Horizontal equity and mental health care: a study of priority ratings by clinicians and teams at outpatient clinics.
BACKGROUND
In Norway, admission teams at Community Mental Health Centres (CMHCs) assess referrals from General Practitioners (GPs), and classify the referrals into priority groups according to treatment needs, as defined in the Act of Patient Rights. In this study, we analyzed classification of similar referrals to determine the reliability of classification into priority groups (i.e., horizontal equity).


METHODS
Twenty anonymous case vignettes based on representative referrals were classified by 42 admission team members at 16 CMHCs in the South-East Health Region of Norway. All clinicians were experienced, and were responsible for priority setting at their centres. The classifications were first performed independently by the 42 clinicians (i.e., individual rating), and then evaluated utilizing team consensus within each CMHC (i.e., team rating). Interrater reliability was estimated using intraclass correlation coefficients (ICCs) while the reliability of rating across raters and units (generalizability) were estimated using generalizability analysis.


RESULTS
The ICCs (2.1 single measure, absolute agreement) varied between 0.40 and 0.51 using individual ratings and between 0.39 and 0.58 using team ratings. Our findings suggest a fair (low) degree of interrater reliability, and no improvement of team ratings was observed when compared to individual ratings. The generalizability analysis, for one rater within each unit, yields a generalizability coefficient of 0.50 and a dependability coefficient of 0.53 (D study). These findings confirm that the reliability of ratings across raters and across units is low. Finally, the degree of inconsistency, for an average measurement, appears to be higher within units than between units (G study).


CONCLUSIONS
The low interrater reliability and generalizability found in our study suggests that horizontal equity to mental health services is not ensured with respect to priority. Priority -setting in teams provides no significant improvement compared to individual rating, and the additional use of these resources may be questionable. Improved guidelines, tutorials, training and calibration of clinicians may be utilized to improve the reliability of priority-setting.
Lovisenberg Diakonale Hospital, Oslo, Norway.
Per Arne
PA
Holman
Torleif
T
Ruud
Sverre
S
Grepperud
D000288:Administrative Personnel / Q000523:psychology / Q000706:statistics & numerical data; D000553:Ambulatory Care / Q000706:statistics & numerical data; D002391:Catchment Area, Health; D003155:Community Mental Health Centers; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D003953:Diagnosis-Related Groups / Q000145:classification; D015276:Health Care Rationing / Q000331:legislation & jurisprudence / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D001523:Mental Disorders / Q000175:diagnosis / Q000628:therapy*; D008605:Mental Health Services / Q000191:economics / Q000592:standards; D020380:Needs Assessment; D009664:Norway; D010043:Outcome and Process Assessment, Health Care / Q000379:methods / Q000592:standards; D010343:Patient Admission / Q000592:standards* / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000592:standards* / Q000706:statistics & numerical data; D036301:Qualitative Research; D012017:Referral and Consultation / Q000145:classification*; D012720:Severity of Illness Index; D016312:Treatment Refusal / Q000706:statistics & numerical data; D000078329:Workforce