Mental Health Communication in Elderly Primary Care Visits and Economic Outcomes

医务室访问是医疗保健的基础，也是初级保健医生最重要的专业活动之一，而初级保健医生往往是老年人心理健康服务的唯一来源。证据继续表明，科学和临床实践之间的差距仍然很大：多达一半患有公认精神障碍的老年人没有接受任何心理健康服务，接受循证治疗的人更少。少数族裔患者的情况更糟。需要精神卫生服务的患者比例如此之高，无法获得循证护理，这是一个紧迫的公共卫生问题，尽管精神疾病的有效治疗取得了进展，但在获得高质量精神卫生保健方面仍然存在种族差异。对患者和医生如何互动的直接观察导致了公众和政策制定者直截了当和容易理解的研究结果。它为研究医生的工作和患者的贡献提供了一个新的视角，具有潜在的重要的新见解。我们建议利用由NIH资助的一项正在进行的研究提供的基础设施和数据，该研究在密歇根州底特律及其周边郊区的亨利·福特健康系统(Henry Ford Health System)中对不同社会经济背景的老年人进行了800次年度体检(旨在全面审查患者健康的体检)的音频记录。这项拟议的研究属于心理健康经济学的范畴。我们计划采用混合方法，将精神卫生服务研究的视角与行为经济学、传播学和统计学相结合。我们将使用录音、行政福利、药物分配、索赔和遭遇记录以及对患者和医生的调查数据来解决我们研究的具体目标：目标1：通过将繁忙诊所中关于精神健康的沟通质量要素与常规年度体检中合并疾病的竞争需求与中间结果，如患者满意度和治疗依从性以及包括服务使用和成本在内的远端临床和经济结果联系起来，检查医患沟通的生产力。目标2：使用不平等待遇医学研究所提出的定义，测试交流内容和时间方面的种族差异。我们将首先定性地比较种族和谐和不和谐的患者-医生对在心理健康和身体健康交流上所花费的内容和时间。我们将评估与执业环境密切相关并对政策有可塑性的因素的贡献，例如就诊时间、精神和身体健康提供者在同一地点的情况下观察到的差异。在研究完成时，我们寻求就具体的组织或临床干预措施提出具体建议，以解决这些国家的优先事项：将证据转化为实践和消除差异。

The medical office visit is the foundation of medical care and one of the most important professional activities of primary care physicians who are often the only source of mental health services for older adults. Evidence continues to show that the gap between science and clinical practice remains wide: as many as one half of older adults with a recognized mental disorder fail to receive any mental health services, and even fewer receive evidence-based treatments. Racial minority patients fare even worse. It is an urgent public health concern that such a high proportion of patients needing mental health services are without access to evidence-based care and that racial disparities in access to quality mental health care persist despite advancements in efficacious treatments for mental illnesses. Direct observation of how patients and physicians interact has led to research findings that are straightforward and easily understood by the public and policymakers. It offers a new perspective to study physicians' work and patients' contributions with potentially important new insights. We propose to leverage the infrastructure and data afforded by an ongoing NIH- funded study which is audio-recording 800 annual physical exam visits (checkups designed for physicians to comprehensively review their patients' health) among socioeconomically diverse older adults in a large integrated delivery system, the Henry Ford Health System, in Detroit Michigan and its surrounding suburbs. The proposed study is within the scope of the economics of mental health. We plan to apply mixed methods approach and combine perspectives from mental health services research with behavioral economics, communication research, and statistics. We will use data from audio-recordings, administrative benefits, medication dispensing, claims and encounter records, and surveys of patients and physicians to address the Specific Aims of our study: Aim 1: Examine the productivity of physician-patient communication by linking elements of quality of communication on mental health in the context of busy clinics and competing demands from co-morbidities in routine annual checkups with intermediate outcomes such as patient's satisfaction and treatment adherence and distal clinical and economic outcomes including service use and costs. Aim 2: Testing for racial disparities in communication content and time using the definition proposed by the Institute of Medicine in Unequal Treatment. We will first qualitatively compare the content and time devoted to mental health and physical health communications between racially concordant and discordant patient-physician pairs. We will assess the contribution of factors that are germane to the practice environment and malleable to policy, e.g., length of visit, co-location of mental and physical health providers to observed disparities. At the completion of the study, we seek to formulate concrete recommendations about specific organizational or clinical interventions that can address these national priorities: translating evidence to practice and eliminating disparities.