treated in psychiatric hospitals. CONCLUSIONS: Case-mix-adjusted treatment patterns varied substantially across hospital types, due to differences in either illness severity or treatment styles.

Characteristics of psychiatrists who perform ECT.

OBJECTIVE: Use of ECT is highly variable, and previous study has linked its availability to the geographic concentration of psychiatrists. However, less than 8% of all U.S. psychiatrists provide ECT. The authors analyzed the characteristics of psychiatrists who use ECT to understand more fully the variation in its use and how changes in the psychiatric workforce may affect its availability. METHOD: Data from the 1988-1989 Professional Activities Survey were examined to investigate the influence of demographic, training, clinical practice, and geographic characteristics on whether psychiatrists use ECT. RESULTS: Psychiatrists who provided ECT were more likely to be male, to have graduated from a medical school outside the United States, and to have been trained in the 1960s or 1980s rather than the 1970s. They were more likely to provide medications than psychotherapy, to practice at private rather than state and county public hospitals, to treat patients with affective and organic disorders, and to practice in a county containing an academic medical center. CONCLUSIONS: Demographic and training characteristics significantly influence whether a psychiatrist uses ECT. Opposing trends in the U.S. psychiatric workforce could affect the availability of the procedure. Expanding training opportunities for ECT and making education, training, and testing more consistent nationwide could improve clinicians' consensus about ECT and narrow variation in its use.

The influence of psychiatric disorders on patients' ratings of satisfaction with health care.

OBJECTIVES: Patient ratings of satisfaction with health care have been used by patients, insurers, and employers seeking data to compare the quality of health plans and systems of care. Concerns with these ratings include their subjective nature and potential for being influenced by patient characteristics unrelated to the quality of their care. The authors examined the influence of an active psychiatric disorder on patient satisfaction with health care, hypothesizing that patients with psychiatric disorders would be less satisfied with their health care, due to the adverse effects of these conditions on mood and cognition. METHODS: The authors used linked claims and survey data from the 1991 Medicare Current Beneficiary Survey. Using logistic regressions that controlled for patient sociodemographic and clinical characteristics, the authors examined the influence of an active psychiatric disorder on satisfaction with overall quality of health care and with specific dimensions of quality. The authors also examined the effects of specific types of psychiatric disorders. RESULTS: Aged and disabled beneficiaries with psychiatric disorders were significantly less likely than those without disorders to be satisfied with the overall quality of health care, follow-up care, and the physician's concern for their overall health. Disabled beneficiaries were also less likely to be satisfied with the health information provided. Further variation was found by type of psychiatric disorder. CONCLUSIONS: One interpretation of these findings is that Medicare beneficiaries with psychiatric disorders receive lower quality care, a possibility that warrants further investigation. Alternatively, patients with psychiatric disorders may report lower satisfaction despite receiving comparable health care; this interpretation points toward the need for casemix adjustment when comparing satisfaction ratings across health plans and the development of quality measures less susceptible to subjective biases.

Assessing the quality of psychiatric care: research methods and application in clinical practice.

The drive to contain the costs of health care in the United States is focusing attention on how quality of care is affected. This article discusses research methods for assessing the quality of psychiatric care and reviews findings from some major studies evaluating care. These findings are mixed, highlighting areas in which quality of care is less than optimal, as well as the importance of continued research and the need to develop better research methods. Evidence-based criteria and more-sensitive risk-adjustment techniques must be employed if data on quality are to yield fair comparisons among health plans. The challenge is to refine the methods now in use at both the research and clinical levels, so that better-quality assessments can be made for policy formulation, physician education, and consumer choice.

Use of electroconvulsive therapy in the Medicare population between 1987 and 1992.

OBJECTIVE: Use of electroconvulsive therapy (ECT) in the Medicare population was examined to document trends and variations in the rate of use, expenditures, and patterns of treatment. METHODS: Medicare part B enrollment and claims data were used for a 5 percent nationally representative sample of Medicare beneficiaries for calendar years 1987 through 1992. Descriptive and multivariate analyses were performed. RESULTS: Weighted results showed that nationally the number of Medicare beneficiaries treated with ECT increased from 12,000 in 1987 to 15,560 in 1992. The rate of ECT use per 10,000 Medicare beneficiaries also increased from 4.2 to 5.1. Increases in use occurred among women, whites, and the disabled population (under age 65). Males, nonwhites, and the elderly did not share in the increase. Utilization and expenditure data showed an increase in outpatient ECT and a decrease in inpatient use between 1987 and 1992. The share of Medicare part B ECT expenditures in the outpatient setting increased steadily, from 7 percent in 1987 to 16 percent in 1992. Patients averaged eight ECT treatments, ranging from 6.7 in the West to 8.3 in the Northeast. CONCLUSIONS: The findings document that after a long period of declining use in the United States, ECT use in the Medicare population increased between 1987 and 1992. The analysis also documents a shift toward increasing use of outpatient ECT.