Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006) / Chapter Skim
Currently Skimming:
4 Strengthening the Evidence Base and Quality Improvement Infrastructure
4 Strengthening the Evidence Base and Quality Improvement Infrastructure
Pages 140-209
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often is not consistent with this evidence base. Further, in the absence of evidence on how best to treat some M/SU conditions, treatment for the same condition often varies inappropriately from provider to provider.
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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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. Subsequent studies have continued to document clinicians' departures from evidence-based practice guidelines for conditions as varied as attention deficit hyperactivity disorder (ADHD)
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and from the absence of widely accepted standards of care. Variations in the absence of clinical practice guidelines have been documented, for example, in the use of seclusion and
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Recent studies have shown improvements in access to and receipt of care for those with the most severe mental illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004)
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of individuals with symptoms of a serious mental illness received treatment (Kessler et al., 2005) , and there is evidence of a decline in access for those with less severe mental illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004)
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. Despite roughly similar levels of need, ethnic minorities are less likely to receive mental health care than are white Americans.
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This risk reduction model of prevention targets the risk factors known to be associated with an illness or injury. By contrast, despite scientific evidence on risk factors associated with some mental illnesses (predominantly in children and adolescents)
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in psychiatric treatment revealed relatively few data available, and only a handful of studies of adverse drug events in inpatient psychiatric settings. Although studies of adverse drug events in general hospitals have yielded data on errors involving psychotropic drugs, less is known about medication errors in psychiatric hospitals and psychiatric units of general hospitals.
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. Consumers and their advocates, professional associations, provider organizations, and the federal government recommend substantial reductions in the use of seclusion and restraint (American Association of Community Psychiatrists, 2003; NAMI, 2003; NASMHPD, 1999, 2005; SAMHSA, 2004b)
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These include (1) gaps in the evidence base, (2)
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Related issues of improved care coordination, use of information technology, implications of a more diverse workforce, and creation of incentives in the marketplace to support this five-part strategy are addressed in succeeding chapters. IMPROVING THE PRODUCTION OF EVIDENCE Gaps in the Evidence Base Efficacious Treatments Over the past two decades, there has been an impressive increase in the number and quality of studies on M/SU problems, illnesses, and therapies for both children (Burns and Hoagwood, 2004, 2005; Pappadopulos et al., 2004; Weisz, 2004)
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. Although the knowledge gaps discussed above also exist for general health care, some of the tools and strategies used to build the evidence base
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Filling the Gaps in the Evidence Base As is the case for general health care, federal agencies, philanthropic organizations, and other private-sector entities undertake many efforts to identify priority areas in M/SU health care in need of evidence, fund and conduct research, and support systematic reviews of research findings to identify evidence-based therapies. A strategy for coordinating these various efforts is articulated in Chapter 9.
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Preventive Services Task Force notes that a well-designed cohort study may be more compelling than a poorly designed or weakly powered randomized controlled trial (Harris et al., 2001)
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, underpin many of the quality measures found in the National Committee for Quality Assurance's (NCQA) Healthplan Employer Data and Information Set (HEDIS)
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With the exception of a code for psychoanalysis, none of these codes identify the specific type of psychotherapy administered (e.g., cognitive therapy, behavior modification, cognitive behavioral therapy, interpersonal therapy, dialectical behavioral therapy, prolonged exposure therapy for individuals suffering from posttraumatic stress disorder, Gestalt therapy, movement/dance/art therapy, humanistic therapy, existential therapy, eye movement desensitization therapy, primal therapy, person-centered therapy, multisystemic therapy, and the many variants of these. Nor are there procedure codes for the use of diagnostic or behavioral assessment instruments.
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made up of performance measurement experts representing AHRQ, CMS, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) , NCQA, and the AMA's Physician Consortium for Performance Improvement (the Consortium)
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, the Substance Abuse and Mental Health Services Administration (SAMHSA) , the National Association of State Mental Health Directors, Inc.
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. Similar, expanded efforts in coordination with public- and private-sector experts in coding, evidence-based practices, and use of administrative datasets could help substantially in building the evidence base on the effectiveness of different M/SU treatments.
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, linking outcome data on patients treated for posttraumatic stress disorder with administrative data showed that long-term, intensive inpatient treatment was not more effective than short-term treatment and cost $18,000 more per patient per year (Fontana and Rosenheck, 1997; Rosenheck and Fontana, 2001)
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with their diverse traditions and training are involved in independently diagnosing and treating M/SU conditions than is the case for general health care. Their professional organizations are increasingly conducting evidence reviews and promulgating their own practice guidelines.
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Because M/SU health care involves both medical and psychosocial issues and professions that have their historical origins in either the biological or social sciences, reviews are conducted by entities with different origins and research traditions and sometimes produce different types of empirical evidence and judgments about their meaning. Table 4-1 lists some of the leading organizations or initiatives that conduct evidence reviews of M/SU health care services and make determinations with regard to effective practices.
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. National Registry of The Substance Abuse and Mental Health Services Evidence-based Programs Administration's (SAMHSA)
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. Practice guidelines have addressed major depression, psychoses, posttraumatic stress disorder, and substance use.
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Because the education, criminal justice, and social welfare systems play key roles in the funding and delivery of M/SU treatment services, there is some expected overlap between Cochrane and Campbell reviews, and seven completed Campbell reviews are also registered as Cochrane reviews. To address this overlap, the Cochrane and Campbell Collaborations are pursuing coordination of their activities, including joint registration of methods groups, as well as links with other conveners and members of Cochrane and Campbell methods groups and with the steering group representatives of both organizations*
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conduct reviews of the evidence as a prelude to promulgating clinical practice guidelines. The American Psychologi cal Association's criteria for determining effective practices (American Psychological Association, un dated)
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Many of these same organizations are also involved with the dissemination of their review findings in the form of practice guidelines and other clinical decision-support tools. IMPROVING DIAGNOSIS AND ASSESSMENT The production of evidence will be less fruitful if it is not accompanied by accurate diagnosis and comprehensive longitudinal assessment.
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Foremost, in contrast with general health conditions, relatively few laboratory, imaging, or other physical measures can detect the presence of a mental illness or substance dependence.10 Accurate diagnosis relies instead upon descriptive methods whereby patients or their caregivers inform clinicians about symptoms, and clinicians apply their expert judgment to determine whether diagnostic criteria for a condition are met. Moreover, individual clinicians vary in the breadth, depth, and theoretical basis of their training (see Chapter 7)
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Further, clinicians should be encouraged to employ standardized clinical assessment instruments to measure target symptoms consistently and systematically, and document results over the course of treatment (American Psychiatric Association Task Force for the Handbook of Psychiatric Measures, 2000)
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170 HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS BOX 4-2 Key Factors Associated with Successful Dissemination and Adoption of Innovations Characteristics of the Innovation Characteristics of Individual Adopters Innovation more likely to be adopted if it: Uptake of innovation influenced by · Offers unambiguous advantages in individual's: effectiveness or cost-effectiveness. · General cognitive and psychological · Is compatible with adopters' values, traits conducive to trying innovations norms, needs.
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Key Dissemination Efforts Substance Abuse and Mental Health Services Administration As part of its Science to Service Initiative, SAMHSA has multiple activities under way to disseminate information on evidence-based practices, promote the incorporation of such practices into general and M/SU health care, and facilitate feedback from the field to guide research. For example, SAMHSA's Center for Mental Health Services is developing six "tool kits" addressing Illness Management and Recovery, Medication Management, Assertive Community Treatment, Family Psychoeducation, Supported Employment, and Integrated Dual Diagnosis Treatment for Co-Occurring Disorders.
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, as well as topic-specific publications. NIDA's Principles of Drug Addiction Treatment: A Research-based Guide, for example, is a synthesis of the treatment research organized into 13 key principles, questions and answers, and a listing of some programs for which a strong evidence base exists.11 Veterans Health Administration VHA's clinical practice guidelines initiative (described in Table 4-1)
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These activities are often connected with their development and distribution of practice guidelines. Underused Sources of Communication and Influence The dissemination activities described above are conducted by organizations that generally are perceived as specialty M/SU organizations and thus may be most likely to communicate and have influence with specialty M/SU health care providers.
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Yet the listing of chronic disease programs on the center's website includes arthritis, cancer, diabetes, epilepsy, global health, healthy aging, healthy youth, heart disease and stroke, nutrition and physical activity, oral health, a block grant program to implement national objectives contained in the Healthy People report, prevention research programs, elimination of racial disparities, pregnancy-related illnesses, tobacco use, and an initiative for uninsured women (addressing high blood pressure and cholesterol, nutrition and weight management, physical inactivity, and tobacco use) -- but not M/SU illnesses.
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National Center for Chronic Disease Prevention and Health Promotion prevents premature death and disability from chronic diseases and pro motes healthy personal behaviors. Office of Genomics and Disease Prevention provides national leader ship in fostering understanding of human genomic discoveries and how they can be used to improve health and prevent disease.
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. This omission is in spite of the evidence presented in Chapter 1 and acknowledged in the President's New Freedom Commission report that mental illnesses rank first among conditions that cause disability in the United States (New Freedom Commission on Mental Health, 2003)
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To better build and disseminate the evidence base, the Department of Health and Human Services (DHHS) should strengthen, coordinate, and consolidate the synthesis and dissemina tion of evidence on effective M/SU treatments and services by the Substance Abuse and Mental Health Services Administration; the Na tional Institute of Mental Health; the National Institute on Drug Abuse; the National Institute on Alcohol Abuse and Alcoholism; the National Institute of Child Health and Human Development; the Agency for Healthcare Research and Quality; the Department of Justice; the De partment of Veterans Affairs; the Department of Defense; the Depart ment of Education; the Centers for Disease Control and Prevention; the Centers for Medicare and Medicaid Services; the Administration for 13Personal communication with Steve Seitz, User Liaison Program, Agency for Healthcare Research and Quality on December 9, 2004.
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An ongoing process accommodating changes in the science base over time will be necessary to synthesize the evidence base; assess interventions based on the strength of their scientific evidence; and develop and continually update a reliable categorization and coding scheme for individual M/SU prevention, screening, assessment, psychotherapy, psychosocial, and other treatment interventions. Given fiscal constraints, and in an effort to mainstream M/SU health care, the committee recommends that DHHS make use of public- and private-sector structures and processes already in place that synthesize evidence, develop procedure codes such as the HCPCS codes and CPT codes for administrative datasets, develop performance measures and measurement approaches for the public and private sectors, and carry out
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As these codes are developed, the federal government should require their use in all federally mandated and supported administrative data collection activities. In addition, as discussed above, the committee believes that the collection of outcome data can both inform clinical care at the point of care delivery and contribute to the development of evidence on effective treatments.
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A National Inventory of Mental Health Quality Measures, funded by AHRQ, NIMH, SAMHSA, and The Evaluation Center@HSRI (The Human Services Re 14The terms "performance measurement" and "quality measurement," like "performance measures" and "quality measures," are often used interchangeably because quality measures are a type of performance measures (financial performance, for example, is another type)
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Necessary Components of a Quality Measurement and Reporting Infrastructure Effectively measuring quality and reporting results to providers, consumers, and oversight organizations requires structures, resources, and expertise to perform several related functions: · Conceptualizing the aspects of care to be measured. · Translating the quality-of-care measurement concepts into performance measure specifications.
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, the Center for Quality Assessment and Improvement in Mental Health (Hermann and Palmer, 2002; Hermann et al., 2004) , the Behavioral Healthcare Performance Measurement System for inpatient care of the NRI, the Outcomes Roundtable for Children and Families (Doucette, 2003)
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. These efforts are in addition to performance measure sets that address health care overall and include some M/SU performance measures, such as NCQA's HEDIS and measures used by VHA (see Appendix C)
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. For example, the HEDIS performance measures addressing M/SU health care apply to general health plans seeking accreditation, but not to managed behavioral health care organizations.16 Another problem caused by the separation of M/SU and general health care, as well as by the separation of mental and substance-use care, relates to access to data.
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The instructions specify, for example, data sources to be used to calculate a measure, rules for including and excluding some individuals from the rate, time frames for data capture, and sampling strategy if sampling is used. Translating measurement concepts into quality measures also requires detailed knowledge of multiple data sources, including health plan enrollment and encounter data, inpatient and outpatient claims data, pharmacy and laboratory databases, administrative data coding sets, and patient surveys, as well as knowledge of the capabilities of organizations' information systems and of the appropriateness of and techniques for case-mix adjustment.
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, or (2) there is an ongoing commitment of sufficient resources to enable the analysis of quality measures, making them so useful that those calculating and submitting them do so voluntarily (e.g., NRI's Behavioral Healthcare Performance Measurement System and AHRQ's Healthcare Cost and Utilization Project [H-CUP]
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In contrast, submission of the Behavioral Healthcare Performance Measurement System inpatient hospital measures to NASMHPD or NRI is not required, but facilities that choose to do so may use those measures to fulfill accreditation reporting requirements. Auditing to Ensure That Performance Measures Have Been Calculated Accurately and According with Specifications Reported measures may not accurately represent an individual's or organization's performance.
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Purchasers and quality oversight organizations also need comparative information for incentivizing and rewarding best performance. Risk adjustment of performance measures may sometimes be necessary, especially when reporting measures of patient outcomes as opposed to measures of the processes of care delivery.
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Periodic rotation of the measures to be calculated may therefore be needed, especially as new performance measures are developed. Need for PublicPrivate Leadership and Partnership to Create a Quality Measurement and Reporting Infrastructure Ensuring the existence of a quality measurement and reporting infrastructure that is responsive to the issues outlined above requires leadership.
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and private-sector (private insurance) purchasers and other stakeholders on the reporting of standardized measures of child health care in HEDIS, in the endorsement of a wide variety of performance measures by both the public and private sectors through the National Quality Forum, and in the agreement reached by the public and private sectors on a common set of performance measures for inpatient psychiatric care through a partnership among NASMHPD, NRI, the National Association of Psychiatric Health Systems (NAPHS)
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.18 Continued involvement and support of SAMHSA and DVA in this and other national performance measurement and reporting initiatives for general health care, as well as their encouraging other M/SU organizations to participate, would help bring the resources of the private sector to bear on M/SU performance measurement and achieve consistency across the public and private sectors -- both of which would facilitate the creation of a performance measurement and reporting infrastructure for M/SU health care. An additional benefit is that M/SU health care would be able to participate on the ground floor in quality measurement initiatives, such as the development of new CPT II codes to capture outcome and otherwise nonreimbursed process-of-care measures in administrative datasets.
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increased retention in treatment for substance abuse and reduced utilization of inpatient psychiatric care, (7) increased social supports/social connectedness, (8)
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Second, there is not yet an agreed-upon National Quality Measurement and Reporting System in place. Until such a system begins to take shape, SAMHSA and DVA need to develop as much expertise as possible in quality measurement and reporting so they can be strong partners in the system's development and implementation.
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BOX 4-4 The Network for the Improvement of Addiction Treatment (NIATx) NIATx is a partnership between The Robert Wood Johnson Foundation's "Paths to Recovery" program and the Center for Substance Abuse Treatment's "Strengthen ing Treatment Access and Retention" program.
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To measure quality better, DHHS, in partner ship with the private sector, should charge and financially support an entity similar to the National Quality Forum to convene government regulators, accrediting organizations, consumer representatives, pro viders, and purchasers exercising leadership in quality-based purchas ing for the purpose of reaching consensus on and implementing a com mon, continuously improving set of M/SU health care quality measures for providers, organizations, and systems of care. Participants in this consortium should commit to: assessment process, (3)
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· Ensuring the analysis and display of measurement results in for mats understandable by multiple audiences, including consumers, those reporting the measures, purchasers, and quality oversight organizations. · Establishing models for the use of the measures for benchmarking and quality improvement purposes at sites of care delivery.
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2002. A review of quantitative studies of adherence to mental health clinical practice guidelines.
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2003. Bridging the gap: A hybrid model to link efficacy and effectiveness research in substance abuse treatment.
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Paper presented at a conference, Advancing Mental and Behavioral Health Care Quality Measurement and Improvement for Children and Adolescents. Baltimore, MD, March 30, 2004.
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Journal of Substance Abuse Treatment 23(4)
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2004. Evidence Based Services Committee 2004 Biennial Report -- Summary of Effective Interventions for Youth With Behavioral and Emotional Needs.
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2004. Achieving consensus across diverse stakeholders on quality measures for mental healthcare.
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U.S. spending for mental health and substance abuse treatment, 19912001.
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2002. Contemporary drug abuse treatment: A review of the evidence base.
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2004. A review of the growing evidence base for pediatric psychopharmacology.
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The Cochrane Database of Systematic Reviews 1. SAMHSA (Substance Abuse and Mental Health Services Administration)
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2005. Evidence based?
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2005. Clinical Practice Guidelines.
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2000. Using randomized controlled trials to evaluate socially complex services: Problems, challenges, and recommendations.
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