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Improving Quality of Care for Individuals with Mental Illness
Fall 1999
Table of Contents
- Introduction
- What do we mean by quality of care?
- The science behind quality of care research
- Measuring appropriateness of treatment
- Recommended treatments from the Schizophrenia PORT
- Improving the quality of care for the mentally ill
- Origins of quality problems
- Additional information
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Profile of Dr. Alexander S. Young
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Director's Letter
Introduction
We often hear that the United States has the best healthcare system in the world. So it is worth examining how well we are doing with one important class of disorders, serious psychiatric illnesses such as depression and schizophrenia. As a group, psychiatric disorders are among the most common and disabling of all the medical disorders found in society today. For instance, about 2.5% of all healthcare expenditures are for the treatment of schizophrenia, and its annual cost to society has been estimated to be $23 billion. Psychotic disorders often result in substantial loss of productivity and have powerfully negative impacts on families. In addition, individuals with schizophrenia continue to account for a large proportion of the homeless population, and crowd our jails. Indeed, the Los Angeles County Jail has been described as the largest mental institution in the US. Relative to other medical disorders, treatments for psychiatric disorders are highly effective. With proper care, the success rate of treatment for a mental illness such as schizophrenia is fairly high, in the range of 60%, compared to only about 45% for treatments of heart disease. How then can we understand this continued suffering in light of the availability of effective treatments?
One clue to understanding this seemingly contradictory situation comes from research on the quality of care provided in usual treatment settings. Recent studies have found that the prevailing level of treatment quality for serious psychiatric conditions is poor to moderate, and that although the majority of people with depression and schizophrenia have access to healthcare, only about one-quarter receive care that is likely to be effective. Why are people not receiving the care they deserve? Bridging the gap between new treatments developed in clinical research and the care that most individuals actually receive is at the heart of research into quality improvement. This article will present some issues and research being done in the MIRECC in the area of quality assessment and improvement.
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What do we mean by quality of care?
Defining quality of care is not an easy task. One widely cited definition from the Institute of Medicine states that quality care consists of the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." This is certainly a mouthful, but what it is essentially saying is that high quality care consists of "appropriate" care administered with a high level of skill. Dr. David Blumenthal, a noted researcher in the field of quality improvement, states that high technical quality consists of "doing the right thing right". In addition to doing the right thing, the patient must also think you are doing the right thing, and be satisfied with his/her care. These three domains are often called technical quality, subjective quality, and consumer satisfaction. Taken together, they help form part of the overall picture of quality.
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The science behind quality of care research
Until recently, individual physicians were left with the responsibility of assuring that individuals received high quality care, while hospitals monitored extremely poor outcomes (death or severe infections). Attempts to improve quality by organizations were viewed as veiled attempts at cost containment rather than improvement of care. However, our ability to monitor quality has dramatically improved over the last decade, bringing established scientific methodology to the field of quality assessment. Evaluations of quality commonly examine three aspects of care: structure, process and outcome. Evaluations of structure look at characteristics of physicians and hospitals, such as how nice the waiting room is or what medications are included in a formulary. These domains can have a substantial effect on customer satisfaction, and can affect the process of care by limiting access to beneficial treatments. Evaluations of process look at the details of the encounter between patient and doctor -- is the doctor providing and the patient using the best treatments. Treatment process is important because it can be changed, and because it affects outcomes. Outcome evaluations focus on the patients' subsequent health status; did he or she get better, worse or stay the same. Outcomes are inherently important. However, poor outcomes have many causes, and, in fact, medical care only has a small effect on outcomes. Other factors, such as genetics, severity of illness, sanitation, and smoking have stronger effects on outcomes.
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Measuring appropriateness of treatment
If high quality care includes "doing the right thing right" then we must establish diagnostic and treatment standards before we can attempt to measure treatment appropriateness. Determining the "right" thing involves review of scientific evidence and consideration of clinical experience. Panels of experts generally conduct this review and then use this information to develop treatment standards that can be used by clinicians. The Agency for Healthcare Policy and Research, National Institute of Mental Health (NIMH), American Psychiatric Association and Veterans Healthcare Administration have all developed treatment recommendations for schizophrenia. One particularly useful set of guidelines for improving appropriateness of care are from the Schizophrenia Patient Outcome Research Team (Schizophrenia PORT). They propose specific treatment strategies regarding, for instance, the use of antipsychotic medications, the management of medication side effects, and the availability of assertive community treatment and family management (see insert).
Recommended treatments from the Schizophrenia PORT / % of patients with schizophrenia who are receiving these treatments *
- Appropriate dose of antipsychotic medication for new or relapsed symptoms / 62%
- Appropriate dose of ongoing antipsychotic medication / 29%
- Medication for side effects / 46%
- Medication for depression / 46%
- Medication for anxiety / 41%
- Additional medication for psychotic symptoms / 14%
- Family education and support / 9%
- Vocational rehabilitation / 23%
- Assertive Community Treatment / 10%
* Statistics from the National Alliance for the Mentally Ill
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Dr. Alexander Young has used both measurement of process and measurement of outcomes in research projects evaluating treatment quality in mental illness. In one study of the treatment of schizophrenia, he examined treatment appropriateness at two publicly financed mental health care clinics, one VA and one non-VA, using treatment recommendations from the Schizophrenia PORT. Measuring the quality of care for schizophrenia is particularly challenging because this illness is chronic, it is difficult to accurately assess symptoms of schizophrenia, and people with schizophrenia are often lost to follow-up. While studying patients' charts, Dr. Young found that medical records often failed to report on the presence of severe symptoms or medication side effects, indicating that using medical records alone is not sufficient for measuring appropriateness of care. Patient interview can also provide incomplete or inaccurate information because of the impact this illness has on the patients' ability to communicate. Using a combination of information from patients, caregivers, providers, and medical records presumably provides a more accurate measurement of treatment quality. In this study, Dr. Young used patient interviews and medical record reviews to study patients who were in regular, ongoing treatment, and found that 38% were receiving poor quality medication management, and 52% had inadequate psychosocial care.
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Improving the quality of care for the mentally ill
The bad news is that patients treated for schizophrenia in public clinics appear to be receiving poor quality care with outcomes that are much worse than those found in state-of-the-art research projects. The good news is that poor care appears to be modifiable, and may be amenable to structured approaches that target both key problems in the process of care, and patients who are at greater risk for receiving poor quality care.
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Origins of Quality Problems
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Underuse |
When people do not receive treatment that they are likely to benefit from; this is the most common problem in psychiatric disorders |
| Overuse |
When people receive treatments that they are not likely to benefit from; this has found to be a common problem with back pain and some cardiac procedures but not frequent in mental health treatment |
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| Error |
When a mistake is made; for example many side effects from psychotropic medication go untreated and it has been reported that 1% of hospitalized patients are injured due to negligence |
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It is likely that better evaluation, and medication and psychosocial management is needed to improve outcomes for patients with SMI. Research has also identified populations who are at greater risk for poor care, such as minorities, poorly compliant patients, drug or alcohol abusers, and patients of doctors who are inexperienced at treating schizophrenia. Recently developed and scientifically tested quality improvement interventions for depressive disorders have resulted in patients with improved symptoms, quality of life, and functioning. Interventions such as these are being developed for treatment of schizophrenia. Our goal is to help facilitate their widespread introduction into community clinical settings where they have the potential to substantially improve the lives of individuals suffering from this disorder.
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For More Information
- Chassin MR. Quality of health care. Part 3: improving the quality of care. N Engl J Med. 1996;335:1060-3.
- Lehman, AF; Steinwachs, DM. Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team
(PORT) Client Survey.Schizophrenia Bulletin, 1998, 24(1):11-20
- McGlynn EA, Norquist GS, Wells KB, Sullivan G, Liberman RP. Quality-of-care research in mental health: responding to the challenge. Inquiry.
1988;25:157-170.
- Young AS. Evaluating and improving the appropriateness of treatment for schizophrenia. Harv Rev Psychiatry. 1999;7:114-118.
- Young AS, Sullivan G, Burnam MA, Brook RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998;55:611-7.
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Disclaimer:
This web site, is offered as a public service and is not intended to substitute for professional medical care.
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