Dissertation/Thesis Abstract

Conformance with evidence-based schizophrenia treatment recommendations in a large metropolitan behavioral health system
by Lascher, Steven M., Ph.D., The Johns Hopkins University, 2008, 237; 3309800
Abstract (Summary)

Study objective. To examine conformance of inpatient treatment of schizophrenia with Lehman et al.'s 2003 PORT treatment recommendations and to identify patient, provider and hospital factors associated with conformance with emphasis on racial/ethnic disparities.

Design. Retrospective cross-sectional observational study using administrative data, electronic health records of patients with schizophrenia who were discharged from inpatient psychiatric care during calendar year 2005, and physician credentialing data. Dependent variables were derived from the 2003 PORT Inpatient Treatment Recommendations and were modeled using General Estimating Equations to account for correlated data among patients from the same psychiatrist. Predictors were categorized as patient demographics, severity and case mix, discharge disposition, physician characteristics, and whether the hospitals were academic medical centers and introduced into the model as groups.

Setting. Four hospitals within the St. Vincent Catholic Medical Centers of New York Behavior Health System. Two hospitals teach residents and two do not. One non-teaching hospital is a psychiatric hospital.

Subjects. A 30% simple random sample (n=576) was drawn from all discharges in calendar year 2005 from four hospitals with an ICD-9 principal discharge diagnosis in the 295** series (N=1921). Additionally, demographic characteristics from 39 psychiatrists who treated these patients were included and associated with the patients they treated. The patient sample is 39.5% Blacks, 36.6% Whites, 16.5% Hispanics, 4% Asians, and 3% others; 59.4% are male, with an average age of 42.5 years with men being, on average, 7 years younger than women.

Main results. More than 96% of patients receive antipsychotics as recommended. For antipsychotic dosing, 55% meet the PORT recommendation criteria: 23.7% receive over-range, and 21.3% receive under-range dosage. There is no evidence of racial/ethnic differences in conformance. Over-range dosage is positively associated with depot antipsychotic administration (OR 3.76, p<0.001).

Treatment with depot antipsychotics is protective of under-range dosage (OR 0.38, p<0.05). Being treated by American medical school graduates (OR 1.98, p<0.05) and by psychiatrists who completed medical school more than 10 years previously are associated with higher odds of under-range dosage (OR 4.97, p<0.01). Among persons with medication adherence problems, 34.1% receive depot antipsychotics medication as recommended and the rate of use is greater for Hispanic patients (OR 3.86, p<0.01) and greater with a documented history of adherence problems (OR 3.93, p<0.001).

Of those with extrapyramidal symptoms, all receive antiparkinson prophylaxis as recommended; of those on first generation antipsychotics, only 65.5% receive antiparkinson prophylaxis. Conformance is positively associated with being treated by an Asian (OR 0.43, p=0.05) or male physician (OR 0.39, p<0.01) and negatively associated with treatment at a teaching hospital (OR 4.15, p<0.01). For those treated with second generation antipsychotics, 75.5% are treated in concordance with the recommendations. Concordance is positively associated with other race/ethnicity patient category (0.26, p<0.01), and Asian physicians (OR 0.27, p<0.001).

Of those patients with family contact, 77.7% are offered a family intervention. The odds of conformance is lower for patients with somatic comorbidities (OR 0.47, p<0.05). All discharge dispositions other than to home are associated with a lower likelihood of receiving family interventions. Being treated by a minority (compared to White) or male physician is positively associated with family interventions.

Of those patients with co-morbid depression 96.4% receive antidepressives in conformance with recommendations.

Conclusions. Comparing these results to the PORT schizophrenia benchmark study of 1998, there appears to be some improvement in the management of depression, antiparkinson medications, and referrals for family interventions. Even so, the overall rates of conformance could be substantially improved. In a racially/ethnically mixed sample of patients with schizophrenia, no associations by race/ethnicity with over or under-range dosage is found. Physician characteristics are associated with varying conformance rates specifically related to under-range dosage, antiparkinson prophylaxis for both first and second generation antipsychotics, and family interventions. These results provide an important benchmark on which to implement initiatives to improve the quality of inpatient schizophrenia care.

Indexing (document details)
Advisor: Steinwachs, Donald
School: The Johns Hopkins University
School Location: United States -- Maryland
Source: DAI-B 69/04, Dissertation Abstracts International
Subjects: Mental health, Epidemiology, Health care management
Keywords: Antiparkinson prophylaxis, Behavioral health, Disparities, Guideline conformance, adherence, compliance, Quality of care, Schizophrenia
Publication Number: 3309800
ISBN: 978-0-549-57829-1
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