prite2020

nikhil dhawan, md

2020-08-11 Tue 15:00

Created: 2020-08-11 Tue 07:20

1 ACT

  • 24 hours a day coverage
  • purpose is to help keep people out of the hospital.

2 Interventions of cybersecurity (delete?)

3 Notice the "OR" which makes it the best choice.

  • "The technical needs of a telehealth program will depend on the type of telemedicine its organization intends to practice: synchronous or asynchronous. Synchronous or live telemedicine involves a real-time interaction between the participants at 2 or more sites. Asynchronous or store-and-forward telemedicine involves recording medical information at 1 site and then transmitting the recorded information to another site or sites for evaluation by a medical specialist at a later time."

4 Capitation

  • Capitation payments are payments agreed upon in a capitated contract by a health insurance company and a medical provider. They are fixed, pre-arranged monthly payments received by a physician, clinic or hospital per patient enrolled in a health plan, or per capita. The monthly payment is calculated one year in advance and remains fixed for that year, regardless of how often the patient needs services.
  • https://www.investopedia.com/terms/c/capitation-payments.asp

4.1 Different payment systems

4.1.1 Capitation

  • perhaps gives incentives for physicians to contain costs since the more they spend the less they will ultimately make.
  • there is a risk that if you spend too much, you will have to pay the difference out of pocket.
  • luckily physicians can buy yet another kind of insurance for that.
  • to me this mostly incentivizes doing the least possible to make more money.

4.1.2 Fee-for-Service

  • physicians in this model are now incentivized to do as many services as possible.
  • more services, more money.
  • more visits, more money.
  • in this model, patients have easier access to care.
  • can't get an appointment with a psychiatrist? if you go to a ffs psychaitrist, you can usually get an appointment quickly.
  • financial risk here is not having enough patients which is a problem in some specialties (e.g., rad/onc)

4.1.3 Discounted Fee-for-Service

  • physicians are reimbursed by a percentage of their total charge or a specific dollar amount set by an insurance company.
  • imho, this is most common.
  • it adds an unfathomable layer of complexity with hospitals/physicians charging certain rates, insurance companies paying different amounts of money, and without insurance rates also change.

4.1.4 Salary

  • no financial incentives to practive "cost-effective" medicine.
  • imho, less bias in creating treatment plans in this model.

5 Medicare

6 Medical-certified leave

  • Apparently there is this finding in the literature that medically certified sickness is associated with bullying and an unsupportive supervisor.
  • Nielsen, M. B., Indregard, A.-M. R., Krane, L., & Knardahl, S. (2019). Workplace Bullying and Medically Certified Sickness Absence: Direction of Associations and the Moderating Role of Leader Behavior. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.00767

7 Legal levels of evidence

7.1 Probable cause

"Probable cause is a requirement found in the Fourth Amendment that must usually be met before police make an arrest, conduct a search, or receive a warrant. Courts usually find probable cause when there is a reasonable basis for believing that a crime may have been committed (for an arrest) or when evidence of the crime is present in the place to be searched (for a search)."

"… probable cause can also justify a warrantless search or seizure. Persons arrested without a warrant are required to be brought before a competent authority shortly after the arrest for a prompt judicial determination of probable cause."

  • this is what happens in our probable cause hearings ofter OPC is filed.

7.2 Preponderance of the evidence

  • only civil trials
  • greater than 50% chance that the claim is true.

"Under the preponderance standard, the burden of proof is met when the party with the burden convinces the fact finder that there is a greater than 50% chance that the claim is true. This is the burden of proof in a civil trial."

7.3 Clear and convincing evidence

  • both civil and criminal trials

"According to the Supreme Court in Colorado v. New Mexico, 467 U.S. 310 (1984), "clear and convincing" means that the evidence is highly and substantially more likely to be true than untrue; the fact finder must be convinced that the contention is highly probable."

  • medium level of burden, but higher level than preponderance of the evidence.

7.4 Beyond a reasonable doubt

  • only used in criminal procedures

"Beyond a reasonable doubt is the legal burden of proof required to affirm a conviction in a criminal case."

  • www.law.cornell.edu

8 Highest cognitive ability

  • managing finances requires the most cognitive ability and therefore has the highest burden for capacity

9 COMPASS

"…care managers were asked to provide feedback regarding the program and the main challenges they faced during implementation. These comments (n=178) were grouped into five general categories: (1) patient nonadherence, lack of motivation, poor engagement and difficulty in reaching patients as the main challenge (24.7% of all comments); (2) lack of time to accomplish all the tasks necessary to care for these complex patients (15.7%); (3) lack of engagement of the primary care team, psychiatry and the health care system in support of the COMPASS team (15.7%); (4) difficulties with enrolling the targeted sample (12.9%); and (5) the high burden of documentation and the ineffectiveness of the CMTS for patient management and tracking (11.2%)."

10 Simpson Angus Rating Scale

"The Simpson Angus Scale (SAS; Hawley et al., 2003) is a performance scale that measures drug-induced parkinsonism symptoms. " -https://www-sciencedirect-com.libproxy.uthscsa.edu/topics/medicine-and-dentistry/simpson-angus-scale

11 EEG

"EEG changes in encephalopathies are similar, whether the cause is septic, metabolic, toxic, or structural. There is a progressive increase in slow wave activities, the degree of which parallels the severity of brain dysfunction. In mild encephalopathic states, slowing of normal alpha (α) rhythms occurs, and with more severe encephalopathy, the appearance of theta (θ) and continuous or non-continuous delta (δ) activities. A variety of additional EEG patterns can be seen, such as frontal intermittent rhythmic delta (FIRDA), periodic lateralised or bilateral epileptiform discharges (PEDs, BIPEDs), and triphasic waves. None of these patterns is specific to a particular pathophysiological process or diagnosis, but PEDs are most likely to occur in acute or subacute focal destructive pathologies or focal epileptogenic lesions; triphasic waves are typically found in metabolic encephalopathies; and some patients with mesial fronto-parietal lesions or third ventricle tumours show FIRDA in their EEG."

  • Article below is definitely worth a read.
  • Smith, S. J. M. (2005). EEG in neurological conditions other than epilepsy: when does it help, what does it add? Journal of Neurology, Neurosurgery & Psychiatry, 76(suppl2), ii8–ii12. https://doi.org/10.1136/jnnp.2005.068486

12 Incidence and prevalence

  • Incidence: number of new cases that develop in a population in a specified time period
  • Prevalence: proportion of a population who have the disease/characteristic in a given time period, regardless of when they first developed the characteristic.

12.1 cumulative prevalence

  • "Cumulative incidence is calculated as the number of new events or cases of disease divided by the total number of individuals in the population at risk for a specific time interval."
  • There seem to be multiple definitions of this.

12.2 lifetime prevalence

  • the proportion of a population who, at some point in life has ever had the characteristic.

12.3 incidence density

12.4 period prevalence

  • the proportion of a population that has the characteristic at any point during a given time period of interest. “Past 12 months” is a commonly used period.

12.5 point prevalence

  • the proportion of a population that has the characteristic at a specific point in time.

12.6 reference

NIMH site: https://www.nimh.nih.gov/health/statistics/what-is-prevalence.shtml

13 CATIE-AD

Reduced suspiciousness with olanzapine or risperidone.

  • Sultzer, D. L., M. D., Davis, S. M., Dr. P. H., Tariot, P. N., M. D., Dagerman, K. S., M. S., Lebowitz, B. D., Ph. D., Lyketsos, C. G., M. D. ,. M. H., Rosenheck, R. A., M. D., Hsiao, J. K., M. D., Lieberman, J. A., M. D., & Schneider, L. S., M. D. (2008). Clinical Symptom Responses to Atypical Antipsychotic Medications in Alzheimer’s Disease: Phase 1 Outcomes From the CATIE-AD Effectiveness Trial. American Journal of Psychiatry, 165(7), 844–854. https://doi.org/10.1176/appi.ajp.2008.07111779

14 Veracity ethical principles (bad)

This means telling the truth which is apparently an ethical principle.

  • 10.4236/ojn.2019.92019

15 Voluntarism ??

16

17 Appelbaum health care decision making criteria

18 EHR

  • initial cost of introducing a system

19 informed consent for research

From our very own IRB website: http://research.uthscsa.edu/irb/Consent.shtml

  • if you want to do a study you can do an IRB here!

19.1 What if a research-related injury occurs?

The researchers have taken steps to minimize the known or expected risks. However, you may still experience problems or side effects, even though the researchers are careful to avoid them. In the event of a research-related injury or if you experience an adverse reaction, please immediately contact your study doctor. See the section "Contact Information" for phone numbers and additional information. You may also need to tell your regular doctors.

If you are injured or made sick from taking part in this research study, medical care will be provided. This care may be billed to you or your insurance. Depending on the circumstances, this care may be provided at no cost to you. We have no plans to give you money if you are injured. The investigator can provide you with more information.

If you sign this form, you do not give up your right to seek additional compensation if you are harmed as a result of being in this study.

20 stricter confidentiality for substance use disorders

These federal confidentiality law and regulations protect the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records except in limited circumstances.

21 lithium

lithium is old. it's a natural element. it cannot be patented and is therefore incompatible with the US healthcare system.

22 what is the strongest predictor of lacking capacity for financial decision making?

  • lack of insight

23 buprenorphine vs methadone

Switch to methadone which has better analgesic effect.

24 adverse effect of methadone

hypogonadism

25 Controlling for multiple confounders

Regression analysis Survival Odds Ratio T test Relative risk

26 Correction for multiple tests

Bonferroni

27 Effectiveness trials

28 inappropriate control group

this is because people who take antidepressants likely have differences in terms of diseases, etc compared to "healthy controls" who don't take antidepressants.

29 Effect estimation

effect size

30 Type I vs Type 2 error

31 Reliability and Validity

31.1 Reliability

Reliability refers to how consistent or repeatable measurements are. There are three primary approaches to measuring reliability, each useful in particular contexts and each having particular advantages and disadvantages:

  • Multiple-occasions reliability
  • Multiple-forms reliability
  • Internal consistency reliability

31.1.1 Multiple-occasions reliability

Also known as test-retest reliability. This is a measure of stability over time (temporal stability). If you test twice are the results the same with the assumption that the value has not changed.

31.1.2 Multiple-forms reliability

Also known as parallel forms reliability. This refers to how similar results from different versions of a test are.

  1. Split-Half Reliability

    \quote{ a pool of items believed to be homogeneous is created, then half the items are allocated to form A and half to form B. If the two (or more) forms of the test are administered to the same people on the same occasion, the correlation between the scores received on each form is an estimate of multiple-forms reliability. This correlation is sometimes called the coefficient of equivalence.}[pg 11]. You make questions to measure how well someone knows a subject. You then split the questions into test \(A\) and test \(B\). Then you give test \(A\) and test \(B\) to the students. The correlation between these scores is called the coefficient of equivalence.

31.1.3 Internal consistency reliability

This tests how reliable all the elements of the test are testing the same thing or the same construct. This is complicated to measure. You need to look at the inter-item correlation between different items in the test. If correlations are high then it is said to have high internal consistency reliability. Split half-reliability can measure internal consistency reliability, but each question must be homogenous. That means that each question in a test, for example, is of the same difficulty. You can overcome the need for homogenity by using cronbach's alpha.

  1. Average inter-item correllation

    To calculate this, take the correlation between each item. Then you take an average of them.

  2. Average item-total correllation

    To calculate this, add up scores on each individual item. Then determine how well they correlate with the total. Then you average all those correlations.

31.2 Validity

Validity is how well a test measures what it is supposed to measure. In this book she discusses four types of validity, content validity, construct validity, concurrent validity, and predictive validity.

31.2.1 Content Validity

This refers to how well the test measures all aspects of the domain of interest.

31.2.2 Face Validity

Similar to content validity. Does the test seem valid to a member of the general public or by someone who is evaluated by the test. If a test doesn't appear to be testing what it is supposed to test, then the person taking the test might not be motivated to answer well.

31.2.3 Concurrent Validity

How well can inferences from a measurement predict a behavior or a performance.

31.2.4 Predictive Validity

How well can scores from a measurement predict an event in the future.

32 Olanzapine CYP

Also with clozapine

33 ADHD and substance use

34 PRITE is wrong.

give olanzapine for many reasons.

35 ECT indications

  • not personality disorders

36 OCPs estrogen

Lamotrigine in pregnancy

37 AA

  • foundational factor.
  • Receiving chips as motivation is more like contingency management.

38 Risk of bleeding

"Mechanisms include increased gastric acid secretion and inhibition of serotonin entrance into platelets."

  • mirtazapine doesn't have this association.
  • Selective Serotonin Reuptake Inhibitor Use and Risk of Gastrointestinal and Intracranial Bleeding. Yuet WC, et al. J Am Osteopath Assoc. 2019 Feb 1;119(2):102-111. doi: 10.7556/jaoa.2019.016. Review.

39 Bipolar depression

  • Now we got vraylar or cariprazine.
  • Don't forget psychotherapy!

40 Carbon monoxide poisoning causing limb flapping

  • Globus pallidus most common involvement of CO poisoning.
  • Brain injury after acute carbon monoxide poisoning: early and late complications. Lo CP, et al. AJR Am J Roentgenol. 2007 Oct;189(4):W205-11. doi: 10.2214/AJR.07.2425. Review.