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：

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临床医生之间抗抑郁药治疗和重度抑郁症结局的异质性


重要性虽然有大量工作研究了抗抑郁药治疗结果的患者水平差异，但对临床医生水平差异的程度知之甚少。了解这些差异对于开发风险模型、精准治疗策略和更有效的护理系统可能很重要。目的描述学术医疗中心、社区医院和附属诊所门诊医生在诊断为重度抑郁症患者的治疗选择和结局方面的差异。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 家社区医院及其附属门诊网络的电子健康记录的数据。参与者是去身份化的临床医生，他们在 2008 年至 2022 年期间每年至少收取 10 次国际疾病分类第九版（ICD-9）或第十版（ICD-10）的重度抑郁症诊断费用。数据分析发生在 2023 年 9 月至 2024 年 1 月期间。主要结局和措施处方的异质性，定义为不同抗抑郁药的数量占给定临床医生处方的 75%;指标处方后未返回随访的患者比例;以及接受稳定、持续的抗抑郁治疗的患者比例。结果在 11 934 名治疗重度抑郁症的临床医生中，无监督学习根据 ICD 代码确定了 10 个不同的集群，对应于门诊精神病学以及肿瘤学、产科和初级保健。 在这些集群之间，选择性 5-羟色胺再摄取抑制剂、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不同处方抗抑郁药的数量存在很大差异。在临床医生集群之间也检测到失访率和实现稳定治疗的差异，前者范围为 27% 至 69%，后者范围为 22% 至 42%。临床医生集群与治疗结果显著相关。结论和相关性治疗被诊断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。结合这些组标识符产生了与包含单个代码的更复杂的模型相似的预测，这表明在风险分层工作中考虑治疗环境的重要性。