abstract Importance Individuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. The relationship between measures of ...treatment quality and mortality for these individuals is unknown. Objective To examine the association between 5 quality measures and 12- and 24-month mortality. Design, setting and participants Retrospective cohort study of patients with co-occurring mental illness (schizophrenia, bipolar disorder, post-traumatic stress disorder and major depression) and substance use disorders who received care for these disorders paid for by the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder. Main outcomes measure Mortality 12 and 24 months after the end of the observation period. Results All measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant. Conclusions and relevance This is the first study to show an association between process–based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures. By devising strategies to improve performance on these measures, health care systems may be able to decrease the mortality of this vulnerable population.
Following up on its Crossing the Quality Chasm report, in 2006 the Institute of Medicine issued a report that included sweeping recommendations to improve the quality of behavioral health care in the ...United States. To date, few of those recommendations have been implemented, and there is little evidence that behavioral health care quality has improved significantly over the past ten years. However, the advent of health care reform, parity of insurance coverage, and growing recognition of the impact of behavioral health disorders on population health and health care costs have created new demands and opportunities for expanded and innovative strategies to assess the quality of care for this patient population. We provide an overview of the current state of quality measurement in behavioral health, identify key priorities for measure development, and describe the most important challenges. We recommend a coordinated plan that would boost investment in developing, evaluating, and implementing behavioral health quality measures; conduct research to develop the evidence necessary to support a more robust set of measures; overcome barriers to the improvement and linking of data sources; and expand efforts to build the capacity of the clinical workforce, in partnership with consumers, to improve quality.
Abstract Objective We report the population prevalence of probable depressive disorders and current panic attacks in women with bladder pain syndrome/interstitial cystitis (BPS/IC) symptoms and ...describe their characteristics and access care. Method We conducted a telephone screening of 146,231 households and telephone interviews with women with BPS/IC symptoms. A weighted probability sample of 1469 women who met the criteria for BPS/IC was identified. Measures of BPS/IC severity, depressive symptoms, panic attacks and treatment utilization were administered. T and χ2 tests were used to examine differences between groups. Results Over one third of the sample ( n =536) had a probable diagnosis of depression, and 52% (n=776) reported recent panic attacks. Women with a probable diagnosis of depression or current panic attacks reported worse functioning and increased pain and were less likely to work because of bladder pain. Conclusions In this community-based sample, rates of probable current depression and panic attacks are high, and there is considerable unmet need for treatment. These findings suggest that clinicians should be alert to complaints of bladder pain in patients seeking treatment for depressive or anxiety disorders and to complaints of emotional or personal problems in patients seeking treatment for painful bladder symptoms.
This study assessed patient-reported alcohol treatment offers by health care providers following routine annual screening for alcohol use in primary care.
A telephone interview within 30 days of the ...annual screen assessed demographics, alcohol and other drug use, mental health symptoms, and offers of formal treatment for alcohol by a Veterans Affairs health care provider. We included male patients (n = 349) at high risk for an alcohol use disorder (AUD) who had not received alcohol treatment in the past 3 months. We assessed self-reported receipt of any offers of formal treatment for alcohol use and associations of offers of formal treatment for alcohol with demographic and clinical variables.
A total of 145 patients (41.5%) reported an offer of at least 1 type of formal treatment for alcohol use. More severe alcohol misuse (odds ratio, 1.07; 95% confidence interval, 1.03-1.11) and younger age (odds ratio, 0.97, 95% confidence interval, 0.95-0.99) were associated with reporting an offer of formal treatment.
Most primary care patients at high risk for an AUD were not offered treatment following annual screening. Our results highlight the importance of training primary care providers in what constitutes appropriate medical treatment for this population and the most effective ways of offering treatment.
Abstract Introduction Evidence based psychotherapies (EBPs) remain underutilized. Models for EBP training and implementation that are cost-effective, minimally disruptive, and sufficiently flexible ...are needed. Internet-based technology is a promising platform, but questions remain about how this technology can address the barriers to implementation. We developed and examined the implementation of an online training for the Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) intervention—a manualized, sixteen-session group depression treatment for individuals with substance use disorders (SUDs). We explored the feasibility of replacing in-person BRIGHT training with a self-paced, online training. Methods A highly partnered and iterative process was followed to translate the written BRIGHT manual and associated didactic training materials into a media rich, interactive, and detailed (12–16 h) online training. Subsequently, 8 volunteer counselors across 7 Veterans’ Affairs SUD programs completed the training. Semi-structured interviews focused on the counselors' experiences and their plans for implementing BRIGHT groups. A template approach, using a mixture of deductive and inductive coding, was used for data analyses. Findings The most important barrier to completing training was a lack of protected time. Most counselors were not afforded protected time and reported a sometimes frustrating and fragmented training experience. Many used personal time at work and at home to complete the work. Facilitators to completing the training included positive reactions/attitudes towards the training modules, supervisor support, counselor dedication, and strong beliefs supporting providing services for depression. Many counselors were also concerned about the feasibility of fitting 16 group sessions (2 h each) into their program's clinical schedule, but many had devised potential solutions or "work-arounds" to accommodate or approximate the recommended treatment course (e.g., using lunch times, reducing some content/exercises). Conclusion This work contributes to the literature on implementation of complex EBPs and addresses the strengths and limitations of web-based technologies in supporting the implementation of EBPs.
Professional practice guidelines (PPGs) are intended to promote a high level of professional practice and serve as an educational resource, providing pragmatic guidance in a clinical area for ...psychologists. Measurement-based care (MBC) is an evidence-based psychological practice with accumulating empirical support and alignment with patient-centered care. In connection with the American Psychological Association's Advisory Committee for Measurement-based Care and the Mental and Behavioral Health Registry, this article outlines various lines of support for the development and implementation of an MBC PPG. In addition to research evidence, we address the demonstrated need of this guideline across three domains: public benefit, professional guidance, and legal and regulatory issues. Consistent with the aspirational spirit of a PPG, this article proposes a draft PPG statement and highlights how an MBC PPG would improve service delivery, facilitate implementation of an evidence-based practice associated with symptom reduction, improved retention, and greater patient satisfaction, as well as create a framework that will better align changes in reimbursement models with patients' and providers' treatment goals. We also identify key future directions and critical gaps in MBC science and implementation that require attention.
Clinical Impact Statement
Question: Is there a need for a measurement-based care (MBC) professional practice guideline? Findings: Extant evidence supports the use of MBC across stakeholder benefit; professional guidance; and legal, regulatory, and ethical domains. Meaning: Patients, psychologists, and organizations would benefit from the development and implementation of an MBC professional practice guideline. Next Steps: Additional work is needed to identify (a) the critical components and context needed for MBC to be most beneficial to diverse patient populations, (b) what concepts should be measured and when, and (c) how to adapt and evaluate mental and behavioral telehealth.
Full text
Available for:
CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ
Alcohol screening and brief intervention (BI) are recommended preventive health practices. Veterans Health Administration (VA) uses a performance measure to incentivize BI delivery. Concerns have ...been raised about the validity of the BI performance measure, which relies on electronic health record (EHR) documentation. Our objective was to assess concordance between EHR-based documentation and patient-reported receipt of BI, and to examine correlates of concordance.
Patients with a documented positive screen for unhealthy alcohol use at VA Greater Los Angeles primary care clinics were surveyed (within 15 days on average) in 2013-2014. Documented BI was indicated by an EHR note that the patient was advised to drink within recommended limits or reduce or abstain from drinking. Patient-reported receipt of BI corresponded to an affirmative response to questions on whether a VA provider advised the patient to drink less or abstain. Patient report and documentation were assessed over the same period.
Documented and patient-reported receipt of BI had low concordance. Almost all patients who reported receiving BI had documentation of BI (93%; 95% CI 90%, 95%), but only 63% 59%, 67% of patients with documented BI reported receiving it. BI concordance was associated with more severe unhealthy alcohol use and drinking-related consequences, mental health comorbidity, and greater readiness-to-change alcohol use.
Discrepancies between EHR documentation and patient-reported BI raise concerns about performance measure validity. Patient-reported receipt of BI could be an alternative or complementary measure of BI.
Objective. To review the existing literature (1980–2003) on survey instruments used to collect data on patients' perceptions of hospital care.
Study Design. Eight literature databases were searched ...(PubMED, MEDLINE Pro, MEDSCAPE, MEDLINEplus, MDX Health, CINAHL, ERIC, and JSTOR). We undertook 51 searches with each of the eight databases, for a total of 408 searches. The s for each of the identified publications were examined to determine their applicability for review.
Methods of Analysis. For each instrument used to collect information on patient perceptions of hospital care we provide descriptive information, instrument content, implementation characteristics, and psychometric performance characteristics.
Principal Findings. The number of institutional settings and patients used in evaluating patient perceptions of hospital care varied greatly. The majority of survey instruments were administered by mail. Response rates varied widely from very low to relatively high. Most studies provided limited information on the psychometric properties of the instruments.
Conclusions. Our review reveals a diversity of survey instruments used in assessing patient perceptions of hospital care. We conclude that it would be beneficial to use a standardized survey instrument, along with standardization of the sampling, administration protocol, and mode of administration.
Abstract Few integrated substance use and depression treatments have been developed for delivery in outpatient substance abuse treatment settings. To meet the call for more “transportable” ...interventions, we conducted a pilot study to test a group cognitive–behavioral therapy (CBT) for depression and substance use that was designed for delivery by outpatient substance abuse treatment counselors. Seventy-three outpatient clients were randomized to usual care enhanced with group CBT or usual care alone and assessed at three time points (baseline and 3 and 6 months postbaseline). Our results demonstrated that the treatment was acceptable and feasible for delivery by substance abuse treatment staff despite challenges with recruiting clients. Both depressive symptoms and substance use were reduced by the intervention but were not significantly different from the control group. These results suggest that further research is warranted to enhance the effectiveness of treatment for co-occurring disorders in these settings.
Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing ...these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.
PDF
