Assessing the outcome of community-based psychiatric care: building a feedback loop from 'real world' health services research into clinical practice

Patient-reported needs predict perceived psychosocial disability and quality of life beyond symptom severity in schizophrenia

PURPOSE

We examined whether patient-rated or clinician-rated needs are more strongly associated with perceived psychosocial disability (PPD) and subjective quality of life (SQOL) of schizophrenia patients, beyond symptom severity.

METHODS

Hierarchical regression analyses were computed to test patient and clinician-rated unmet and met needs (estimated by eighty-two patient-clinician pairs) as predictors of PPD and SQOL above and beyond demographics and psychopathology. Needs, symptomatology, PPD and SQOL were estimated using Camberwell Assessment of Need (CAN), PANSS, WHODAS 2.0 and WHOQOL-BREF respectively.

RESULTS

Needs were significantly associated with all WHODAS 2.0 and WHOQOL-BREF domains above and beyond demographics and PANSS variables. Clinician-rated needs were better predictors of only one WHODAS 2.0 domain, while patient-rated needs were better predictors of all other WHODAS 2.0 and WHOQOL-BREF domains. Patient-rated unmet needs were more strongly than met needs associated with the most WHODAS 2.0 and WHOQOL-BREF subscores.

CONCLUSION

This study offers the first evidence that patient-rated needs, especially unmet needs, are strongly associated, above and beyond symptomatology, with global and domain-specific PPD of schizophrenia patients. Accordingly, strong relations of patient-rated needs with SQOL emerged. Identifying and addressing patient-reported needs could facilitate PPD and SQOL improvement more effectively than interventions confined solely to symptom remission.IMPLICATIONS FOR REHABILITATIONSchizophrenia is associated with poor rehabilitation and recovery outcomes, i.e., perceived psychosocial disability (PPD) and subjective quality of life (SQOL).Assessment of patients' needs constitutes the basis of determining treatment goals and planning tailor-made interventions to achieve crucial rehabilitative outcomes.Higher levels of patient-reported unmet needs are associated with poorer SQOL and higher global and domain-specific PPD of schizophrenia patients, above and beyond symptom severity.Addressing patient-reported needs through personalized interventions can facilitate more effectively PPD and SQOL improvement, than treatment confined to symptomatic alleviation.

Patient-reported outcome measurements (PROMs) and provider assessment in mental health: a systematic review of the context of implementation

Purpose

To review and integrate the vast amount of literature yielded by recent growing interest in patient-reported outcome measurement and routine outcome measures (PROMs/ROMs), in order to suggest options and improvements for implementation. PROMs are the systematic assessment of service users’ health using standardized self-report measures. Specifically, for ROMs, it includes routine provider or caretaker assessment measures. Both are administered to ascertain routinely, the impact of treatment in mental health settings and to improve care. A review is needed because of the large differences in setting, conceptualization, practice and implementation. Here, we examine the different major projects worldwide.

Data sources

Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science’s Direct.

Study selection

We conducted a systematized review of the literature published from 2000 to 2018 on the implementation and sustainability of PROMs and ROMs in mental health services for adults.

Data extraction, synthesis and Results

We described and characterized the programs in different countries worldwide. We identified 103 articles that met the inclusion criteria, representing over 80 PROMs/ROMs initiatives in 15 countries. National policy and structure of mental health services were found to be major factors in implementation. We discuss the great variability in PROMs/ROMs models in different countries, making suggestions for their streamlining and improvement.

Conclusion

We extracted valuable information on the different characteristics of the numerous PROMs/ROMs initiatives worldwide. However, in the absence of a strong nationwide policy effort and support, implementation seems scattered and irregular. Thus, development of the implementation of PROMs/ROMs is left to groups of enthusiastic clinicians and researchers, making sustainability problematic.

Patient satisfaction with inpatient psychiatric treatment and its relation to treatment outcome in unipolar depression and schizophrenia

OBJECTS

Patient satisfaction with psychiatric treatment has emerged as an important factor with respect to the quality of health care.

METHODS

Patient satisfaction using the Zurich Satisfaction Questionnaire (ZUF-8) as well as symptom severity (measured with the Hamilton Depression Scale [HRSD], Brief Psychiatric Rating Scale and Clinical Global Impression Scale) was assessed at admission and discharge of inpatient treatment in patients with a major depressive episode (MDD, N = 217) and schizophrenia (N = 75). Differences between the two diagnostic groups (using T-tests) and correlations of patient satisfaction with different social and treatment variables were calculated (Pearson product-moment correlation).

RESULTS

The mean score of patient satisfaction was 26.8 points (ZUF-8; range 8-32 points), without differences between MDD and schizophrenia (t = 0.45, p = 0.78). Patients with MDD and personality disorder showed lower satisfaction than patients with MDD without personality disorder (t = 2.31, p = 0.03). Patient satisfaction correlated negatively with severity of depressive symptoms at discharge (HRSD: r = - 0.38; p < 0.01) and number of comorbidities (r = - 0.42; p < 0.01) in MDD. Number of prescribed drugs correlated negatively with patient satisfaction in both groups (depression: r = - 0.28, p = 0.02; schizophrenia: r = - 0.24; p = 0.03).

CONCLUSIONS

Patient satisfaction was high without differences between MDD and schizophrenia. Severity of disease and comorbidites in MDD and number of prescribed drugs in both groups were related with reduced patient satisfaction.

Fifty years' development and future perspectives of psychiatric register research

OBJECTIVE

This article illustrates the development of psychiatric register research and discusses the strengths, limitations, and possible directions for future activities.

METHOD

Examples illustrating the development from the post-World War II introduction of psychiatric register research until today are selected.

RESULTS

The strengths of register research are seen especially within health service. Until recently, when starting linking registers to biobanks, register research had limited value in cause-seeking. Register research benefits from the possibilities for following identifiable persons over long time (lifelong) and the possibilities for linking to other registers and databases. Important limitations of register research are the heterogeneity and questionable validity of the clinical data collected.

CONCLUSION

Future register research can go in the direction of big is beautiful collecting data from all possible sources creating giga-registers. In that case, low data quality will still be an unsolved problem. Or it can take the direction of smaller local clinical databases which has many advantages, for example, integrating clinical knowledge and experience into register research. However, in that case, registers will not be able to deal with rare conditions and diseases.

Outcomes from Italian community psychiatric services studies

Outcome measurement, to be valid, reliable, and useful to both program planning and evaluation of interventions, should be based on the principle of multiaxiality (i.e., considering the perspectives of all those involved in the care process, including clinicians, patients, caregivers, users' representatives, third-party payers) and of multidimensionality (i.e., considering an intervention's effect on various dimensions of patients' life, including clinical outcomes such as psychopathology, disability, and needs for care and self-perceived outcomes such as quality of life and service satisfaction). Unfortunately, in Italy, this methodology has not been applied on a large scale. However, some Italian centers with a long-lasting tradition in the area of psychiatric epidemiology have provided evidence that outcome assessment in routine practice is not only sustainable but also advantageous in the medium- and long-term. This article summarizes the results obtained in some of these studies, including three longitudinal studies on the outcome of community psychiatric care promoted by the research group of South Verona, such as the South Verona Outcome Project, the Psychosis Incident Cohort Outcome Study, and the Genetics Endophenotypes and Treatment: Understanding early Psychosis - &bullet; Psychosis: early Intervention and Assessment of Needs and Outcome trial.Implementation of routine outcome assessment can lead-and to a certain extent has already led-to a cultural change among Italian mental health service staff members, to facilitate a) the establishment of a revision-of-practice process, b) greater acceptance of the importance of evidence, and a predisposition to put it into practice.

Mental health care Monitor Older adults (MEMO): monitoring patient characteristics and outcome in Dutch mental health services for older adults

Information on which older adults attend mental health care and whether they profit from the care they receive is important for policy-makers. To assess this information in daily practice, the "Mental health care Monitor Older adults" (MEMO) was developed in the Netherlands. The aim of this paper is to describe MEMO and the older adults who attend outpatient mental health care regarding their predisposing and enabling characteristics and need for care. In MEMO all patients referred to the division of old age psychiatry of the participating mental health care organisations are assessed at baseline and monitored at 4, 8 and 12-month follow-up. Primary outcomes are mental and social functioning, consumer satisfaction, and type of treatment provided (MEMO Basic). Over the years, MEMO Basic is repeated. In each cycle, additional information on specific patient groups is added (e.g. mood disorders). Data collection is supported by a web-based system for clinicians, including direct feedback to monitor patients throughout treatment. First results at baseline showed that the majority of patients that entered the division of old age psychiatry was female (69%), had low education (83%), lived alone (53%), was depressed (42%) and had a comorbid condition (82%). It seemed that older immigrants were not sufficiently reached. The current study is the first in the Netherlands to evaluate patient characteristics and outcome in mental health care provided for older adults in day-to-day practice. If MEMO works out successfully, the method should be extended to other target groups.

Schizophrenia in real life: courses, symptoms and functioning in an Italian population

Background

In the general belief, schizophrenia is associated with the concepts of seriousness, incurability, dangerousness: this is incorrect. In recent decades, the interest in course studies increased and different trends emerged, not necessarily chronic, with the possibility of remission.

The plan of this research was to draw a picture of the schizophrenia syndrome in a specific geographic area, in the past and at present time: this allows to detect needs, weaknesses and strengths, for a better planning of future interventions.

Methods

The course of all cases diagnosed as schizophrenia (N = 1,759) in the period 1978–2008, was retrospectively studied in the entire population of an Italian province by observing, for a mean period of 12 years per person, age at first psychiatric consultation, number and length of admissions for both acute symptoms and residential-rehabilitation programs, number of interventions in outpatients. The cases under treatment (N = 842), were evaluated in terms of symptoms, using the Brief Psychiatric Rating Scale, and in terms of functioning, using the Personal and Social Functioning Scale.

Results

The disease course differs significantly between genders: males have an earlier age at first consultation (about 7 years earlier), higher admission rates, greater number of outpatient interventions and personal and social functioning significantly worse.

Hospitalization resulted often unnecessary: 23.1% of cases were never hospitalized and 67.2% spent less than one week per year in hospital.

A quarter of the cases meets the international criteria for remission and more than 75% are asymptomatic or mildly symptomatic; only 5.3% of cases shows severe symptoms. However, Personal and Social Functioning highlights, in about 1/3 of cases, relevant or serious problems mainly in Work and Relationships areas, whilst Aggressiveness is a serious problem only in 9%.

Conclusions

In this population, schizophrenia in real life shows great individual variability in course, symptoms and functioning: in most cases nowadays it appears a less severe and chronic disease than in the past, but further improvements are needed on disability prevention and social inclusion.

Psychosis Incident Cohort Outcome Study (PICOS). A multisite study of clinical, social and biological characteristics, patterns of care and predictors of outcome in first-episode psychosis. Background, methodology and overview of the patient sample

AIMS

This paper aims at providing an overview of the background, design and initial findings of Psychosis Incident Cohort Outcome Study (PICOS).

METHODS

PICOS is a large multi-site population-based study on first-episode psychosis (FEP) patients attending public mental health services in the Veneto region (Italy) over a 3-year period. PICOS has a naturalistic longitudinal design and it includes three different modules addressing, respectively, clinical and social variables, genetics and brain imaging. Its primary aims are to characterize FEP patients in terms of clinical, psychological and social presentation, and to investigate the relative weight of clinical, environmental and biological factors (i.e. genetics and brain structure/functioning) in predicting the outcome of FEP.

RESULTS

An in-depth description of the research methodology is given first. Details on recruitment phase and baseline and follow-up evaluations are then provided. Initial findings relating to patients' baseline assessments are also presented. Future planned analyses are outlined.

CONCLUSIONS

Both strengths and limitations of PICOS are discussed in the light of issues not addressed in the current literature on FEP. This study aims at making a substantial contribution to research on FEP patients. It is hoped that the research strategies adopted in PICOS will enhance the convergence of methodologies in ongoing and future studies on FEP.

The relationship between consumer insight and provider-consumer agreement regarding consumer's quality of life

This study examined the relationship between insight and mental health consumers and providers agreement regarding consumers rated quality of life (QoL). Seventy mental health consumers and their 23 care providers filled-out parallel questionnaires designed to measure consumer QoL. Consumers' insight was also assessed. For most QoL domains, agreement between consumers and providers was higher for persons with high insight. For the Psychological well being dimension a negative correlation was uncovered for persons with low insight indicating disagreement between consumer and provider. These findings are discussed within the context of the literature on insight and agreement between consumer and provider as related to the therapeutic alliance.

Measuring clinical change in routine mental health care: differences between first time and longer term service users

OBJECTIVE

The aims were to assess the feasibility of routinely collecting outcome data in everyday mental health services across Italy and to evaluate clinical change in a cohort of patients stratified by illness duration.

METHOD

A prevalence sample of patients attending nine Italian community mental health services (CMHS) was assessed over one year with the Health of the Nation Outcome Scales (HoNOS). The patients were classified on the basis of the duration of their contact with services. Clinical outcome was evaluated taking into account parameters of reliable and clinically significant change (RCSC). Predictors of change included clinical and socio-demographic characteristics at first assessment and six month reliable improvement.

RESULTS

2059 patients were evaluated with only 3% attrition at follow up; 22% of first time and about 7% of longer term users achieved reliable improvement at one year. First contacts had a better outcome than longer term users and significant differences were seen at both group and individual level. Reliable improvement at six months was the best predictor of clinical improvement at one year for the whole cohort.

CONCLUSION

The study demonstrated the feasibility of routine outcome assessment and gave an expected and realistic picture of the one-year outcome of a representative sample of patients attending a group of Italian CMHS. RCSC showed potential utility as a means of communicating with clinicians and decision makers.

So what shall we do about assertive community treatment?

The usefulness of Assertive Community Treatment (ACT) in European countries with well-developed community care systems has been disputed, despite considerable relevant literature. This paper aims to assess reasons for and against implementing ACT in such countries. ACT may not be useful where generic community mental health teams are not yet well-developed, where admission rates are already low, or where an alternative model based on close integration of a full range of types of care is in place. Good reasons for introducing ACT include listening to patients' preferences, being able to monitor a high risk group of patients more successfully, good staff satisfaction, and the potential for using ACT teams as a platform for delivering interventions for difficult to treat psychosis. The ACT model is more likely to thrive in future if a recovery orientation can be adopted.

Outcome management in in-patient psychiatric care

OBJECTIVE

To delineate methods and to describe patient appraisal as well as effect of outcome management in in-patient psychiatric care.

METHOD

Two hundred and ninety-four adults with mental illness receiving in-patient treatment at a psychiatric hospital in rural Bavaria gave informed consent to participate in this cluster-randomised trial. Participants were asked to provide information on treatment outcome via weekly computerised standardised assessments. Patients and clinicians in the intervention group received continuous feedback of outcome.

RESULTS

Patients were willing and able to regularly provide outcome data and valued feedback. However, use of feedback in conversations between patient and clinician was rare. Outcome management failed to impact on patient-rated outcome during in-patient treatment.

CONCLUSION

Outcome management is feasible in people receiving in-patient psychiatric care, but failed to show an overall short-term effect. Strategies need to be developed to improve active use of routinely collected treatment outcome data in mental health care.

A comparison of patient and staff satisfaction with services after relocating to a new purpose-built mental health facility

OBJECTIVE

This study measured patient satisfaction levels and staff views regarding their expectations and workplace and other opinions after relocation to a new purpose-built mental health facility within the grounds of a general repatriation hospital.

METHOD

Patients were interviewed face-to-face using a standardized satisfaction survey at least 2 months after the move to the new facility. In addition, surveys were sent by mail to all clinical staff rostered to work the same period that the patient interviews were conducted.

RESULTS

One hundred patients were interviewed and 123 staff returned the survey (56% response rate). Patients and staff rated the new ward environment and food services most highly and were least satisfied with patient information and medical services. Less satisfaction was expressed about resource issues such as information technology and dedicated staff facilities. Most staff (70-80%) rated services provided to patients to be the same or better than their original expectations.

CONCLUSIONS

The results indicate that the hospital move did not have any measurable negative impact on overall service provision or patient satisfaction. In fact, expectations were met or improved for several clinically relevant areas after relocating the mental health facility. Another survey is planned in 12 months to assess if patient and staff ratings change.

Improving clinicians' attitudes toward providing feedback on routine outcome assessments

Clinicians have been found to hold predominantly negative attitudes toward routine outcome assessments (ROA). This study aims to assess changes in clinicians' attitudes to ROA, and in particular, the provision of feedback from such assessments following a training workshop. Ninety-six mental health workers attended a training workshop on ROA, which was supported by the use of a CD-ROM video resource. Participants completed a questionnaire before and after training that assessed their attitudes toward ROA and the provision of feedback from these assessments. Attitudes toward feedback were predominantly positive at baseline. Significantly more positive attitudes on general attitudes and specific attitudes related to the provision of feedback were found following training. Generating positive clinician attitudes is the first step toward improving the processes and effectiveness of ROA. Controlled trials with a follow up of clinicians' behaviour are needed to determine whether the changes found are maintained and reflected in practice.

Applications and usefulness of routine measurement of patients' satisfaction with community-based mental health care

OBJECTIVE

This study was conducted within the framework of the South-Verona Outcome Project (SVOP) in a sample of patients, with the full spectrum of psychiatric diagnoses, who are attending the South-Verona Community-based Mental Health Service (CMHS). It aims to exemplify some applications of routine measurements of service satisfaction and specifically: i) identify strengths and weaknesses, in the patients' perspectives, of a 'real world' service; ii) monitor whether this specific service provides satisfactory care over 3 years and iii) identify if there are any patients' characteristics that might be associated with service dissatisfaction.

METHOD

Service satisfaction was measured with the Verona Service Satisfaction Scale (VSSS) across three subsequent waves of the SVOP; frequency distributions of scores in the various VSSS domains were compared. The relationship between satisfaction with psychiatric care and a number of well-established mental health indicators, including socio-demographic, clinical and service intervention variables, was investigated using random-effect models.

RESULTS

The organization of service and the behaviour and manners of the professionals were the main service strengths. Weaknesses were identified in the physical layout of facilities, in the lack of involvement of relatives and in the information provided. Overall satisfaction was medium-high, while subjects with longer duration of service contact and higher disability were the most dissatisfied. The predictors we examined, however, explained only modest percentages of variance.

CONCLUSION

Repeated, routine assessments of service satisfaction have provided a clear view of the South-Verona CMHS' strengths and weaknesses; this set of information was crucial for the continuous quality improvement process in the service.