Two approaches to improving mental health care: positivist/quantitative versus skill-based/qualitative.

The quality improvement model currently used in medicine and mental health was adopted from industry, where it developed out of early 20th-century efforts to apply a positivist/quantitative agenda to improving manufacturing. This article questions the application of this model to mental health care. It argues that (1) developing "operational definitions" for something as value-laden as "quality" risks conflating two realms, what we measure with what we value; (2) when measurements that are tied to individuals are aggregated to establish benchmarks and goals, unwarranted mathematical assumptions are made; (3) choosing clinical outcomes is problematic; (4) there is little relationship between process measures and clinical outcomes; and (5) since changes in quality indices do not relate to improved clinical care, management's reliance on such indices provides an illusory sense of control. An alternative model is the older, skill-based/qualitative approach to knowing, which relies on "implicit/ expert" knowledge. These two approaches offer a series of contrasts: quality versus excellence, competence versus expertise, management versus leadership, extrinsic versus intrinsic rewards. The article concludes that we need not totally dispense with the current quality improvement model, but rather should balance quantitative efforts with the older qualitative approach in a mixed methods model.

Clinical expertise and the limits of explicit knowledge.

This article questions the view that medical decision-making can be reduced to a series of explicit rules, adherence to which will necessarily improve outcomes. Instead, it attempts to rehabilitate the concepts of clinical expertise and clinical experience, arguing that medicine, like other areas of expertise, depends on forms of implicit knowledge that can only be acquired through years of experience. Recent research on "fast and frugal" heuristics in medical decision-making suggest that statistical techniques are not necessarily superior to clinician judgment. Since clinical decisions are made on individual patients within the constraint of limited information, they must rest on clinical expertise and not clinical rules.

Quantifying the contribution of VA service-connected disability pensions to the "check effect".

OBJECTIVE: The study attempted to quantify the effect of receiving a disability pension check at the beginning of the month on the timing of substance-related hospitalizations in Department of Veterans Affairs (VA) facilities. METHODS: All substance-related hospitalizations during fiscal year 2005 were identified in the VA National Psychosis Registry (13,402 hospitalizations among 8,813 individuals) and in a random sample of VA patients without serious mental illness (689 hospitalizations among 508 individuals). Multivariable logistic regression examined the impact of pension check receipt on timing of hospitalizations while controlling for other predictors of substance-related hospitalizations. RESULTS: Receipt of a service-connected pension was associated with an increased risk of admission during the first two weeks of the month (odds ratio=1.08; 95% confidence interval=1.01-1.16). CONCLUSIONS: Staggering the disbursement of VA disability pensions (sending half the checks at the beginning and half in the middle of the month) might modestly reduce peak demand for substance-related inpatient services.

Demand characteristics and quality improvement: who is fooling whom?

Since some of the data used for quality assurance purposes (i.e. rating scales) requires the active participation of clinicians, administrators use various mandates or incentives to insure its collection. However, although improving clinician compliance these measures may bias clinician responses. It is suggested that the concept of 'demand characteristics' originally developed by Orne to describe how non-specific aspects of the experimental setting shape what the human subject does may be applicable. For example a measure that might increase clinician compliance with completing GAF ratings on an inpatient unit might also influence the scores to make them coincide with the expectation that all patients are very ill when admitted and improved when discharged. Why such a phenomenon would be difficult to detect and what it might say about the relationship between managers and those they manage is also explored.

Depression screening as a quality indicator.

Objective Although practice guidelines for depression screening are evidence based, with their development relying on reviews of controlled studies, their adaptation and use as quality indicators have not been subject to rigorous study. This paper will therefore review the evidence supporting this practice.Methods A rational evaluation was carried out on both controlled studies and other sources of evidence related to the technical, clinical and policy assumptions underlying the use of depression screening guidelines as quality indicators.Results 1) Technical assumptions: depression screening could be used as a quality indicator. Current information technology does not allow accurate determination of who would benefit from being screened, whether they actually were screened, or the optimal percentage that should be screened. 2) Clinical assumptions: depression screening would improve outcomes. The evidence suggests that although depression screening might increase the diagnosis of depression, depressed patients so recognised tend to be less ill, less in need of treatment, or less likely to benefit from treatment, while screening, in the absence of other interventions, does not improve outcomes. 3) Policy assumptions: depression screening should be a focus of quality improvement. However, relative to other preventative measures, depression screening is a low priority. It does not meet usual cost-effectiveness criteria. There are more robust interventions for depression (i.e. collaborative care) that could be a focus of quality improvement efforts.Conclusion Although routine depression screening may be an acceptable practice guideline, its use as a quality measure is not supported.

The electronic medical record: optimizing human not computer capabilities.

The widespread adoption of computerized medical records provides medical administrators and payers the means to promote more standardized and thorough medical records by insuring clinicians complete mandatory screens, history and physical templates, and formatted treatment plans. But there is a dearth of evidence that such measures, whether computerized or not, improve clinical outcomes and reason to suspect that they may impede care. While these measures maximize the computer's capabilities they are insensitive to human capabilities. A series of 'check-offs', 'fill-ins' and 'drop-downs' might facilitate quality assurance activities, but such standardized measures can interfere with the clinicians' processing of information into narrative structures that are necessary for memory and decision making. Computerization does not necessitate this standardization. The adoption of an electronic medical record could provide the opportunity to move beyond standardized measures that were developed to oversee written records and instead harness the computers' capabilities to promote the unique, specific, and narrative quality of the clinical encounter.

Glaucoma screening of patients with and without dementia.

Glaucoma's damage to peripheral vision compromises mobility to a greater extent than ocular pathology limiting central vision. Half of glaucoma is undiagnosed, as the majority of primary care physicians do not screen for glaucoma. Glaucoma is more prevalent in older adults with dementia than without dementia. This study tested the hypothesis that, in adults 60 and older with dementia, glaucoma screening failure is significantly higher than without dementia. An observational cross-sectional research design with a categorical outcome variable was used. Potential participants/caregivers were questioned regarding glaucoma diagnosis and treatment. Those denying glaucoma or treatment qualified for free screening. Participants (n = 103) were 75% African American (75 females, 28 males, average age 75 +/- 7.59). Thirty-three had dementia. Referral rate with dementia was significantly higher than without dementia (54% vs. 27%, chi(2) = 7.32, p = 0.0007) (95% CI = 0.304-0.816), affirming the study hypothesis. Lack of glaucoma screening and treatment follow-up by a majority of primary care physicians treating geriatric patients demonstrates a need for medical professionals to address function, particularly mobility, to discuss glaucoma's effects with patients/caregivers, and to consider measuring intraocular pressure.

Improving care, improving performance, or just improving numbers?

This Open Forum reviews the literature on computerized systems that purport to either assess or improve clinical care in mental health. There is little empirical support for these claims. These limitations are in keeping with the author's own experience in developing and using such systems. In light of this evidence and experience, the author argues, nonquantitative methods of assessment can be not only complementary to use of computerized systems but possibly corrective. The author concludes with the caveat that if the only things you can change are the things you can measure, then perhaps the only things you are changing are measurements.

The impact of immigration on psychiatric hospitalization in Illinois from 1993 to 2003.

OBJECTIVE: Illinois public hospitalizations over a ten-year period were studied to determine the impact of recent immigration. The study also explored clinical and demographic differences between immigrant groups and native-born Americans. METHODS: Information was collected from the state hospital Clinical Information System for 1993, 1998, and 2003. Variables included age, sex, race, marital status, education, diagnosis, length of stay, birthplace, citizenship, primary language, English proficiency, and availability of a Social Security number. Logistic multiple regression was used to analyze trends in the proportion of psychiatric admissions of foreign-born patients, with foreign born as the dependent variable and year as the independent variable. Chi square analysis was used for trends across time. RESULTS: In the hospitalized population, the proportion of immigrants was 7.3% in 1993, 10.9% in 1998, and 13.1% in 2003. With covariates adjusted for, the average increase of 8.0% per year in the odds of being foreign born was statistically significant (odds ratio=1.08, 95% confidence interval=1.06-1.10). Nevertheless, the proportion of foreign-born hospital admissions, including Asian and Mexican immigrants, was below their population ratio in Illinois. Mexican-origin immigrants constituted the largest group of admissions and were younger, less educated, had poorer English skills, and were more likely to be undocumented than other immigrants. CONCLUSIONS: The percentage of foreign-born patients admitted was lower than their percentage in the overall population. In previous immigration waves, immigrants were hospitalized at disproportionately higher rates than nonimmigrants. The gap is slowly narrowing as new admissions are increasingly likely to be foreign born, suggesting that public psychiatric hospitals should prepare for these changing populations.