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Dr. Blais, Dr. Nierenberg, and Dr. Rauch are with the Department of Psychiatry, Harvard Medical School, and with Partners Psychiatry and Mental Health, Boston. Dr. Frank is with the Department of Health Care Policy, Harvard Medical School. Send correspondence to Dr. Rauch at McLean Hospital, 115 Mill St., Belmont, MA 02478 (e-mail: firstname.lastname@example.org).
Dr. Liptzin (1) provides a helpful overview of the various quality improvement initiatives with regard to their impact on health care, and on psychiatry in particular. Although we share a number of his concerns regarding externally mandated programs, we wish to offer an alternative perspective on the relative merits of outcomes measurement.
Structures, processes, and outcomes contribute to the quality of medical care. Process measures, such as those in the HEDIS, are the most common quality metrics in medicine. Psychiatry has several well-known process measures, but most of them have little or no empirical relationship to outcome (2). Even when process measures are strongly linked to diseases (such as HgA1c levels in diabetes), improving process does not guarantee improved outcomes (3).
We believe that outcomes measurement holds considerable promise for improving the quality of mental health care, and here we highlight some of the demonstrated benefits. Outcome measurement improves treatment response rates. Although there is clear efficacy data for psychiatric treatments, real-world effectiveness is not as well documented. Effectiveness studies such as STAR*D and STEP-BD have shown that integrating outcome measurement into routine clinical care results in real-world outcomes similar to those in efficacy studies (4,5). Outcomes measurement facilitates treatment collaboration. In the collaborative care model for bipolar disorder, clinicians and patients use longitudinal outcome data to jointly evaluate progress and make clinical decisions (5). In addition, outcomes measurement reduces bad outcomes. When outcomes data are used to signal psychotherapists that a patient's condition is deteriorating, treatment failure rates are reduced (6). Finally, outcomes measurement offers more precise methods for tracking treatment progress and defining response (5).
Implementing outcomes measurement is challenging, and important issues remain. In particular, using outcomes measures to compare providers creates incentives to treat patients who are most likely to improve. Methods for risk adjustment in psychiatry are as yet inadequate, and we must ensure that no program penalizes our sickest patients or their treatment providers. Moreover, we must recognize that quality can never be reduced to a single domain. Still, there are many benefits to measuring outcomes, and even imperfect systems, if applied sensibly, have the potential to improve care. The recent experience with the Blue Cross Blue Shield outcomes measurement program is illustrative. Even though not every aspect of the program was exemplary, it did contain a number of necessary features for improving care. It used a standardized instrument with known psychometric properties and proven sensitivity to change (7). The vendor provided rapid scoring and feedback delivered to the point of care. Aggregate data were maintained and available for evaluation. These are key components of a successful outcomes measurement program.
Dr. Liptzin describes the chaos and frustration that could ensue if multiple payers mandated separate outcomes programs. His warning is justified. Consequently, as practitioners and researchers, working collaboratively with payers, regulators, and other stakeholders, we have the opportunity and responsibility to take the lead in developing a model outcomes measurement program. Through such an effort, we would also begin to develop the necessary infrastructure, define clinically meaningful outcome measures, and enhance the care of our patients.
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