Psychiatric Quarterly, Vol. 72, No.

3, 2001

THE ROLE OF PSYCHOMETRIC DATA IN

PREDICTING INPATIENT MENTAL HEALTH
SERVICE UTILIZATION
Patricia M. Averill, Ph.D., Derek R. Hopko, Ph.D.,
David R. Small, M.B.A., Helen B. Greenlee, M.P.H.,
and Roy V. Varner, M.D.

Inpatient mental health readmission rates have increased dramatically in re-

cent years, with a subset ofconsumers referred to as revolving-door patients. In
an effort to reduce the financial burden associated with these patients and in-
crease treatment efficacy, researchers have begun to explore factors associated
with increased service utilization. To date, predictors of increased service us-
age are remarkably discrepant across studies. Further exploration, therefore,
is needed to better explicate the relevance of"traditional" predictors and also
to identify alternate strategies that may assist in predicting rehospitalization.
One method that may be helpful in identifying patients at high risk is the de-
velopment of a psychometric screening procedure. As a means to this end, the
present study was designed to assess the potential usefulness ofpsychometric
data in predicting mental health service utilization. The sample consisted of 131
patients hospitalized during an index period of8 months at an acute-care psy-
chiatric hospital. Number of readmissions was recorded in a 9 month post-index
,?

The authors are affiliated with the University of Texas-Houston Medical School and
the Harris County Psychiatric Center.
Address correspondence to Patricia M. Averill, University of Texas-Houston Harris
County Psychiatric Center, 2800 South MacGregor Way, Houston, TX77021.

215

OO33-272010110900-0215$19.50/0 @ 2001 Human Sciences Press, Inc.

l
exhaust tlieir beneiits. Hou,ever. after
adjustrnent fbr severlty of illness, hvo
managed care variables-being sub-
ject to a forrliulary and having ref'er-
rals restricted to selected hospitals or
specialist panels-rvere still assclciat-
ed rvith an effect of'financial consid-
erations on the provision o{'optirri:rl
treatment.
These results suggest that longitu-
dinal research is needed to more rig-
orously chartrcterize the specific fi-
nancial considerations and how they
affect treatrnent, sucli as lr4iich med-
ications or other speci{ic tretrtluents
rvere substituted or changed and the
quality and outcones o{' care ulti-
mately pror.ided. I 4.
Acknowledgments
This study u,trs suppoftecl bt'the Jolui D.
ald Catherine T. NlacArthur Forurdation
Role of a Medicalstaff Coding
Committee in Docum efitatron,
CoditrB, and Billing Compliance
Nelson P. Gruber, M.D.
Helen Shepherd, M.P.A.
Roy V. Varner, M.D.
Physician documentation, Cur-
rent Procedural Terminology
(CPT) coding, and compliance
with federal billing regulations
are essential given the govern-
ment's significant efforts to ad-
dress fraud and abuse and the
grave {inancial and legal conse-
quences of noncompliance. Be-
cause Medicare guidelines do not
focus substantially on psychiatric
care, compliance is especially
challenging for psychiatrists and
psychiatric centers. Four years
PSYCHIAIRIC SERIICES o http://psychservices.psychiatryonline.org;
and the Celter for Ment:rl Health Ser-
vices of the Substance Abuse and Mental
Health Sen'ices Adniilistration. Halold
Alan Pincus, M.D., aud Deborah A.
Zarin, NI.D., are co-prilcipal investigatols
of tlie Practice Research Network. rvltose
rnembers contributed their tirne to partic-
ipate in this study.
References
1. Buck JA, Uurlanci B: Ciovering rnental
health and substalco abuse services.
Health AIIairs 16(,1):120-126, 1997
2. Health Care l'lan Desigl alcl Cost fields:
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3. Findlay S: Managed beLarioral health care
in 1999: arr irrdustrl,at n crossroads. Health
Af{airs 18:116-124, 1999
Jensel GA, Nlorrisey MA, Gaflney S, et al:
The leu, dominance of rnanaged carc; in-
surarce trends in thc 1990s. Health Affairs
16( l ):1 25-i36, 1997
5. Sturm R, Pacula Rf,: lVleltal health paritv
ago, the University of Texas-Har-
ris County Psychiatric Center
formed a medical staff coding
committee to assist the center and
its psychiatrists in dealing with
compliance issues. The committee
has evolved into a highly effective
and important component of the
institution's overall compliance
program. The authors discuss the
origins, development, and accom-
plishments of the medical staff
coding committee. (Psychiatric
Seraices 53: 1629-1631, 2002)
i December 2002 Vol.
ald enrployer-spolsored health insurance
in 1999-2000: I. limits. Psychiatric Senices
51:1361,2000
6. Weissmal E, Pettigrerv K, Sotsky S, et al:
'Ihe cost of irccess to mental health services
irr uralaged care. Psychiatric Services 51:
66,+-666, 2000
7. Natiorral Advisory Nlental llealth Courrcil:
Parity inFinancirrg Merrtal Health Ser-
vices: Nlarraged Care Efl'ects ol Cost, Ac-
cess, ald Qualitv Rockville, Md, National
hrstitute ol NIental [{ealth, 1998
8. Stunn R, NlcCulloch J, Goldman \\I: Men-
tal health and substance. abuse parity: a case
study ol Ohio! state enployee program.
Joulnal r,rf Mental Health Policy and Eco-
nornics I0:129-13,{, 1998
9. Fralk RG, Morlock LL: \{anaging Frag-
rnelte<l Public Health Serwices. Nerv York.
Milbank Memorial Fuld, 1997
10. Pirrcus HA, Zarin DA, Tanielian TL, et al:
Psvchiatric patielts and treatrnents in I997:
{indings iiorn the Arnerican Psychiatric
Practice Research Nehvork. Archives of
General Psychiatry 56:441-449, 1999
.l)l n siciar r doc'r rr rrentatior r. Currettt
I. Procedural Terrrrinr-rlogy (CPT)
coding, and cornpliance r,vith federal
billirg regulations are essential given
the governrnent'.s significant efforts to
address fi'tiud and abuse :rnd the grave
{irrancial and legtrl consequences clf
noncornpliance (1,2). Compliance has
beeri especially challenging fbr psy-
chiatrists and psychiatric centers, be-
cause Meclicare guidelines do not fo-
cus substantially on psychi:rtric care.
At the 250-bed University of
Texas-Harris County Psychiatric
5l No. 12 1629
 CME Anlrcr.n
Use of the Brief Psychiatric Rating Scale to Facilitate
Differential Diagnosis at Acute Inpatient Admission
Derek R. Hopko, Ph.D.; Patricia M. Averill, Ph.D.; David Small, lvl.B.A.;
Helen Greenlee, M.P.H.; and Roy V. Varner, Ivl.D.
Background: The advcnt ofmanaged carc has
ncccssitated strate-qies fbr quickly and accurately
diagnosing psychiatric disorders.'[he aim ofthe
pl'esent study rvas to ascertain rvhcther the Brief
Psychiatric Rating Scalc-Anchored (BPRS-A)
would bc a usctirl adjunct to more traditional di-
agnostic strategies at aoute inpatient aclmission.
fuIethod: [Jsing a sample of 207 inpaticnts
aclnritted duling an 8-nronth inclcr pcriocl, rvc cx-
arnined the utility of the tsI'llS-A in predicting
rvhether patients were more likely to be cliag-
nosed rvith schizophrenia. bipolar disorder, or
rnajor deprcssion (DSM-lV).
Results: Discriminant fiurction analyscs rvcre
userl to correctly predict 68%. 60%, and 749to of
patients tliagnosed with schizophrenia. bipolar
disorder, ancl nrajor dcprcssion, respectively. The
mtiiu prcdictors oldiagnostic category, in dc-
scending ordcr, rvcrc BPRS-A depresscd mood
itcm, BPRS-A positivc syrnptoms scale, BPRS-A
cxcitement itcn, BPRS-A guilt feclings itcm,
BPRS-A mannerisms and posturing item, and
nurnber of previous episodes.
Cottclusiut: As efforts are dilectecl torvard
continuous quality irnprovernent within rnental
health scttings, an emphasis must be placed on
inrproving the efticiency and accuracy of diag-
nostic plocetlures. The IIPRS-A shorvs prornise as
a tinre -ctllcicnt assessnlent instrument that may
trc usclirl in lacilitating dill'ercntial ditrgnosis at
inpatient adrrission and may inclcasc thc likcli-
hood that eflcacious prelelcasc intcrventions and
appropriate aftcrcarc scrvices arc irnplcmentcrl.
(.1 (;lin Ps.vchiarrl' 200 I ;(t2:304-3 l2)
Raceivctl Altril 18, 2000: ac'cepted Sept. 6, 2000. Fronr the Universit.v
ol'Texos-*Houston ll'letliui &:lutol 1Dr Hopkt); uil Harris Counq, psy-
thiatric Cenrer flouslut (Drs.,4verill ond lltutret; Mr. Smull, ttnd lvls.
Greenlee).
Reprint requess ro: Detek R. Hopko, Ph.D., Universit-v ot'Texas-
Hotrstort iVlctlical School, ]tlental Scienc:es lnslitute, l.]00 iv[oursund lve.,
Housbn, TX 7 70 I 0- 3 497 (e-mai I : Derek. R. I{upko(tlurh.rnrc.edu).
304
ltc origination and cxpansion of the managcd behav-
ioral health care industry have resulted in significant
changes in the provision of nrental healtl-r services. The
impact of managed care is quite extcnsivc, ranging from
widespread eff'ects in the training and practice of clinical
practitionersr-'r to significant reductions in duration of treat-
rnent in both inpaticnt and outpatient settings.a5 A prob-
lcn.ratic outgrowth of thcse changes has been an increased
focus on tirne-lirrrited treahnent and cost-cor.rtainment
rncchanisrns tlrat may ncgatively aff'oct treatment efl-
cacy.t''' Moreover, rvithin the field of rnenlal hcalth, thc
application of continuous quality improvement (CQI) has
Iaggcd bchind its application within other health carc scr-
vices.s To address thesc problerns, researchcrs should
focus on those lactors that n.ray increase the efficacy of
time-limited nlental lrealth care and sin-rultancously in.r-
provc the accountability ofrncntal health providers.
Only rccently has a movernent toward the application
of CQI within an inpatient mental health setting been
initiated.e In general, CQI refers to thc application of sci-
cntific mcthodology as it relates to improvernent of coor-
dination of care alnong health care providers and the
provision of health care services. Based cn this paradigrn,
problerns related to quality of care are not a function
of employee characteristics (e.g.. eflbrt. skill lcvel), but
lathcr of the way thoir work is organized.e Accordingly,
thc primary objectives of CQI involvc ( l) thc application
of problem-solving techniques to intprove treatlnent out-
corrre; (2) systematic monitorirrg, evaluation, artd itnprove-
rncnt rvith regard to the efficiency of work procedures: and
(3) the implementation of a plan to addrcss problems and
better enable arr or:ganizatiorr to achieve its goals.
Consistent with the CQI philosophy. the prcscnt stucly
r,vas designed to focus on qualiry improvement within thc
Han'is County Psychiatric Cerrter (HCPC). an inpatient
rncntal healtli setting locatcd in Flonston. Tcx. Spccifi-
cally. the objectivc was to lnake progress toward improv-
ing the quality ofinitial diagnostic assesslrellt procedures
to expcdite implcrnentation of an appropriato treatmcnt
J Clin Psychiatry 62:4, April 2001
 Translational Data Management

tDx BRAIN
lnpatient Patient approvals
Ambulatory Care Demographics Research
Registration
Protocol Protocol inclusion/
Specialized care Treatment Scheduling Managment exclusion criteria
settings Consent to contact
Consent to bank sample lnformed Consent

Genomics
ublications Proteomics
External Communitv activities lmaging
Collaboration Public edutational
Biomarkers
6vents
Physician groups
Specialty care providers Molecular and Human Genetics
and care givers Cancer Center
Breast Center
Tissue banks
Disease risk
identification
Centricity Health monitorino
Treatment effectiVeness lnteroperablo extraction
Prognoses I
stanaarai=J3ols HL7
Diagnostic screening Communication
and testing protocools CDISC
Con necti v ity_ tech nology
Encryptron ancl
abstraction

Study Manager
Electronic data capture
and transmission Population based risk
assessment
integrated safety Clinical outcome
Anonymized
capture and modeling
Practice guidelines
study projoct and financial Translational Science to
data interoperability clinical care
between BCM and Collaborative research
government agencies (FDA, Graduate training
NIH), clinical research program
networks and other Patient education
collaborative research programs
partners
Performance Improvement Plan

Developing a
strategy for OOR
Assurance and
Compliance
Objective

1. To create a consistent manner in which

research protocols are reviewed and acted
upon
By OOR Assurance and Compliance Analysts
By IRB members
By board Chairs and Vice Chairs
2. To document the ways that the IRB
complies with regulations and
accreditation standards
112212003
Objective cont'd

3. To develop specific measures that will

document the stability of the elements of
the protocol review process and IRB
actions
,' ,;..;,,,, ,,, Informed consent and waiver of consent, plans for
protecting vulnerable populations, etc.)
4. To monitor these measures over time to
ensure that how the IRB performs it's
functions of human protection oversight is
in line with how the regulations and
standards presr#ihc
Objective cont'd

5. By reviewing the data collected through the

measures, identify the review process steps that
contribute to or cause undesirable and
inconsistent results ("*. Tabled protocols, extended
turnaround times, multiple administrative modifications)
6. Change identified review process steps where
needed to stabiltze the review process and
strengthen the attribute of consisten cy.

112212003
Things to be considered first
1.
$gt"e on a practical definition of performance
improvement
"Do the right thing, the first time"

oProtocols are completed administratively correct

the first time submitted.
Desired Result:
1. I in number of protocols returned for administrative
modification
2. I in the number of protocols administratively approved the
first time
3. J in turnaround tiryrffdsapproved protocols
Things to be considered first, cont'd

2. Aglree to goal
Goal I
"Continually and by increments, improve the way's
we assure compliance with human subject
research protections while proactively
supporting the Baylor research community"

Develop a set of criteria (checklist) that would be

used to trigger review of specific protocol
components.

112212003
Things to be considered first, cont'd

Assigned lo
commiftee by
analyst

A. St otq(stions led
to devlop the actual
mea$re B. StofqusstioEused
to devolop ih aclual
measure

C. SetofqustioB used
to develop th6 aclual
masurg

112212003
Things to be considered first, cont'd

a lnformed Consent
a
o #H
a
a o A statement that the study involves research, an explanation of the purposes ol the research and the expected duration of the subject's
participation, a description of the procedures to be followed, and identification of any procedures which are experimental.
a o A description of any reasonably foreseeable risks or discomforts to the subject.
a o A description of any benefits to the subjects or to others that may reasonably be expected from the research.
a o A disclosure of appropriate alternative procedures or courses of treatment, if any, which might be advantageous to the subject.
a o A statement describing the extent, if any, to which confidentiality of records identifying the subject will be maintained and notes (if
applicable) the possibility that the FDA may inspect the records.
o For research involving more than minimal risk, an explanation as to whether any compensation, and an explanation as to whether any
medical treatmenls are avarlable, if injury occurs and, if so, what they consist of, or where further information may be obtained.
o An explanation of whom to contact for answers to pertinent questions about the research and research subjects' rights, and whom to
contact in the event of a research-related injury to the subject.
o A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is
otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits, to which the subject is
otherwise entitled
o When the additional elements of information for informed consent forms are required as set forth in VA and other Federal regulations.
- o a statement that the particular treatment or procedure may involve risks to the subject (or to the embryo or fetus, if the subject is or may
become pregnant) which are currently unforeseeable;
- o anticipated circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent;
- o any additional costs to the subject that may result from participation in the research;
- o the consequences of a sub.ject's decision to withdraw from the research and procedures for orderly termination of participation by the subject;
- o A statement that significant new findings developed during the course of the research which may relate to the subject's willingness lo continue
participation will be provided to the subject; and
- o the approximate number of sub.jects involved in the study.

112212003
Things to be considered first, cont'd

Goal 2
"MinLmLZe or reduce opportunities for adverse
impact"

Iruitial Reuiew wl no administrative modifications

Desired result: jexpired and tabled protocols

112212003
Things to be considered first, cont'd

Goal 3
"Improve efficiency, using both people and material
resources more effectively and productively"

*Enhance BRAIN with education attachments (NIH

grant) and checklist data
oData collection checklist information is
incorporated into IRB performance review and
regul aruzed performance reporting

112212003
 Things to be considered first, cont'd

Goal 4
"Minimrze or eliminate duplication"

Goal 5

"Increase communication, awareness and

cooperation"

Using the checklist data collected, create

Dashboard report
l1 112212003
Things to be considered first, cont,d

IrtrorrndCorcertr

112212003
Things to be considered first, cont'd

Goal 6
"Meet external pressure for accountability:
Secure Accreditation"

1122t2003
Step 2 The Organizatton

o Establish effective relationships

o Identify strengths, weaknesses, and areas needing
change, considering the following:
Structure and environment
Climate for change
Extent and type of support
Extent and type of resistance (real and
anticipated)

Review Process Map

112212003
Step 3 Develop a written Action Plan

o Describe issues to be resolved

1. Consistent reviews by IRB and Analysts

2. Document compliance with Accreditation
standards
3. NIH Grant

112212003
Step 3 Develop a written Action Plan,
cont'd

o Identifr components to be developed

1. Quality Measures
- Criteria set and./or checklist
i > Informed consent
Child Assent! (guidance developed and provided)
Non-English speakers (guidance developed, awaiting
sub-committee approval)
Volume of blood to be drawnJ (guidance developed and
provided)
ii > Vulnerable populations
Child Assentri (guidance developed and provided)
iii> Risk Categories
Volume of btoodrl(guidance developed and
provided)
Data and Safety Monitoring Plans
Placebo controlled trials
iv> Protocol review

112212003
Step 3 Develop awritten Action Plan,
cont'd

o Identify components to be developed, cont'd

2. Performance Measures
- Process performance
i. Protocol turnaround time
ii. # times protocol requires
modification
iii. # protocols reviewed by IRB by meeting
a. Approved
b. Tabled
c. Renewed
4. Disapproved

112212003
Step 3 Develop awritten Action Plan,
cont'd

o Identify components to be developed, cont'd

3. Bducation topics
4. BRAIN enhancements

112212003
Step 4 - Identify resource
needs

Outline staffitrg, resource and training

needs
For data collection and reporting
For computer and information system support

112212003
StepSand6-Rolesand
education
o Step 5
Determine specific roles and responsibilities

o Step 6
Inform and educate
- What you are doing and *hy
- Document current process of protocol review
- Create consistency in the process review
- Monitor the stability of the research support process
- Identify areas for improvement and continuing education
- Develop a measurement program that incorporates ongoing
accreditation data collection for longitudinal tracking

1l22l2AO3
Step 6 - Education
o Inform and educate, cont'd
New techniques and tools
o BRAIN
o Reports
o Data
o Accreditation
o Benefits of effective, integrated
processes
112212003
Step 7 - Implement

o Pilot data collection and reporting

o Implement in phases
o Plan for a transition period

112212003
Cu rrent Accompl ish ments :
o Where we are now.
Process map for protocol review r/
Agree on quality measures and performance measures {
Design data collection methodology {
Determine, sample size for measures and inter-rater
reliability{
Determine prior[ties for administrative review
enhancementsr/
o Document guiQance to be used to prevent "Return to PI"
process stdp{
o Re-prioritize needed enhancements to BRAIN {
o ldentify educational enhancements and overlays in BRAIN {

112212003
Work in progress:
o What remains to be done
Add accreditation standard notations to process map
Match current checklists elements with process map
Create data collection tools
Validate data collection tools with process map and checklists
Create database
Test data collection tools
lnitiate pilot
. Prospective data collection
o Retrospective data collection
- Data and Safety Monitoring plans
- Placebo controlled trails

112212003