Journal of Clinical Outcomes Management. 2014 November;21(11)
References
) for data extraction. Items A through J in Table 2 are routinely collected in all clinic patients. Items K through P were included in response to the literature indicating that behavioral health problems are chronic and present predominantly with physical, often pain, symptoms and that comorbid physical problems were common [2,3]. Items Q through U identified medications commonly used in this population. Morphine equivalents were calculated, using an adaptation of the literature, to quantify prescription substance use [14]. Because mortality rises significantly at 80 to 120 morphine equivalents per day, we used levels > 120 to represent an “unsafe dose” [15]. Therapeutic doses of antidepressants were obtained to inform the frequent finding that physicians use inadequate doses [16] and were based on “usual doses” outlined in a standard primary care psychiatry textbook [17]. Items V through X informed the degree of disability in what may be a very disabled population [18]. This was the one area in data extraction that required interpretation for assessments of physical, economic, and social disability. We reviewed several disability scales, especially those concerning pain, and adapted these self-report scales for our purposes of extracting disability information from a medical record [19,20]. Major impairment/disability was defined as any one of the first three categories for each item. Item Y informed the level of depression observed on the Patient Health Questionnaire-9 (PHQ-9) [21], while Item Z represented the diagnoses established by psychiatry and trained medical faculty based on the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-V) [22]. Items AA through AC identified how much current and prior care behavioral care patients had received from mental health professionals (psychiatry, psychology, other counselors) and how long they had been cared for in the medical clinic [5].
Two authors, RCS and AD, independently reviewed the EMR records of CPC visits, including follow-up visits and free text sources, and recorded results on an Excel spreadsheet; records of visits prior to CPC consultation were not reviewed nor were later non-CPC visits. They abstracted chart information on the first 5 patients and then updated and refined criteria. This was repeated again for the next 5 patients and near 100% agreement was obtained on all items except disability where > 90% agreement was achieved. All subsequent ratings were independently obtained and any differences were then jointly resolved in this extraction of mostly straightforward descriptive data. RCS is a senior faculty active in teaching and AD is a senior medical resident rated as superior by her faculty.
Results
Of 77 patients referred between 19 February 2013 and 10 December 2013, 13 (16.9%) did not complete the first scheduled or any subsequently scheduled appointments, while the remaining 64 patients (83.1%) completed referral to the CPC. Of the 64 attending the CPC, 6 (9.4%) missed the first appointment but made their first visit an average of 36.2 days later. The mean age was 48.6 years (range 25–75), 44/64 (68.8%) were women, 55/64 (85.9%) were Caucasian, 60/64 (93.8%) were non-Hispanic/Latino, and 63/64 (98.4%) were English speaking. All had insurance of some type, and 25/64 (39.1%) were Medicaid patients. Of 3583 total patients seen in the referring clinics during the same period, we found a mean age of 57 years (range, 17–97), 53% women, 75% Caucasian, 95% non-Hispanic/Latino, 97% English-speaking, and 9% Medicaid.
