The development of quality indicators in mental healthcare: a discrete choice experiment

Basic quality indicators for clinical care of patients with major depression, schizophrenia, and bipolar disorder

OBJECTIVE

To identify a set of indicators to monitor the quality of care for patients with major depression, schizophrenia, or bipolar disorder.

METHODS

A group of 10 experts selected the most automatically applicable indicators from a total of 98 identified in a previous study. Five online sessions and 5 discussion meetings were performed to select the indicators that met theoretical feasibility criteria automatically. Subsequently, feasibility was tested in a pilot study conducted in two hospitals of the Spanish Health Service.

RESULTS

After evaluating its measurement possibilities in the Spanish Health Service, and the fulfillment of all the quality premises defined, 16 indicators were selected. Three were indicators of major depression, 5 of schizophrenia, 3 of bipolar disorder, and 5 indicators common to all three pathologies. They included measures related to patient safety, maintenance and follow-up of treatment, therapeutic adherence, and adequacy of hospital admissions. After the pilot study, 5 indicators demonstrated potential in the automatic generation of results, with 3 of them related to treatments (clozapine in schizophrenia, lithium for bipolar disorder, and valproate in women of childbearing age).

CONCLUSIONS

Indicators support the monitoring of the quality of treatment of patients with major depression, schizophrenia, or bipolar disorder. Based on this proposal, each care setting can draw up a balanced scorecard adjusted to its priorities and care objectives, which will allow for comparison between centers.

A discrete choice experiment to identify the most efficient quality indicators for the supervision of psychiatric hospitals

BACKGROUND

In the Netherlands, health care is regulated by the Health and Youth Care Inspectorate. Forty-six indicators are used to prioritize supervision of psychiatric hospitals. The objective of this study is to define a smaller set of weighted indicators which reflects a consensus among inspectors about which aspects are most important for risk assessment.

METHODS

The set of 46 indicators, complemented with missing information, was reduced to six indicators by means of interviews, group discussions and ranking among the inspectors. These indicators were used as attributes in a discrete choice experiment (DCE) to define their weights.

RESULTS

Twenty-six inspectors defined the top four indicators suitable for the risk assessment of psychiatric hospitals. These are: the policy on prevention of compulsory treatment; the policy on dysfunctional professionals; the quality of internal research after a serious incident; and the implementation of multidisciplinary guidelines on suicidal behaviour. These indicators share the same importance with regard to risk assessment. The screening of somatic symptoms and the policy on integrated care are important indicators too, but less relevant.

CONCLUSION

Through a DCE, we reduced the amount of information for risk assessment of psychiatric hospitals to six weighted indicators. Inspectors can use these indicators to prioritize their inspections.

Quality indicators in the treatment of patients with depression, bipolar disorder or schizophrenia. Consensus study

OBJECTIVE

To define a set of indicators for mental health care, monitoring quality assurance in schizophrenia, depression and bipolar disorders in Spain.

MATERIAL AND METHOD

Qualitative research. Consensus-based study involving 6 psychiatrists on the steering committee and a panel of 43 psychiatrists working in several health services in Spain. An initial proposal of 44 indicators for depression, 42 for schizophrenia and 58 for bipolar disorder was elaborated after reviewing the literature. This proposal was analysed by experts using the Delphi technique. The valuation of these indicators in successive rounds allowed those with less degree of consensus to be discarded. Feasibility, sensitivity and clinical relevance were considered. The study was carried out between July 2015 and March 2016.

RESULTS

Seventy indicators were defined by consensus: 17 for major depression, 16 for schizophrenia, 17 for bipolar disorder and 20 common to all three pathologies. These indicators included measures related to adequacy, patient safety, exacerbation, mechanical restraint, suicidal behaviour, psychoeducation, adherence, mortality and physical health.

CONCLUSIONS

This set of indicators allows quality monitoring in the treatment of patients with schizophrenia, depression or bipolar disorder. Mental health care authorities and professionals can use this proposal for developing a balanced scorecard adjusted to their priorities and welfare objectives.

Discrete choice experiments in health economics: a review of the literature

BACKGROUND

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns.

OBJECTIVE

Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001-2008, we report whether earlier trends continued during 2009-2012.

METHODS

This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms.

RESULTS

A total of 179 health-related DCEs for 2009-2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project.

CONCLUSIONS

The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

Cognitive overload? An exploration of the potential impact of cognitive functioning in discrete choice experiments with older people in health care

OBJECTIVES

This exploratory study sought to investigate the effect of cognitive functioning on the consistency of individual responses to a discrete choice experiment (DCE) study conducted exclusively with older people.

METHODS

A DCE to investigate preferences for multidisciplinary rehabilitation was administered to a consenting sample of older patients (aged 65 years and older) after surgery to repair a fractured hip (N = 84). Conditional logit, mixed logit, heteroscedastic conditional logit, and generalized multinomial logit regression models were used to analyze the DCE data and to explore the relationship between the level of cognitive functioning (specifically the absence or presence of mild cognitive impairment as assessed by the Mini-Mental State Examination) and preference and scale heterogeneity.

RESULTS

Both the heteroscedastic conditional logit and generalized multinomial logit models indicated that the presence of mild cognitive impairment did not have a significant effect on the consistency of responses to the DCE.

CONCLUSIONS

This study provides important preliminary evidence relating to the effect of mild cognitive impairment on DCE responses for older people. It is important that further research be conducted in larger samples and more diverse populations to further substantiate the findings from this exploratory study and to assess the practicality and validity of the DCE approach with populations of older people.