Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions

In the past decade, there has been an increase in research related to the routine collection and active use of standardized patient data in psychotherapy. Research has increasingly focused on personalization of care to patients, clinical skills and interventions that modulate treatment outcomes, and implementation strategies, all of which appear to enhance the beneficial effects of ROM and feedback. In this article, we summarize trends and recent advances in the research on this topic and identify several essential directions for the field in the short to medium term. We anticipate a broadening of research from the focus on average effects to greater specificity around what kinds of feedback, provided at what time, to which individuals, in what settings, are most beneficial. We also propose that the field needs to focus on issues of health equity, ensuring that ROM can be a vehicle for increased wellbeing for those who need it most. The complexity of mental healthcare systems means that there may be multiple viable measurement solutions with varying costs and benefits to diverse stakeholders in different treatment contexts, and research is needed to identify the most influential components in each of these contexts.

A randomized controlled trial of analogue pharmacogenomic testing feedback for psychotropic medications

Objective

To examine the impact of various presentations of pharmacogenomic testing results using a published, color-coded decision support tool (DST) format as a standard stimulus to list possible medications.

Methods

Participants were randomly assigned to groups and asked to decide which psychotropic medication they would prefer if depressed. Three of the groups varied the color-coded category of fluoxetine and received a statement indicating that this was the most prescribed drug for depression. A fourth control condition omitted base rate information. Participants also provided detail about their decision-making processes through a qualitative interview.

Results

Comparison of the first three groups indicated that significantly more participants selected medications from the highest category of likely effectiveness when fluoxetine appeared in this list. Comparison of the control group to its relevant analogue suggested no significant differences in selection strategy. Qualitative interview responses indicated participant comfort with genetic testing despite awareness of having very limited understanding of these techniques and their implications.

Conclusions

Both DST color-coding and base rates were influential in driving drug selection decisions, despite most participants indicating they did not understand this information.

Innovation

Efforts to standardize pharmacogenomic stimuli may lead to advances in methods of studying quantifiable healthcare decisions. Attention to the context for presenting test results may also be a useful source of understanding patient responses, particularly regarding complex tests that are likely to be interpreted heuristically.

Exploring current physicians' failure to communicate clinical feedback back to transferring physicians after transitions of patient care responsibility: A mixed methods study

INTRODUCTION

After patient care transitions occur, communication from the current physician back to the transferring physician may be an important source of clinical feedback for learning from outcomes of previous reasoning processes. Factors associated with this communication are not well understood. This study clarifies how often, and for what reasons, current physicians do or do not communicate back to transferring physicians about transitioned patients.

METHODS

In 2018, 38 physicians at two academic teaching hospitals were interviewed about communication decisions regarding 618 transitioned patients. Researchers recorded quantitative and qualitative data in field notes, then coded communication rationales using directed content analysis. Descriptive statistics and mixed effects logistic regression analyses identified communication patterns and examined associations with communication for three conditions: When current physicians 1) changed transferring physicians' clinical decisions, 2) perceived transferring physicians' clinical uncertainty, and 3) perceived transferring physicians' request for communication.

RESULTS

Communication occurred regarding 17% of transitioned patients. Transferring physicians initiated communication in 55% of these cases. Communication did not occur when current physicians 1) changed transferring physicians' clinical decisions (119 patients), 2) perceived transferring physicians' uncertainty (97 patients), and 3) perceived transferring physicians' request for communication (12 patients). Rationales for no communication included case contextual, structural, interpersonal, and cultural factors. Perceived uncertainty and request for communication were positively associated with communication (p < 0.001) while a changed clinical decision was not.

DISCUSSION

Current physicians communicate infrequently with transferring physicians after assuming patient care responsibilities. Structural and interpersonal barriers to communication may be amenable to change. Clarity about transferring physicians' uncertainty and desire for communication back may improve clinical feedback communication.

A view from the sender side of feedback: anticipated receptivity to clinical feedback when changing prior physicians' clinical decisions-a mixed methods study

When physicians transition patients, the physician taking over may change the diagnosis. Such a change could serve as an important source of clinical feedback to the prior physician. However, this feedback may not transpire if the current physician doubts the prior physician's receptivity to the information. This study explored facilitators of and barriers to feedback communication in the context of patient care transitions using an exploratory sequential, qualitative to quantitative, mixed methods design. Twenty-two internal medicine residents and hospitalist physicians from two teaching hospitals were interviewed and data were analyzed thematically. A prominent theme was participants' reluctance to communicate diagnostic changes. Participants perceived case complexity and physical proximity to facilitate, and hierarchy, unfamiliarity with the prior physician, and lack of relationship to inhibit communication. In the subsequent quantitative portion of the study, forty-one hospitalists completed surveys resulting in 923 total survey responses. Multivariable analyses and a mixed-effects model were applied to survey data with anticipated receptivity as the outcome variable. In the mixed-effects model, four factors had significant positive associations with receivers' perceived receptivity: (1) feedback senders' time spent on teaching services (β = 0.52, p = 0.02), (2) receivers' trustworthiness and clinical credibility (β = 0.49, p < 0.001), (3) preference of both for shared work rooms (β = 0.15, p = 0.006), and (4) receivers being peers (β = 0.24, p < 0.001) or junior colleagues (β = 0.39, p < 0.001). This study suggests that anticipated receptivity to feedback about changed clinical decisions affects clinical communication loops. Without trusting relationships and opportunities for low risk, casual conversations, hospitalists may avoid such conversations.