HealthLawProf Blog

Study Shows Model Can Be Used To Rate Courtroom Psychiatric Experts' Performance

What does it mean when expert psychiatric witnesses in a court case reach opposing conclusions on the same sets of evidence? Does it mean that one side or the other is necessarily being less than honest? According to a report in ScienceDaily, a new study suggests via mathematical modeling that both analyses can be completely accurate.

The study which was published online in Law and Human Behavior, the journal of the American Psychology-Law Society was led by Douglas Mossman, MD, director of the UC College of Law’s Glenn M. Weaver Institute of Law and Psychiatry and the forensic psychiatry fellowship at the UC College of Medicine. The study looked at a group of psychiatrists who evaluated mental competence from case files of 156 criminal defendants and concluded that the group performed at a strikingly high level of accuracy.

In an average of 29 out of every 30 cases, the psychiatrists could distinguish competent defendants from incompetent defendants. That’s a level of performance that exceeds standard diagnostic performance in other areas of medicine, such as spotting breast cancer in mammograms or using advanced imaging methods to detect Alzheimer’s disease.

“These results help us see how courtroom experts can be quite accurate in distinguishing competence from incompetence, but still reach different conclusions,” says Mossman of the study, which was published online in Law and Human Behavior, the journal of the American Psychology-Law Society. “It’s a matter of where experts draw the line on the issue of competence.”

Continues Mossman: “Experts may disagree with each other even though they are very good at making all the right distinctions. You’re apt to get disagreement when you ask experts for a ‘yes’ or ‘no’ answer, as the courts do, on issues that can have gray areas, like competence to stand trial.”

The problem is there is no independent, infallible “gold standard” to establish conclusions in forensic psychiatry, as there is in most other areas of medicine.

“If there were some way, however, to measure accuracy without a ‘gold standard,’ mental health experts might be more credible,” Mossman says. “Over the last two decades, statisticians have developed mathematical techniques that – in some cases – make it possible to estimate diagnostic accuracy without gold standards.”

These techniques – which have been successfully used in areas as diverse as imaging liver cancer and detecting infections in dairy cattle – form the backbone of the study. Using statistical methods known as latent class modeling, the study looked at the performance of psychiatrists who made evaluations based on the 156 case files presented to them.

“The techniques are applicable to lots of questions in law and mental health,” Mossman says. “There are many, many other kinds of cases where courts depend on mental health experts’ opinions. If you have the right kind of data, these methods would allow you to evaluate the accuracy of court evaluations.”

Mossman, himself an experienced psychiatric expert from dozens of court cases, says that by using this method to establish the accuracy of experts, the value of their opinions can be demonstrated and even assigned a mathematical quantity. But experts are still going to reach different conclusions.

“The legal system asks experts to give ‘yes’ or ‘no’ answers, but that’s not how things usually are in medicine,” he says. “Very often, a physician’s diagnostic judgment really is a probability, an in-between answer. In courtroom testimony, experts are supposed to provide a clear opinion, not an ambiguous answer, even when the problem involves a shade-of-gray kind of question. That’s where the real opportunity for difference of opinion comes into play.”

[KVT]

Updated State Health Data from Kaiser Family Foundation

Statehealthfacts.org, which is part of the the Kaiser Family Foundation website, has recently added new and updated data on Demographics and the Economy, Health Coverage & Uninsured, Medicaid & CHIP, Medicare,Providers & Service Use, and Minority Health. 

Demographics & the Economy

• Population Characteristics
  The latest demographic data for the population including age, gender, citizenship status, family structure, income, metropolitan area, and race/ethnicity based on analysis of the Census Bureau’s 2009 Current Population Survey (CPS) by the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute are now available for all states and the nation. Updated demographic data on people living in povertyare also available for all states.
• Households in Poverty
  Updated data from the Census Bureau on poverty rates and median incomes based on household income have been added for 2006-2008 and 2007-2008 for all states and the nation.
• Employment Status
  Updated household employment data from the Bureau of Labor Statistics (BLS) on workers represented by unionsfor 2008 have been added and are available for all states and the nation. The 2008 state-by-state distribution of workers by occupationalcategory based on the 2009 CPS is also available by state.
• Unemployment
  The latest data from the BLS on unemployment rates have been added for all states and the nation for August 2009.
• Food Stamp Program
  The most recent information from the United States Department of Agriculture’s (USDA) Food and Nutrition Service on monthly food stamp enrollment is now available for all states and the nation for July 2009.
• State Fiscal Distress
  Aggregate state rankings in foreclosures, unemployment, and food stamp participation have been updated with the most recent unemployment data and the latest food stamp enrollment data.

Health Coverage & Uninsured

• Health Insurance Status
  Health coverage data for key populations - the nonelderly, children, adults, men, women, parents, and adults without dependent children– have been updated to 2008 based on analysis of the 2009 CPS by the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute. New data on the health insurance status of childrenand adultsbased on income ranges outlined in health reform bills currently being debated in Congress have also been added and are available for all states and for the nation.
• Coverage Trends
  Data on state and national health coverage trends from 2005-2008 and 2007-2008 based on analysis of the CPS are now available for the nonelderly, adults, and children.

Medicaid & CHIP

• Medicaid Budget Policy
  Updated data from the latest 50-state Medicaid budget survey by the Kaiser Commission on Medicaid and the Uninsured on state Medicaid budget policies to control costs in Medicaid or to expand the program are now available for state FY 2009 and FY 2010. The number of states that have implemented or proposed Medicaid cost-containment actionsrelated to provider payment changes, eligibility cuts, pharmacy controls, benefit reductions, co-pays, managed care expansions, disease and case management, fraud and abuse, and long term care are available by state. Also available is information about “positive” Medicaid policy actions, such as increased provider payments, expanded benefits, increased eligibility, and changes in the delivery of long term care services.

Medicare

• Medicare Population Demographics
  Updated demographic data on Medicare enrollees by age, federal poverty level, gender, and race/ethnicity based on analysis of the 2009 Current Population Survey have been added and are available for all states and the nation.

Providers & Service Use

• Access to Care
  Updated data from the Center for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System Survey on the percentage of the adults who reported not seeing a doctor due to cost are now available for 2008.
• Health Care Employment
  Updated data from the Bureau of Labor Statistics on the population employed in the health care field are now available for 2008 for all states and the nation.

Minority Health

• Minority Population
  The latest Black, Hispanic, Asian-American/Pacific Islander, and Native American population data based on analysis of the 2009 Current Population Survey have been added for all states and the nation.

[KVT]

UK Border Agencies Start Pilot Program Using DNA Testing to Prove the Origin of Asylum Seekers Claiming to Be From Somalia

The UK Border Agency came under attack for its proposed plan to use genetics to determine nationality. According to a report in Nature, a pilot project was implemented to confirm the claims of 100 asylum seekers that they are from war-torn Somalia. The plan calls for checking the individuals for specific mutations called SNPs (single polymorphisms) in mitochondrial DNA, the Y chromosome and elsewhere in the genome. But those geneticists contacted by Nature for their views on the merits of the plan were more than skeptical. According to one geneticist “[t]he idea that genetic variability follows national boundaries is absurd.” The article goes on to explain why:

It is true that the recent development of large SNP databases have made it possible to determine the geographic origins of Europeans to within a few hundred kilometers (see Nature 456, 98–101; 2008). But comparable data on many human populations, especially in regions such as Africa, remain patchy at best, and it is unclear what data the border agency will use to establish the origins of these particular asylum-seekers.

On a more fundamental level, the idea that genetic variability follows man-made national boundaries is absurd. Cross-border migration is common throughout the world; Y-chromosome analysis can easily be thrown off by a distant male ancestor; and SNP-based identifications are inexact to say the least. As an example of this last point, individuals whose parents come from two geographic regions are often classed into a third region from which neither parent originated.

***

These problems seem to be ignored in the guidelines provided to border agents testing the asylum-seekers. Given the scientific credibility of DNA evidence, it is not difficult to imagine that these agents — who are presumably not geneticists — might place undue weight on results that are, at best, difficult to interpret and, at worst, spurious.

Migration organizations and geneticists alike have been vocal in their protests against the plan, and in response the UK government seems to have backpedalled. In a statement released earlier this week from the Home Office, which runs the border agency, the program was described as only a proof-of-concept project that would not be used to make decisions about any asylum-seeker.

[KVT]

Unequal Access to Quality of Care: Hispanic Children with Brain Tumors

Hispanic children with brain tumors have less access to specialists in neurosurgery than other children. This disparity in access could negatively impact both immediate prognosis and long-term survival according to research by a team from Johns Hopkins. The study,  which was published in this October’s Pediatrics , is called Disparities in Access to Pediatric Neurooncological Surgery in the United States .

 

The study looked at 4,421 children with brain tumors over the span of 18 years. The study found that access was worst among Hispanics, as well as among those of lower socio-economic status and those living in areas with higher immigrant population and with few neurosurgeons.

Two of the authors of the study made statements to ScienceDaily

'What was shocking to us was the finding that, despite the push over the last decade to equalize access to high-quality care, gaps are still there, particularly among Hispanics, and, if anything, they may be getting even worse,’ said lead investigator Raj Mukherjee, M.D., M.P.H., a postdoctoral fellow in the Department of Neurosurgery at Hopkins.

Research has shown that patients treated at specialty hospitals that admit a high volume of patients with similar conditions fare better in the long and short term, investigators say. For example, studies show that patients undergoing brain surgeries in hospitals that perform the fewest neurosurgeries have up to 16 times the mortality rate of patients treated in hospitals performing the highest number.

‘Given that brain tumors are the most common solid tumors in children, lack of access to specialized care simply means that thousands of pediatric patients are getting less-than-optimal treatment, putting them at risk for relapse and a host of neurological complications,’ says pediatric neurosurgeon George Jallo, M.D., co-author on the study and director of Neurosurgery at Johns Hopkins Children's Center.

[KVT]

O'Neil Institute for National and Global Health Announces New Blog on Legal Issues in Health Reform

 

A new blog called "Legal Issues in Health Reform" was announced by Timothy Westmoreland, the Co-Director of Legal Solutions in Health Reform, O’Neill Institute for National and Global Health Law at the Georgetown University Law Center. Tim's announcement reads as follows:

 

The initial posts by Mark Hall and Tim Jost engage the debate over "the constitutionality of health reform," specifically the constitutionality of an individual mandate. Check it out at http://oneillhealthreform.wordpress.com.

 

One of the primary purposes of the blog is to create a venue for more extensive analysis of legal issues that may first appear in the media.

 

Mark's and Tim's posts rebut arguments - made recently in the Washington Post, Wall Street Journal, LA Times and elsewhere - that Congress lacks the constitutional authority to enact major components of reform proposals now moving through Congress.  Other recent posts include discussion of whether the individual mandate is a tax, federalism and procedural due process, and a response to the proposed legislation amending health insurance anti-trust laws.

 

As health reform legislation continues to develop and move forward, the O'Neill blog will be a community resource for thoughtful analysis of the legal issues presented in the various bills. You can sign up for the blog's RSS feed as a way to conveniently follow these important debates.  And feel free to join the discussion - the blog is open to comments from the public.

 

[KVT]