Transcript J Consul Clin Psychol - A Collaborative Outcomes Resource Network

Outcomes Informed Care
An introduction to concepts, research, and practical applications
G.S. (Jeb) Brown, Ph.D.
Center for Clinical Informatics
Contributors: Carson Graves & Christa Castaneda; Regence
Top 10 reasons not to
measure outcomes
10. Changes in the patients’ self report of
frequency/severity of symptoms is not a valid
measure of outcome.
9. Therapists will cheat and submit phony data.
8. Patients don’t like to complete questionnaires.
7. Our patients are different.
6. Too busy doing other more important things
(paper work, etc).
Top 10 reasons not to
measure outcomes
5. Insurance company will use information to deny
benefits.
4. Insurance company will use information to
harm therapists.
3. It is a violation of patient rights.
2. We practice evidence based medicine so we
know our outcomes are good.
And the # 1 reason is
There is no benefit to the
patient or clinician!
What does the research show?
• Decades of research have shown that
psychotherapy is effective for a variety
of conditions.
• Likewise, decades of research have
shown that medication is effective for a
variety of conditions.
• Sometimes, combination treatment has
seemed to be even more effective.
But…
…There is great variability in outcomes from one
patient to next, whether the treatment is
•
Psychotherapy
•
Medication
•
Combination treatment.
What accounts for the
variance in outcomes?
Furthermore…
• Decades of research support the assertion that
different methods of psychotherapy produce
similar results.
• Likewise, different psychotropic medications may
produce similar results.
How to choose one?
What accounts for the
variance in outcomes?
The Dodo Bird Effect 1-9
Rosenzweig S. (1936)
Some implicit common factors in
diverse methods of psychotherapy: “At
last the Dodo said, ‘Everybody has
won and all must have prizes.’”
Am J Orthopsychiatry 6:412-5.
Meta-analysis &
common factors
• Three decades of meta-analytic studies have served
to reinforce Rosenzweig’s 1936 observation.
• Lack of evidence for specific treatment effects
bolster the argument that almost all of the effects of
psychotherapy are due to factors common to all
psychotherapies.
• No evidence that effect sizes have increased over the
past three decades of psychotherapy/pharmacy
research!!!!
Meta-analysis and placebo
 Meta-analysis of multiple studies of
antidepressants let us estimate the relative
importance of common factors (placebo
effects) versus drug effects. 10-12
 Placebo effects are a major portion of the
measured improvement.
 Studies reporting large effect sizes for
medication also had large effect sizes for
placebos.
Drug effect accounts for 25%
of measured improvement
Antidepressant effect
(25%)
Placebo effect
Natural course of the
illness
In the last decade…
• Meta-analyses reveal that the clinician is more
important than the technique in the variance in
psychotherapy outcomes. 20-32
• Some recent analyses show the prescribing
clinician is at least as important as the drug in
pharmacotherapy outcomes.
• Other recent analyses suggest the
psychotherapist effects the impact of
medication in combination treatment!
Clinician as active ingredient
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Traditional analysis of variance assumes the clinician
does not matter.
Hierarchical linear modeling specifies the clinician as a
variable and possible source of variance.
Reanalysis of NIMH data: clinician is primary source of
variance.
(Bolt, Dong-Min & Wampold, 2006) and (McKay,
Imel & Wampold, 2006)
Analysis of managed care data: therapist is primary
source of variance.
(Wampold and Brown, 2005)
Cross validation analysis
 Psychotherapists in national managed care
network ranked based on all cases from 19992002 if sample size =>30
 If a therapist’s mean residualized final score <
0 then clinician rated “Highly effective”; else
clinician rated “Less effective”.
 Outcomes evaluated in the 2003-2004 cross
validation period for a new sample of cases.
Cross validation results
Clinician cross validation results - 2003 to 2004
Therapists assessed on at least 30 cases between 1999-2002.
Highly effective clinicians had mean Change Index Score > 0
Effect size
1
Highly effective clinicianspsychotherapy only
0.9
0.8
0.7
0.6
Highly effective clinicianspsychotherapy and medication
0.5
0.4
Less effective clinicianspsychotherapy only
0.3
0.2
0.1
0
Less effective clinicianspsychotherapy and medication
0-50
51-120
Intake scores (mean split)
What the heck is effect size?
 An effect size of 1 means the client improved
one standard deviation on the outcome
measure.
 An effect size of .8 or higher is considered
large.
 Meta-analyses of large sample of
psychotherapy studies suggest the effect size
for psychotherapy is approximately .8.
 There is no evidence that effect sizes have
increased over past 30 years!
Again,
why measure outcomes?
• A large, growing body of research over the
past decade suggests that
routine measurement of outcomes leads
to improved outcomes, particularly for
those patients most at risk. 26-35
What improves, what doesn’t:
• +
Cases at risk for negative outcome
• -- Clinician ability to identify failing
cases
(M. Lambert, Personal communication)
Feedback must become a
routine part of clinical practice!
And so we conclude…
In behavioral healthcare, focusing
on the treatment (therapy
technique, medication) is not
enough to optimize outcomes –
we must also focus on the
outcomes for each patient
and the skill of the clinician!
What should be validated?
The Psychotherapist!
“We are at the origin of a revolution of using outcomes to
inform practice and guide management of services. Care
must be taken to use this precious data to benefit patients
rather than curtail costs. In the end, we (practitioners,
researchers and third parties) should be united in our
desire to optimize the benefits that psychotherapy can
provide to patients. To do so, we must emphasize those
aspects of psychotherapy that account for the variability in
outcomes. At this point, the evidence indicates that the
psychotherapists is critical.” (page 208)
Bruce Wampold, PhD
In Evidence-Based Practices in Mental Health;
Norcross, Beutler & Levant (Eds), 2006
Outcomes
informed
clinicians…
1. Recognize the importance of clinician skill in
providing effective treatments.
2. Support the desire to improve outcomes by
actively evaluating them, and applying the
feedback to the treatment.
3. Believe that patients benefit when referred
to clinicians with practice-based evidence of
effectiveness.
 www.psychoutcomes.org
 Non-profit set up to encourage the use of
client/patient-completed outcome measures in
behavioral health care and related fields.
 TWiki site provides information, fosters
collaboration, and offers support for
organizations launching and nurturing
outcomes-informed care initiatives.
The truth about
outcomes questionnaires!
 All patient self report outcome questionnaires tend to
load on a common factor: “global distress”.
 Due to the high degree of correlation between items,
well constructed questionnaires of 10-15 items can
have coefficients of reliability and construct validity
comparable to measures of 30 or more items.
 Even ultra brief questionnaires of 4-9 items may have
adequate reliability and validity for must measurement
needs.
Measurement 2.0
Measurement 1.0 0
Measurement 2.0
 Reliance on copyrighted and
published questionnaires
 Item banks and resulting
questionnaires belong to community
of users.
 Copyright holder may charge
fees for the use of
questionnaires
 Copyright holder may place
conditions or restrictions on
the use of questionnaires
 No fees for questionnaires
constructed from items in the shared
item bank
 Each organization is responsible for
their own measurement methods and
determines the appropriate content
and use of questionnaires
Measurement 2.0
Questionnaire Development
Measurement 1.0
0

A pool of items are tested in various samples

Item analysis used to select items for final
questionnaire

Questionnaire validated, usually in correlation
studies with questionnaires measuring the same
construct

Questionnaire published in final form


Manual published
Many years may pass before a new version is
published
Measurement 2.0

A pool of items are tested in various samples

Item analysis used to select items for multiple
versions of the questionnaires, depending on
the needs of the users

Construct validity determined by factor analysis
and comparison of results to known constructs.
Various organizations may conduct correlation
studies to satisfy internal skeptics.

Questionnaires are constantly evolving as data
accumulates and measure needs change

Online manual constantly updated as data
accumulates and needs of users dictate

Multiple versions available, with the community
of users determining which versions offer the
greatest utility
Brief Adult Screening &
Outcome Questionnaire
15787
Version 10.0
Org ID:
Site ID:
Date completed
Session #
/
/
Clinician ID:
Client ID:
Please print clearly
This brief questionnaire asks about some of the most commonly reported
Sometimes
thoughts, feelings and behaviors among adults seeking
behavioral health
treatment. Please think about the past two weeks and indicate how often each
of the following occurred. This will help you and your therapist/doctor to
plan your treatment and monitor your improvement.
In the past two weeks, how often
did you
Never
Hardly Someever
times
Often
Very
often
…feel unhappy or sad?......................
…have little or no energy?.................
…have a hard time getting along with
family, friends or coworkers?..............
…feel hopeless about the future?...........
…have a hard time paying attention.........
…feel unproductive at work or other daily
activities?................................
..
…feel tense or nervous?....................
…have problems with sleep (too much or too
little)?...................................
…feel lonely?..............................
…think about harming yourself?.............
…have someone express concerns about your
alcohol or drug use?.......................
…have more than five drinks of alcohol at
one time?..................................
…have a problem at work, school, or home
because of alcohol or drug use?...........
Please estimate the percent of your productivity at work, school or
other important daily activities that is lost due to symptoms of
stress, anxiety or depression.
If this is not your first session,
please take a moment to give feedback
on your most recent session.
I felt that we talked about the
things that were important to me.
I felt that the therapist liked and
understood me.
I felt that the session was helpful.
I felt confident that the therapist
and I worked well together.
%
Agree Somewhat Not Somewhat Do not
agree sure disagree agree
For more information on this and other questionnaires visit
www.psychoutcomes.org
15787
Outcomes Informed Process
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One-page self-report questionnaires
Administer every session
Fax to 800# when most convenient
View data within 24 hours on secure
personal webpage
Discuss with patients; create a culture
of feedback within each treatment.
How does it work?
•
•
Forms are faxed to fax server at the Center for Clinical
Informatics Data Center
Data Center functions:
1. human verification of data to assure accuracy
2. capture and warehouse data in secure SQL Server database
3. apply advanced algorithms to score questionnaires and
monitor patient progress
4. host Clinician’s Toolkit for viewing and graphing outcome
data housed in the data warehouse.
5. provide a high level of customer service, user support &
training
Therapeutic alliance
 A large body of evidence suggests that the
relationship and working alliance between the
clinician and patient is an important factor in
the outcome. 36-42
 Routine use of a session rating/therapeutic
alliance scale may permit clinicians to identify
and repair problems in the working alliance.
Recommendations to clinicians
 Practitioners are encouraged to make the creation and cultivation of
the therapy relationship, characterized by the elements found to be
demonstrably and probably effective, a primary aim of their
treatment.
 Practitioners are encouraged to adapt the therapy relationship to
patient characteristics in ways shown to enhance outcomes.
 Practitioners are encouraged to routinely monitor patients’ responses
to the therapy relationship and ongoing treatment. Such monitoring
leads to increased opportunities to repair alliance ruptures, improve
the relationship, modify technical strategies, and avoid premature
termination.
Norcross & Lambert (page 218); In Evidence-Based Practices in
Mental Health, Norcross, Beutler & Levant (Eds), 2006
Benchmarking outcomes
• Takuya Minami, PhD and colleagues have published a
series of articles describing one benchmarking
methodology. 43-45
• Meta-analyses of controlled psychotherapy studies were
used to establish effect size benchmarks for the
treatment of depression.
• Outcomes for treatment of depression by PacifiCare
Behavioral Health’s network providers found clinically
equivalent to benchmark from clinical trials.
Can we improve outcomes?

Increasing the percentage of patients treated by highly
effective clinicians (as identified through practice based
evidence) is the most direct pathway open to a health
plan seeking to improving outcomes across a large
system of care.

Organizations may also improve outcomes by fostering
outcomes informed care methods within the
organization.
Western Psychological & Counseling:
An outcomes informed organization!
2006
Baseline
2007
9%
improvement
Effective range
Close to national average for
clinicians in private practice
Highly Effective Range
Comparable to outcomes from
well controlled psychotherapy
studies
2008
22%
improvement
Recommended reading
Multiple perspectives on
the question of what really
makes a difference in
treatment outcomes.
Comment: In depth
debate and dialog
among top researchers
in the field.
Recommended reading
Rigorous review and
analyses of controlled
studies on psychotherapy
outcome.
Conclusion: much more
variance resides with
the clinician than with
the treatments.
Recommended reading
Comprehensive review of
the research on the role of
the therapeutic relationship
and factors that make a
difference in outcomes.
Evidenced based
relationships?
References
1.
2.
3.
4.
5.
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