Evidence-Based Mental Health Discussions During Periodic Health Exams: The Cup Is 1/3 Full

Background/Aims: Periodic health examinations (PHEs) are the most common reason adults see a physician. The Affordable Care Act mandates one “free” PHE per person per year. We examine if there may be a potential value of PHE due to its role as a “safe portal” by which some patients seek mental health care. Methods: Study data came from audio recordings of 255 PHEs with patients likely to need mental health care. Coding the audio recordings and their transcripts enabled us to examine the timing of a mental health discussion (MHD), its quality and the relationship between MHD quality and physician practice styles, patient health and patient preparedness for the visit. The quality of MHD was measured by concordance with evidence-based practices as a three-level variable (evidence-based, perfunctory or none). Physician practice styles were measured from multiple visits of each physician with other patients: 1) length of visit; 2) talk time by the physician and the patient, which enabled us to measure the physician’s verbal dominance; and 3) how fully the physician elicited the patient’s agenda for the visit. We used electronic health records, patient surveys and direct observation to measure patient health status. The quantitative analysis used a generalized ordered logit model with partial proportional odds for the three-level ordinal dependent variable of MHD quality. Results: Many patients came to their PHEs with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. Only a third had an evidence-based MHD, another third had a perfunctory MHD, and the remaining third had no MHD. The analyses identified significant effects of physician practice styles. Visits with physicians who tend to spend more time with patients, fully elicit patient agendas and let patients talk (as opposed to being verbally dominant) were more likely to have a MHD. Conclusion: If done well the PHE could be a safe portal for patients to raise mental health concerns, but most PHEs may not meet this standard. Improving the quality of PHEs may require reimbursement for longer visits, enabling physicians to more fully elicit patient agendas and to listen more attentively