Transcript Outcomes Informed Care & Performance Management

Outcomes Informed Care & Performance Management:
Implications for Behavioral Healthcare Integration
G.S. (Jeb) Brown, Ph.D.
Center for Clinical Informatics
Contributors:
John Peters
Chair; North California Psychiatry Outcomes Committee
Kaiser Permanente
Carson Graves
Assistant Director, Behavioral Health & Wellness
Regence
Christa Castaneda
Manager, Behavioral Health Provider Services
Regence
"The important question is not
what constitutes effective
intervention, but whether
(consumers) experience the
changes they desire."
--Barry Duncan, PhD
Why measure outcomes?
• 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. 1-9
• Likewise, different psychotropic medications may
produce similar results.
How to choose one?
What accounts for the
variance in outcomes?
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
(Brown and Wampold, 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
Effect size
Therapists assessed on at least 30 cases between 1999-2002.
Highly effective clinicians had mean Change Index Score > 0
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0.9
0.8
0.7
0.6
0.5
0.4
0.3
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Highly effective clinicianspsychotherapy only
Highly effective clinicianspsychotherapy and medication
Less effective clinicianspsychotherapy only
Less effective clinicianspsychotherapy and medication
0-50
51-120
Intake scores (mean split)
The Punch Line:
In behavioral healthcare,
focusing on the treatment
(therapy technique, medication)
is not enough to optimize
outcomes –
we must also focus on the
outcomes and the clinician.
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!
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. Use practice-based evidence to inform
the use of evidence-based practices.
What to measure, with what?
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Patient self-report outcome
questionnaires
Data capture as automated as possible
Measure must be sensitive to change
during treatment at all levels of
functioning
Psychometrically sound
So many measures,
so little time!
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Dx-specific vs. global
Population-specific vs. single measure
Sensitivity to change: pre-post vs. session-tosession
No industry standards - Everyone has a
favorite
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.
Outcomes Informed Pilot
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One-page self-report questionnaires
Administer every session
Fax to 800# when most convenient
View data in 24-36 hours on secure
personal webpage
Discuss with patients; create a culture
of feedback within each treatment.
System Features
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Flexible use of brief questionnaires
Fax to toll free numbers of data entry
Centralized data center with capabilities to:
1. to capture and archive data
2. utilize advanced algorithms to score, analyze and interpret
data
3. distribute desktop data files with integrated Clinician’s
Decision Support Toolkit
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Use of TWiki Web 2.0 technology to provide an
online platform to distribute information, elicit
feedback, and foster clinician collaboration.
Flexibility & evolution
• The outcomes system is designed for flexibility
and responsiveness to input from users.
• ACORN item repository permits use of
questionnaires tailored to the measurement task.
• System design and features evolve over time
based on provider feedback.
• System permits rapid prototyping, testing and
distribution of Clinician’s Desktop Decision
Support Toolkits designed for specific purposes.
 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.
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.
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 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?
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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.
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Organizations may also improve outcomes by fostering
outcomes informed care methods within the
organization.
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Resources for Living and Accountable Behavioral
Healthcare Alliance provide two examples.
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Effect size
Resources for Living
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Training and feedback
Baseline period
Accountable Behavioral
HealthCare Alliance
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?
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.
References
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2.
3.
4.
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