ImportanceWhile abundant work has examined patient-level differences in antidepressant treatment outcomes, little is known about the extent of clinician-level differences. Understanding these differences may be important in the development of risk models, precision treatment strategies, and more efficient systems of care.ObjectiveTo characterize differences between outpatient clinicians in treatment selection and outcomes for their patients diagnosed with major depressive disorder across academic medical centers, community hospitals, and affiliated clinics.Design, Setting, and ParticipantsThis was a longitudinal cohort study using data derived from electronic health records at 2 large academic medical centers and 6 community hospitals, and their affiliated outpatient networks, in eastern Massachusetts. Participants were deidentified clinicians who billed at least 10 International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnoses of major depressive disorder per year between 2008 and 2022. Data analysis occurred between September 2023 and January 2024.Main Outcomes and MeasuresHeterogeneity of prescribing, defined as the number of distinct antidepressants accounting for 75% of prescriptions by a given clinician; proportion of patients who did not return for follow-up after an index prescription; and proportion of patients receiving stable, ongoing antidepressant treatment.ResultsAmong 11 934 clinicians treating major depressive disorder, unsupervised learning identified 10 distinct clusters on the basis of ICD codes, corresponding to outpatient psychiatry as well as oncology, obstetrics, and primary care. Between these clusters, substantial variability was identified in the proportion of selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and tricyclic antidepressants prescribed, as well as in the number of distinct antidepressants prescribed. Variability was also detected between clinician clusters in loss to follow-up and achievement of stable treatment, with the former ranging from 27% to 69% and the latter from 22% to 42%. Clinician clusters were significantly associated with treatment outcomes.Conclusions and RelevanceGroups of clinicians treating individuals diagnosed with major depressive disorder exhibit marked differences in prescribing patterns as well as longitudinal patient outcomes defined by electronic health records. Incorporating these group identifiers yielded similar prediction to more complex models incorporating individual codes, suggesting the importance of considering treatment context in efforts at risk stratification.

中文翻译：

---

临床医生抗抑郁治疗和重度抑郁症结果的异质性


重要性虽然大量的工作已经检验了抗抑郁治疗结果中患者水平的差异，但对于临床医生水平差异的程度却知之甚少。了解这些差异对于风险模型、精准治疗策略和更有效的护理系统的开发可能很重要。目的描述学术医疗中心、社区医院的门诊临床医生在诊断为重度抑郁症的患者的治疗选择和结果方面的差异设计、设置和参与者这是一项纵向队列研究，使用来自马萨诸塞州东部 2 个大型学术医疗中心和 6 个社区医院及其附属门诊网络的电子健康记录的数据。参与者是身份不明的临床医生，他们在 2008 年至 2022 年间每年至少诊断出 10 例《国际疾病分类》第九版修订版 (ICD-9) 或第十版修订版 (ICD-10) 重度抑郁症。数据分析发生在 2023 年 9 月至 2024 年 1 月期间主要结果和措施处方的异质性，定义为占特定临床医生处方的 75% 的不同抗抑郁药的数量；服用指数处方后未返回随访的患者比例；结果在 11934 名治疗重度抑郁症的临床医生中，无监督学习根据 ICD 代码识别出 10 个不同的簇，对应于门诊精神病学以及肿瘤学、产科和初级保健。 在这些组之间，所处方的选择性血清素再摄取抑制剂、选择性去甲肾上腺素再摄取抑制剂和三环类抗抑郁药的比例以及所处方的不同抗抑郁药的数量存在显着差异。不同临床医生群体之间的失访率和稳定治疗率也存在差异，前者的范围为 27% 至 69%，后者的范围为 22% 至 42%。临床医生群体与治疗结果显着相关。结论和相关性治疗患有重度抑郁症的个体的临床医生组在处方模式以及电子健康记录定义的纵向患者结果方面表现出显着差异。纳入这些群体标识符产生了与纳入个体代码的更复杂模型类似的预测，这表明在风险分层工作中考虑治疗背景的重要性。