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.

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.

Computerized performance monitoring systems: learning and living with its limitations.

Computer technology now allows clinical administrators to collect and analyze large data sets for performance monitoring. Despite the obvious usefulness of this technology, there are limitations. The indices that we can measure are at best proxies that might correlate with good clinical care but can also become dissociated from it in a variety of ways. First, there may not be a relationship throughout the entire continuum between the indicator and what we really value. Second, change in an indicator may not be associated with comparable change in the underlying value. Thirdly, the valence of an indicator can change depending on the context. Fourth, the very act of measuring an indicator can change its valence. Although, from a research perspective there may be technical solutions to these problems, in the real world where clinical care and politics meet, this may not be possible. Indices become reified. Measures become benchmarks and benchmarks quotas. Average is not a statistical phrase but a judgment and below average a term of approbation. To maximize the benefits of computerized monitoring, administrators need to be sensitive to this political dimension.

Lawyers' attitudes toward involuntary treatment.

This study examined whether lawyers' attributions of responsibility for mental illnesses affect their decisions about involuntary treatment. A survey that was mailed in 2003 to Illinois lawyers involved in involuntary commitment elicited recommendations for involuntary treatment for characters presented in vignettes. The survey also sought respondents' attributions of personal responsibility for the onset and recurrence of mental illnesses. A total of 89 lawyers responded to the survey, a response rate of 48 percent. Decisions to hospitalize persons with mental illness involuntarily increased significantly with the level of risk of harm and were significantly related to attributions of responsibility for the recurrence of mental illness. Decisions to recommend involuntary medication were not related to attributions of responsibility.

Cost-effectiveness of atypical antipsychotic medications versus conventional medication.

For almost 50 years, typical antipsychotics were the mainstay of pharmacological treatment for schizophrenia. However, during the last decade, the widespread use of expensive atypical antipsychotic medications has led to a dramatic increase in the proportion of the direct costs of schizophrenia being allocated for medications. Although there is evidence that the atypical antipsychotic clozapine may lead to cost savings in patients with refractory schizophrenia, the cost-effectiveness of the other atypical antipsychotics remains in question. Therefore, long-term randomised, prospective cost-effectiveness studies that compared an atypical to a typical antipsychotic have been reviewed in this paper. There were serious methodological problems with all the studies. In general, those that were based on efficacy trials showed an advantage for atypicals, whereas those based on effectiveness studies found the opposite. It seems that, to the extent that studies mimic real world conditions, they fail to support the cost-effectiveness of the atypical antipsychotics.