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  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

In the last decade… Meta-analyses reveal that the clinician is more important than the technique in the variance in psychotherapy outcomes 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 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 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 cross validation period for a new sample of cases.

Cross validation results

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

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.

  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 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 Reliance on copyrighted and published questionnaires Copyright holder may charge fees for the use of questionnaires Copyright holder may place conditions or restrictions on the use of questionnaires Measurement 2.0  Item banks and resulting questionnaires belong to community of users.  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 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

Outcomes Informed Process 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  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 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 % improvement % improvement Effective range Close to national average for clinicians in private practice Highly Effective Range Comparable to outcomes from well controlled psychotherapy studies

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.

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

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