Carol A. Boyer

Assessing clinical predictions of early rehospitalization in schizophrenia.

This study determines patient characteristics that predict early hospital readmission in schizophrenia and evaluates the extent to which inpatient staff accurately predict these readmissions. Adult inpatients with schizophrenia or schizoaffective disorder (N = 262) were evaluated at hospital discharge and 3 months later to assess hospital readmission. At hospital discharge, inpatient staff were asked to identify which patients were likely to be readmitted during this period. Comparisons were made between patients who were or were not readmitted and between readmitted patients who were or were not identified by staff as likely to be readmitted; 24.4% of the sample were readmitted within 3 months of hospital discharge. Early readmission was associated with four or more previous hospitalizations (85.7% vs. 57.7%, p = .004), comorbid substance use disorder (60.3% vs. 35.5%, p = .0006), major depression (40.6% vs. 26.8%, p = .04), absence of a family meeting with inpatient staff (58.2% vs. 41.8%, p = .02), and prescription of a conventional rather than an atypical antipsychotic medication (93.7% vs. 83.8%, p = .045). Twelve of the 63 readmitted patients were correctly predicted by staff to re-hospitalize. Staff tended to overestimate the risk of rehospitalization in patients with a poor therapeutic alliance, low global function, or initial involuntary admission and to underestimate the risk in patients with alcohol use disorders or four or more previous psychiatric hospitalizations. Early rehospitalization is common in schizophrenia and difficult to predict. Greater emphasis on comorbid alcohol use disorders and a history of multiple previous admissions may help clinicians identify patients at greatest risk for early rehospitalization.

Reliability of Medicaid Claims Files for Use in Psychiatric Diagnoses and Service Delivery

To investigate the reliability of Medicaid claims data for use in research, clinical decision-making, and policy, medical records were abstracted of 105 inpatient stays on the psychiatric service of a large general hospital. Primary and secondary diagnoses and outpatient specialty mental health services after hospitalization were compared between Medicaid claims data and medical record information. Primary and secondary diagnoses were reliable, but claims data failed to capture several types of outpatient services. This suggests strategies to use claims files more appropriately.

Examining Critical Health Policy Issues within and beyond the Clinical Encounter Patient–Provider Relationships and Help-seeking Behaviors

Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient—provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care. The challenge in trying to contain the growth of health care costs is two-fold: developing better ways of defining need for care and promoting better access for those who could benefit most from health care. Both of these strategies need to be considered in the context of addressing racial, ethnic, socioeconomic, and health status disparities. Rebuilding the primary care sector as a sociologically informed strategy and a key component of health care reform may optimize both health care delivery and patient outcomes.

The Social Dynamics of Responding to Mental Health Problems

Since social scientists first directed their attention to understanding how individuals recognize and respond to mental illness, they have struggled to capture both the underlying process or dynamic that drives the search for care and the social, cultural, medical, and organizational characteristics that shape the fate of persons dealing with mental health problems. At the present time, the dominant approaches to studying what many people call “help seeking” or “decision making,” and others more generally call “illness behavior” or “service use” focus on well-developed but essentially correlation models of the factors associated with use, compliance and outcomes. The Health Belief Model (Strecher, Champion, & Rosenstock, 1977), the Theory of Reasoned Action and its close counterpart, the Theory of Planned Behavior (Maddux & DuCharme, 1977), and the Behavioral Model of Health Service Utilization (Aday & Awe, 1997; Andersen, 1995) share an approach of outlining a comprehensive set of factors that shape the use of both preventive and curative services. Although these models do not ignore the underlying process of service use, key assumptions focus primarily on the factors that facilitate or discourage entry into formal treatment (for a review, see Gochman, 1997; Pescosolido, 1991; 1992; Pescosolido & Boyer, 1999). Rarely are the dynamics of coping with health problems a part of the empirical study of illness behavior. With the dynamics assumed, empirical studies in this tradition collect information on the extent and volume of use, and on a wide range of factors thought to influence the behavior of those entering care and treatment.

Studying inpatient treatment practices in schizophrenia: An integrated methodology

A multi-phase research project examining current impatient psychiatric practices and the relationships between different treatments and patient outcomes is described. The study sample includes Medicaid patients with a diagnosis of schizophrenia who have been treated in inpatient units of general hospitals in New York State. The research is focused at the heart of the debate concerning the appropriate role of inpatient psychiatric care within a balanced system of mental health services. Addressed are the conceptual issues that guided the project, research strategies, instrument development, measures used and the preliminary findings that informed successive phases. Design issues are reviewed in light of the conceptual and pragmatic decisions made with a multiple site design. A compelling argument is made about the need for a long-term treatment orientation that prepares patients for what lies ahead and that assures communication and continuity between inpatient and outpatient care.

Recent HIV testing among general hospital inpatients with schizophrenia: findings from four New York City sites.

Background: While widely acknowledged to be an important clinical and public health issue, HIV assessment, counseling, and testing for the seriously mentally ill has not been well studied. Objective: To determine what proportion and which inpatients with schizophrenia have been recently tested for HIV. Method: A sample of 300 inpatients with schizophrenia were recruited from four general hospitals in New York City over a one year period. After confirmation of diagnosis with a structured interview, and elicitation of sociodemographic and drug use information, medical record review identified recent HIV testing. Bivariate and multivariate analyses were used to identify subgroups more likely to be tested. Findings: Recent HIV testing had been performed for 17% of the sample and was concentrated among those with higher documented risks. The majority of patients remain untested even in groups with direct risks, such as injection drug use, and indirect risks, such as frequent cocaine use in last year. Some evidence was found that white patients at risk may be less likely to be tested than Hispanic or African American patients. Conclusions: Aggressive efforts are needed to improve knowledge of HIV status among acutely ill patients with schizophrenia.

Psychiatric Reimbursement Reform in New York State: Lessons in Implementing Change

The failure of an innovative and ambitious reform in the psychiatric reimbursement system of New York State is examined for specific lessons of value for other states as they implement new payment strategies to encourage improved treatment of the mentally ill in general hospitals and community settings. The New York payment system was comprehensive, embracing both inpatient and outpatient care, and had significant support in the hospital and professional communities. Still, its impact on hospital performance was small and only partially consistent with its goals. For mental health reimbursement reform to succeed, state administrators must provide more clear, sustained, and forceful signals that take account of the real barriers to implementation; they must also ensure that the financial incentives and rewards are recognized by those who carry out the actions needed to translate goals into reality.

Is the substance abuse of inpatients with schizophrenia overlooked

The utility of medical records and clinician reports for assessing substance abuse among inpatients with schizophrenia or schizoaffective disorder was assessed in a sample of 296 patients recruited from four general hospitals in New York City. Measures derived from the medical record, the discharge summary, and primary clinician reports are compared to the results of a structured diagnostic interview. Analysis of the sensitivity, specificity, positive predictive value, and overall accuracy of the nondiagnostic sources found unexpectedly high levels of detection. Discharge summaries had the lowest sensitivity when compared to the diagnostic interview, raising concern that inpatient staff and clinicians may fail to communicate substance abuse problems to outpatient providers.