Journal Article Annotations
2022, 4th Quarter

Diversity, Equity and Inclusion

Annotations by Jai Gandhi, MD
January, 2023

Racial Disparities in Psychiatric Decisional Capacity Consultations.

PUBLICATION #1 — Diversity, Equity and Inclusion

Racial Disparities in Psychiatric Decisional Capacity Consultations.

William S Garrett, Anita Verma, Daniel Thomas, Jacob M Appel, Omar Mirza

Abstract: Psychiatr Serv. 2023 Jan 1;74(1):10-16. doi: 10.1176/appi.ps.202100685. Epub 2022 Aug 25.

Abstract:

Objective:
In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.

Methods:
The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.

Results:
Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.

Conclusions:
Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient’s capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

Keywords:
Bias; Competency and consent; Consultation-Liaison; Decisional Capacity; Psychosomatic medicine; Racial-ethnic disparities.

Annotation

The finding:
This retrospective study, at a single tertiary care medical center, attempted to examine racial disparities in decisional capacity consultations across four domains. These four domains were the request for capacity consultation, a capacity evaluation (completed by the C-L psychiatry team), an impaired capacity determination, and a change in the current treatment plan (as a result of the impaired capacity determination). Black and Hispanic patients (as documented by the C-L psychiatry team) were disproportionately represented in capacity consultations in comparison to the demographic makeup of inpatient admissions across the same time period. There were no significant racial disparities for capacity evaluations, impaired capacity determinations, or changes in the treatment plan. Patients with less than a high school diploma were more likely to have no change in their treatment trajectory after an impaired capacity determination. Unsurprisingly, the diagnosis of delirium was significantly associated with an impaired capacity determination.

Strength and weaknesses:
Unfortunately, as a study within a single medical center, the generalizability of these results is limited, and whether or not the study achieved the sample size necessary to have adequate power to appropriately assess the relevant outcomes is unclear. The study’s determination of “no change” in treatment trajectory as a negative outcome is questionable; capacity consultation requests are complex, involve numerous variables, and the treatment trajectory after the impaired capacity determination is relative to the decision that was necessary for the patient to make. Nonetheless, this study is a unique contribution to C-L literature on racial disparities that warrant the attention of both C-L psychiatrists and their consulting colleagues.

Relevance:
C-L psychiatrists should be thoughtful about capacity consultation requests for Black and Hispanic patients as this study determines these populations may be overrepresented in capacity consultation requests. Examining factors that may have led to the capacity consultation request will be important given the racial disparities this study uncovered.