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Biomedical subjects

R A Dorwart

Publications and source records attributed to R A Dorwart.

At least 19 recordsLinked to original sources
PubMed1999

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.

Cohort Studies↗
PubMed1998

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.

Activities of Daily Living↗
PubMed1998

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.

Confidence Intervals↗
PubMed1997

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.

Adult↗
PubMed1996

Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy.

OBJECTIVE: The increasing involvement of insurers and hospitals in monitoring patient care is encroaching on the psychiatrist's autonomy in making clinical decisions. This study examined the prevalence of constraints on psychiatric inpatient practices, as well as how characteristics of psychiatrists affect the type and the degree of these external pressures. METHOD: About 2,500 psychiatrists with active hospital affiliations were surveyed by mail, as a subset of APA's 1988 national survey of psychiatrists. They were questioned about whether the hospital or insurers had pressured them to change their inpatient practices or had attempted to discourage admission of certain types of patients. Characteristics of the psychiatrists' background, available from the main survey, were used as independent variables in a set of regression models, with frequency of different constraints as the dependent variables. RESULTS: More than three quarters of those surveyed reported pressure from insurers for early discharge; nearly two-thirds said hospitals limited length of stay; and about half had been discouraged from admitting severely ill patients, the uninsured, or Medicaid recipients. Characteristics of psychiatrists, such as length of time in practice, income, sex, and medical school education outside the United States, were associated with the prevalence of external pressures. CONCLUSIONS: Constraints on psychiatrists' practices are widespread. Their ability to resist pressures depends on their bargaining power, which seems to be lowest for those who have relatively little experience, who are female, or who have gone to medical school outside the United States. Psychiatrists appear to be willing to trade off more constraints for higher incomes. Severely ill patients and those with little or no insurance are more likely than others to be affected by these limits on psychiatrists' autonomy.

Female↗
PubMed1995

Variation in ECT use in the United States.

OBJECTIVE: The authors measured the variation in ECT utilization rates across 317 metropolitan statistical areas of the United States and determined to what degree this variation is associated with health care system characteristics, demographic factors, and the stringency of state regulation of ECT. METHOD: Data from APA's 1988-1989 Professional Activities Survey were used to estimate ECT utilization rates for the metropolitan statistical areas. Multiple regression analysis was used to determine the relative influence of provider, demographic, and regulatory factors on variation in ECT use across areas. RESULTS: Among the psychiatrists surveyed, 17,729 reported treating 4,398 patients with ECT during the study period. No ECT use was reported in 115 metropolitan statistical areas. Among the remaining 202 metropolitan statistical areas, annual ECT use varied from 0.4 to 81.2 patients per 10,000 population. The strongest predictors of variation in ECT use across metropolitan statistical areas were the number of psychiatrists, number of primary care physicians, number of private hospital beds per capita, and stringency of state regulation of ECT. CONCLUSIONS: Rates of ECT use were highly variable, higher than for most medical and surgical procedures. In some urban areas, access to ECT appears limited. Predictors of variation in ECT rates have implications for expanding access to the procedure. The extent of variation suggests psychiatrists continue to lack consensus regarding the use of ECT. Better data on the effectiveness of psychiatric treatments may lead to a broader professional consensus and may narrow variations in clinical practices.

Depressive Disorder↗
PubMed1994

A national study of transitional hospital services in mental health.

OBJECTIVES: Shifts in care for the seriously mentally ill from inpatient to community-based treatment have highlighted the importance of transitional care. Our objectives were to document the kinds and quantity of transitional services provided by psychiatric hospitals nationally and to assess the impact of hospital type (psychiatric vs general), ownership (public vs private), case mix, and revenue source on provision of these services. METHODS: A national sample of nonfederal inpatient mental health facilities (n = 915) was surveyed in 1988, and data were analyzed by using multiple regression. RESULTS: Half (46%) of the facilities surveyed provided patient follow-up of 1 week or less, and almost all (93%) conducted team review of discharge plans, but 74% provided no case management services. Hospital type was the most consistent predictor of transitional care, with psychiatric hospitals providing more of these services than general hospitals. Severity of illness, level of nonfederal funding, urbanicity, and teaching hospital affiliation were positively associated with provision of case management. CONCLUSIONS: Transitional care services for mentally ill patients leaving the hospital were found to be uneven and often inadequate. Reasons for broad variation in services are discussed.

Aftercare↗
PubMed1994

Managing competition in public and private mental health agencies: implications for services and policy.

There were clear differences in our study between the management strategies employed by public agencies and those favored by private agencies. These differences, however, appeared to reflect the realities of financing rather than any fundamental differences in their orientation toward public service. There was no clear evidence that particular management practices affected an agency's performance on measures of financial access or acceptance of referrals from public hospitals. Government regulation and pressure from advocacy groups probably helped to maintain private agencies' focus on these and other public goals. From a public policy perspective, choosing a provider solely on the basis of ownership status is, at best, a naive approach to providing public mental health treatment. Not only is there great variation in process and practices within both private and public groups, but external factors such as competition from private practitioners may also exert a stronger influence on agency behavior than does ownership status. Because most current proposals for health care reform rely heavily on increased competition among providers to achieve their goals, the importance of ownership status as a predictor of conduct or performance may be further diminished. The emphasis on competition could increase differences between urban agencies and those in rural areas where there is less competition and, therefore, require different contracting approaches. As we move toward a health care system based on competition, administrators and policy makers will be forced to abandon their reliance on stereotypical public/private agency behavior as guides for policy decisions. Instead, they will have to consider more carefully the effects of political and market influences as well as agency characteristics when choosing community mental health providers.

Community Mental Health Centers↗
PubMed1993

The RBRVS for psychiatry.

Explore the source record for details and available documents.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1992

A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.

Adult↗
PubMed1992

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study.

OBJECTIVE: As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work. METHOD: A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods. RESULTS: The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.

Fee Schedules↗
PubMed1992

The role of general hospitals in the privatization of inpatient treatment for serious mental illness.

For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated mostly in state hospitals. The extent to which this transfer has taken place and the differences between public and private general hospitals have been unclear. Using data from the 1988 National Mental Health Facilities Study and published data from the 1970s, the authors found that nearly half of all general hospitals providing psychiatric services treat persons with serious mental illness. Significant differences in case and payer mix were observed between public and private general hospitals, although these differences were smaller than in the 1970s. The findings suggest increased involvement by private general hospitals in treating patients reimbursed by public payers, but the findings also indicate that persons with serious mental illness and those using Medicaid are still more prevalent in public general hospitals than in private ones.

Community Mental Health Services↗