care. Clinical assessment and treatment practices (especially psychosocial interventions) have not been standardized and classified for inclusion in the administrative datasets widely used to analyze variations in care and other quality-related issues in general health care. Initiatives to disseminate advances in evidence-based care often fail to use effective strategies and available resources. The development of performance measures for M/SU health care has not received sufficient attention in the private sector, and efforts in the public sector have not yet achieved widespread consensus. Finally, the understanding and use of modern quality improvement methods have not yet permeated the day-to-day operations of organizations and individual clinicians delivering M/SU services—both those in the general health care sector and those providing specialty M/SU health care.

The committee recommends a five-part strategy to build this infrastructure and improve the safety and effectiveness of M/SU health care: (1) a more coordinated strategy for filling the gaps in the evidence base; (2) a stronger, more coordinated, and evidence-based approach to disseminating evidence to clinicians; (3) improved diagnostic and assessment strategies; (4) a stronger infrastructure for measuring and reporting the quality of M/SU health care; and (5) support for quality improvement practices at the locus of health care.

PROBLEMS IN THE QUALITY OF CARE

As in general health care, there is ample evidence of problems in the quality of care for mental and/or substance-use (M/SU) problems and illnesses. These problems include (1) failure to provide care consistent with existing scientific evidence, (2) variations in care that occur when clear evidence on effective care is lacking, (3) failure to provide any treatment for an M/SU illness or to address the risk factors associated with the development of these illnesses, and (4) unsafe care.

Failure to Provide Care Consistent with Scientific Evidence

Numerous studies document the discrepancy between M/SU care that is known to be effective and the care that is actually delivered. An extensive review of all peer-reviewed studies published from 1992 through 2000 in Medline, the Cochrane Collaborative, and related sources that assessed rates of adherence to specific clinical practice guidelines for treating diverse M/SU clinical conditions (including alcohol withdrawal, bipolar disorder, depression, panic disorder, psychosis, schizophrenia, and substance abuse)



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