Youth With Autism More Likely to Experience Restraint in Hospital

Children and adolescents with autism spectrum disorder (ASD) are more than twice as likely as those without ASD to be restrained while hospitalized, according to a report published today in Pediatrics.

“Because people with ASD often have invisible disabilities or disabilities that are less frequently understood, they may get less support in health care settings,” wrote Mary Elizabeth Calabrese, D.O., M.P.H., and colleagues from Boston Children’s Hospital. “Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation that can lead to unnecessary and avoidable physical and pharmacologic restraint.”

Calabrese and colleagues examined retrospective medical data for all pediatric patients aged 5 to 21 years who were admitted to a pediatric inpatient unit between October 1, 2016, and October 1, 2021. Due to differences in protocols in psychiatric units and emergency departments, youth seen in psychiatric units or emergency departments were excluded from this analysis, the authors explained. They examined clinical orders for physical restraint (for example, cuffs or seclusion) and/or pharmacological restraint (for example, an antipsychotic or benzodiazepine injection) due to the patients’ violent or self-injurious behavior.

The final sample included 21,275 youth, including 1,187 (5.6%) youth with ASD. Of the 367 in the sample who experienced restraint, 88 (24%) had a diagnosis of ASD. Compared with youth without ASD, those with ASD were hospitalized longer, were more likely to have a comorbid psychiatric diagnosis, and were more likely to be admitted for a behavioral than a physical issue. After adjusting for these differences, youth with ASD were 2.3 times as likely to be restrained than youth without ASD.

This article was one of three published today in Pediatrics examining trends and disparities in the use of restraints in children’s hospitals. The second report indicates that Black children admitted to a hospital for a mental health crisis are more likely to receive pharmacologic restraint than children who were not Black. The third report shows that the rate of pharmacologic restraint has remained stable between 2016 and 2021, as slight decreases in the use of restraints for youth with ASD or anxiety were offset by increased restraint use for conditions like bipolar disorder and eating disorders.

“Now is the time to envision a path toward ending restraint use at children’s hospitals,” wrote Evan M. Dalton, M.D., M.S.H.P., of Texas Children’s Hospital in Houston and Stephanie K. Doupnik, M.D., M.S.H.P., of the Children’s Hospital of Philadelphia in a commentary.

To read more on this topic, see the Psychiatric News article “APA Resource Document Outlines Principles on Use of Seclusion, Restraint.”

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Patients Found Less Likely to Cancel Telepsychiatry Visits, Study Shows

Patients with depression who scheduled an appointment to see a psychiatrist between July 2020 and October 2022 were less likely to miss or cancel the appointment if it was virtual compared with in person, according to a report published today in Psychiatric Services.

“Appointment completion was higher for telepsychiatry than for in-person care among all patient characteristics studied,” wrote Catherine K. Ettman, Ph.D., of Johns Hopkins Bloomberg School of Public Health and colleagues. The findings “suggest that telepsychiatry is associated with improved efficiency and continuity of care.”

The researchers examined electronic health records for 12,894 patients aged 10 or older with a diagnosis of depression who scheduled 586,266 psychiatric outpatient appointments at Johns Hopkins Medicine between November 2017 and October 2022. They compared the number of in-person and telepsychiatry appointments that patients completed, cancelled, or failed to show up to before the pandemic with these outcomes of in-person and telepsychiatry appointments scheduled from July 2020 to October 2022. (The researchers did not analyze the appointment trends between March 2020 and June 2020 due to the fall in overall appointment completion rates caused by the pandemic.)

Prior to the pandemic, the number of patients who scheduled and completed in-person appointments vastly outnumbered those who scheduled and completed telepsychiatry appointments. Between July 2020 and October 2022, however, telehealth appointments outnumbered the in-person appointments. During this period, 13.3% of telepsychiatry appointments were canceled compared with 18% of in-person appointments.

Overall, telepsychiatry appointments were 1.30 times more likely to be completed than in-person appointments. Moreover, the likelihood that a telepsychiatry appointment would be completed relative to an in-person appointment increased steadily between July 2020 and October 2022. Ettman and colleagues noted that the increased likelihood of completion of telepsychiatry appointments remained regardless of the patient’s age, gender, race, insurance, or employment status.

“[H]ealth systems may wish to maintain telepsychiatry to optimize delivery of care and to improve patient outcomes,” Ettman and colleagues wrote.

However, they noted that telehealth may not be accessible to all patients and may exacerbate existing disparities. For instance, they found that patients who were younger, female, White, employed, or had higher socioeconomic status or private insurance were significantly more likely to schedule telepsychiatry appointments compared with in-person appointments after the pandemic’s onset.

“These findings merit future study,” they wrote. “Additional research on patient preferences, potential disparities in access to care, and efforts to reduce barriers to telehealth is warranted.”

For related information, see the Psychiatric News article “After the Pandemic: What Will the ‘New Normal’ Be in Psychiatry?”

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Performance Assessments in Graduate Medical Education May Be Biased Toward White Residents

Internal medicine residents who are Asian or belong to racial groups that are underrepresented in medicine often receive lower ratings on performance assessments than their White peers in the first and second years of postgraduate training, a study in JAMA Network Open has found. The findings suggest a racial and ethnic bias in trainee assessment that may have a far-reaching impact.

“This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder workforce diversity,” wrote Dowin Boatright, M.D., M.B.A., M.H.S., of the New York University Grossman School of Medicine and colleagues. For example, trainee assessments are often considered in decisions regarding promotion, chief resident selection, readiness for unsupervised practice, and entry into competitive subspecialty graduate medical education programs.

The researchers examined data from the performance assessments of 9,026 internal medicine residents from the graduating classes of 2016 and 2017 who were in internal medicine residency programs accredited by the Accreditation Council of Graduate Medical Education (ACGME). Among the residents, 50.4% were White, 36.1% were Asian, and 13.5% belonged to groups that are underrepresented in medicine, defined as Latinx only; non-Latinx Native American, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Latinx Black. The researchers focused on scoring for the midyear and year-end ACGME Milestones. These Milestones are used by residency programs’ Clinical Competency Committees to assess residents’ knowledge, skills, attitudes, and other attributes in clinical competency domains such as medical knowledge, patient care, professionalism, and others.

The researchers found no significant difference in the first postgraduate year (PGY) midyear total Milestone scores between White residents and residents from groups underrepresented in medicine. However, total Milestone scores were a median of 1.27 points higher for White residents compared with Asian residents.

From the midyear PGY1 assessment onward, White residents began to receive increasingly higher scores compared with Asian residents and residents from groups underrepresented in medicine. These disparities peaked in PGY2, when White residents’ total scores were a mean of 2.54 points higher than those of residents from groups underrepresented in medicine and 1.9 points higher than Asian residents. However, the gap in scores narrowed by the PGY3 year-end assessment, when the researchers found no racial and ethnic differences in the total Milestone scores.

The researchers also found differences in the ratings for individual clinical competency domains between White residents and Asian residents and residents from groups that are underrepresented in medicine, with White residents scoring higher than the other groups.

“Although differences in ratings … in competency domains were small, these inequalities could reflect substantive differences in how residents from minoritized racial and ethnic groups are perceived in summative assessments,” Boatright and colleagues wrote.

For related information, see the Psychiatric News article “Leadership, Centering Equity Vital to Future of Medical Education.”

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Tackling Overdose Epidemic Will Require Addressing Disparities in SUD Prevention, Care

Despite efforts to address the epidemic of deaths from drug overdose in the United States, drug-overdose deaths are rising faster in Black, Latinx, and American Indian and Alaska Native populations than in the White population.

“Numerous trials have documented the efficacy of medications for opioid use disorder and other SUD interventions. But such treatments are often less available to members of historically marginalized groups than to White patients,” noted Carlos Blanco, M.D., Ph.D., of the National Institute on Drug Abuse (NIDA), Elisabeth U. Kato, M.D., M.R.P., of the Agency for Healthcare Research and Quality, and others in a Perspective piece in the New England Journal of Medicine.

“Ensuring that all people with SUD receive evidence-based treatment will require overcoming barriers to high-quality care, such as lower rates of adequate health insurance among Black, Latinx, and American Indian and Alaska Native populations than among White populations; a dearth of community-based clinicians who treat uninsured and underinsured people; stigma surrounding SUDs; underinvestment by the public sector in historically marginalized communities; and limited access to digital tools in many of these communities,” they continued.

Addressing such disparities also requires research, including studies to further the understanding of the effects of social determinants of health (for example, housing and employment) on patients’ engagement with treatment for substance use disorders and advances in data collection.

The authors wrote, “Ensuring that research reduces disparities will require multiple steps,” including the following:

• Include members of underrepresented groups in the development of preventive interventions and treatments.
• Recruit study participants from historically underrepresented groups, including those with varying levels of education. Ensure that studies are large enough to measure differences in outcomes according to race and ethnic group.
• Establish equitable partnerships with people who have or have had substance use disorders and their families, clinicians, policymakers, payers, and advocates. Share study findings with participating communities.
• Diversify the scientific workforce.
• Measure the effects of policies and interventions on equity.

“Applying an equity lens to efforts to address the worsening overdose epidemic and other SUD-related harms is critical to eliminating racial and ethnic disparities and improving health outcomes,” the authors concluded. “Such an approach could also serve as a framework for narrowing disparities in other patient populations.”

For related information, see the Psychiatric News article “Opioid Overdose Death Rate Rose Faster for People of Color.”

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Telehealth Services Increased During Pandemic, but Age and Regional Disparities Exist

Telehealth visits accounted for nearly two-thirds of all mental health visits by patients enrolled in private insurance plans in the early months of the COVID-19 pandemic, according to a report published Tuesday in Psychiatric Services in Advance.

However, telehealth use for mental health services from April to June 2020 was lower in rural areas compared with urban areas, and lower among those over 65 years of age compared with those 24 to 35 years of age.

“Telehealth-based mental health services increased overall, but future work might examine why uptake was lower in rural areas and among older individuals and how broadband infrastructure and digital literacy may affect telehealth use,” wrote lead author Jiani Yu, Ph.D., of Weill Cornell Medical and colleagues.

The researchers analyzed roughly 25 million separate mental health claims submitted between January and June 2020 in a national data set of commercial enrollees from FAIR Health, a nonprofit organization managing a database of more than 33 billion privately billed health insurance claims. They calculated telehealth use rates for different conditions as a percentage of all mental health services.

The researchers found that the telehealth use rate for all mental health services increased from 2.2% in January 2020 to 65.2% in April 2020, remaining stable at 65.6% in June 2020. By comparison, telehealth rates for acute respiratory diseases and infections (the service category with the next-highest telehealth use rate behind mental health) decreased from 44.3% to 28.1% from April to June 2020.

Services for generalized anxiety disorder made up the largest share of mental health telehealth services (28.4%), followed by major depressive disorder (23.6%), and adjustment disorder (18.6%).

The changes in the rates of telehealth use for mental health conditions early in the pandemic varied according to where the patients lived, the authors noted. In April 2020, telehealth use for mental health was similar in urban (65.6%) and rural (60.5%) areas, but by June 2020, telehealth use decreased to 49.6% in rural areas while urban use remained high at 66.8%.

“As mental health digital interventions continue to proliferate, new evidence on the cost-effectiveness of telehealth may determine whether mental health services will still primarily be delivered remotely,” the researchers wrote.

For related information, see the Psychiatric News article “Will Telehealth Rules Change After Pandemic? Prepare Now.”

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