Hospital Service Utilization is Reduced Following Neuropsychological Evaluation in a Sample of U.S. Veterans

The aim of this study was to evaluate the objective value of neuropsychological evaluation (NPE) through reduction in Emergency Room (ER) visits and hospitalizations. Retrospective analysis examined trends in ER visits and hospitalizations in 440 U.S. veterans who completed NPE between the years of 2003 and 2010. Within-subjects comparisons showed significant decreases in incidence of hospitalization and length of hospitalization in the year after evaluation compared to the year prior. Mean number of hospitalizations declined from 0.31 (SD = 0.64) pre-NPE to 0.22 (SD = 0.59) post-NPE; there were a total of 41 fewer hospitalizations in the year following NPE. Mean length of hospitalization decreased from 1.9 days (SD = 5.6) pre-NPE to 1.06 days (SD = 3.9) post-NPE; there were a total of 368 fewer days of hospitalization post-NPE. This reduction was not attributable to age or time. Incidence of ER visits also decreased from pre-NPE (M = 0.74, SD = 1.3) to post-evaluation (M = 0.69, SD = 1.3), though this was not significant. These findings provide preliminary evidence of the clinical and potential economic value of neuropsychological services within a medical setting. Follow-up studies should examine individual and exam-specific factors that may contribute to reduced utilization.     

Utilization Rates of Ecologically Oriented Instruments Among Clinical Neuropsychologists

The ecological validity of neuropsychological instruments has become an important topic in recent decades, as neuropsychologists are asked to address real-world outcomes with increasing frequency. Although novel instruments that tap skills required for everyday functioning have been developed, it is unclear whether these instruments are migrating from research laboratories into the applied settings of clinical neuropsychologists. The current study surveyed assessment practices of neuropsychologists with regard to their utilization of instruments designed with ecological concerns in mind. Respondents included 747 North American, doctorate-level psychologists (40% usable response rate) affiliated with Division 40 of the American Psychological Association, National Academy of Neuropsychology, or the International Neuropsychological Society. Results indicated that approximately one-third of respondents reported use of ecologically oriented instruments (EOIs), and these instruments were generally utilized with much less frequency than traditional measures. Additionally, certain practice demographics affected usage rates of EOIs. Study findings are interpreted in the context of a growing body of literature that calls attention to the importance of developing and utilizing instruments that are able to handle the complex, real-world issues increasingly addressed during the neuropsychological assessment process.     

The utility of neuropsychological consultation in identifying medical inpatients with suspected cognitive impairment at risk for greater hospital utilization

Objective: This was a retrospective study designed to examine the relationship between inpatient neuropsychological status and future utilization costs. Methods: We completed a retrospective chart review of 280 patients admitted to a large academic medical center who were referred for bedside neuropsychological evaluation. Patients were grouped based on neuropsychological recommendation regarding level of supportive needs post-discharge (low, moderate, high). Level of support was used as a gross surrogate indicator of cognitive status in this heterogeneous sample. We also included patients who refused assessment. Outcome variables included time to readmission, number of emergency department visits, inpatient admissions, length of hospitalization, and total costs of hospitalizations, 30 days and 1 year following discharge. Results: Multivariate analysis indicated patients who refused assessment had higher inpatient service utilization (number of ED visits, number of admissions, and total cost of hospitalization) compared to those with moderate needs. Also, high needs patients had higher total cost of hospitalization at 1 year, and those with low needs used the ED more, compared to those with moderate needs. Conclusions: Our findings replicate prior studies linking refusal of neuropsychological evaluation to higher service utilization costs, and suggest a nonlinear relationship between cognitive impairment severity and future costs for medical inpatients (different groups incur different types of costs). Results preliminarily highlight the potential utility of inpatient neuropsychological assessment in identifying patients at risk for greater hospital utilization, which may allow for the development of appropriate interventions for these patients.     

WAIS-IV Reliable Digit Span is no More Accurate Than Age Corrected Scaled Score as an Indicator of Invalid Performance in a Veteran Sample Undergoing Evaluation for mTBI

Reliable Digit Span (RDS) is a measure of effort derived from the Digit Span subtest of the Wechsler intelligence scales. Some authors have suggested that the age-corrected scaled score provides a more accurate measure of effort than RDS. This study examined the relative diagnostic accuracy of the traditional RDS, an extended RDS including the new Sequencing task from the Wechsler Adult Intelligence Scale-IV, and the age-corrected scaled score, relative to performance validity as determined by the Test of Memory Malingering. Data were collected from 138 Veterans seen in a traumatic brain injury clinic. The traditional RDS (? 7), revised RDS (? 11), and Digit Span age-corrected scaled score (? 6) had respective sensitivities of 39%, 39%, and 33%, and respective specificities of 82%, 89%, and 91%. Of these indices, revised RDS and the Digit Span age-corrected scaled score provide the most accurate measure of performance validity among the three measures.     

Factors Associated with Word Memory Test Performance in Persons with Medically Documented Traumatic Brain Injury

Objectives: (1) To examine the rate of poor performance validity in a large, multicenter, prospectively accrued cohort of community dwelling persons with medically documented traumatic brain injury (TBI), (2) to identify factors associated with Word Memory Test (WMT) performance in persons with TBI. Method: This was a prospective cohort, observational study of 491 persons with medically documented TBI. Participants were administered a battery of cognitive tests, questionnaires on emotional distress and post-concussive symptoms, and a performance validity test (WMT). Additional data were collected by interview and review of medical records. Results: One hundred and seventeen participants showed poor performance validity using the standard cutoff. Variable cluster analysis was conducted as a data reduction strategy. Findings revealed that the 10 cognitive tests and questionnaires could be summarized as 4 indices of emotional distress, speed of cognitive processing, verbal memory, and verbal fluency. Regression models revealed that verbal memory, emotional distress, age, and injury severity (time to follow commands) made unique contribution to prediction of poor performance validity. Conclusions: Poor performance validity was common in a research sample of persons with medically documented TBI who were not evaluated in conjunction with litigation, compensation claims, or current report of symptoms. Poor performance validity was associated with poor performance on cognitive tests, greater emotional distress, lower injury severity, and greater age. Many participants expected to have residual deficits based on initial injury severity showed poor performance validity.     

Intra-Individual Variability Across Neurocognitive Domains in Chronic Hepatitis C Infection: Elevated Dispersion is Associated With Serostatus and Unemployment Risk

Approximately one-third of persons infected with the hepatitis C virus (HCV) evidence mild cognitive impairment that is consistent with frontostriatal systems dysfunction, including cognitive dyscontrol, and impacts everyday functioning. The present study examined the effects of HCV on neurocognitive dispersion, or within-person variability in neurocognitive performance across domains, which may be a function of poor sustained cognitive control. High dispersion was also hypothesized to increase risk for unemployment. The study sample included 37 individuals with HCV infection (HCV+) and 45 demographically comparable uninfected comparison participants (HCV?). Dispersion was operationalized as an intra-individual standard deviation (ISD) calculated across the demographically adjusted T-scores of 13 standard neuropsychological tests. Multiple linear regression and logistic regression approaches were used to evaluate associations between dispersion and HCV serostatus and employment status, respectively. HCV serostatus was significantly associated with higher dispersion, independent of mean level of neurocognitive ability, psychiatric factors, and liver disease severity. Within the HCV+ group, higher dispersion was associated with an increased risk of unemployment among individuals with higher overall mean neurocognitive ability. Increased neurocognitive dispersion among HCV+ individuals may indicate vulnerability to cognitive dyscontrol expressed as poor regulation of performance across tasks. Higher dispersion may manifest as functional difficulties in daily life, particularly among neurocognitively normal HCV-infected persons, which speaks to the potential clinical value of considering intra-individual variability when evaluating risk for everyday function problems in this population.     

Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the Veterans Health Administration

OBJECTIVE: Our objective was to describe the adequacy of follow-up care for depression and its association with antidepressant treatment duration among veterans with and without diabetes mellitus (DM). METHOD: This was a retrospective study (1997-2005) of 2178 veterans (33% with DM) in a Midwestern Veterans Health Administration facility who had a new episode of unipolar depression. Adequate follow-up care was defined by a health care visit within 7 and 14 days, and >/=3 visits following antidepressant treatment initiation. Adequate treatment duration was defined by a medication possession ratio of >/=80%. Multivariate logistic regression was used to calculate odds ratios (ORs) adjusted for demographic, clinical and health care utilization characteristics. RESULTS: Only 27% received >/=3 follow-up visits within 12 weeks, and <23% received follow-up within 2 weeks of antidepressant initiation. Subjects with DM were 1.36-fold more likely [95% confidence interval (95% CI)=1.05-1.75] to have received >/=3 visits but were similarly likely to have received follow-up within 7 days (OR=1.02; 95% CI=0.74-1.41) or 14 days (OR=1.08; 95% CI=0.83-1.40) of antidepressant initiation. Adequate follow-up care was the most important predictor of adequate treatment duration (OR=2.10; 95% CI=1.54-2.88). CONCLUSION: DM had little influence on the adequacy of follow-up care for depression, with few exceptions. Follow-up care for depression is underutilized and has a significant impact on antidepressant treatment duration. Strategies to more effectively manage depression treatment are required.     

Performance on a Visual Sustained Attention and Discrimination Task is Associated with Urinary Excretion of Norepineprhine Metabolite in Children with Attention-Deficit/Hyperactivity Disorder (AD/HD)

ABSTRACT

The degree of association between performance on a sustained attention task requiring visual discrimination and urinary excretion of catecholamine metabolites was examined in a cohort of 6- to 12-year-old children (n = 31) strictly selected and diagnosed with attention-deficit/hyperactivity disorder (AD/HD) according to DSM-IV and other strict criteria. Sustained visual attention and discrimination were measured using the Test of Variables of Attention (T.O.V.A.). Urinary excretion of dopamine (DA) and norepinephrine (NE) metabolites was measured by reversed high-pressure liquid chromatography (HPLC). Pearson product-moment correlations were used to investigate the relationship between T.O.V.A. errors of omission (OMM), errors of commission (COM), response time (RT), and response time variability (RTV) and catecholamine metabolites of DA and NE. All T.O.V.A. indexes under investigation were significantly correlated with urinary excretion of NE metabolites, but correlations were low-to-moderate in magnitude (.37–.50). In contrast, there were no statistically significant correlations between T.O.V.A. indices and DA metabolites. These findings and their concordance with past research in human adults and animals, as well as theoretical issues associated with the present results, are discussed.