Strategies for Measuring the Quality of Psychotherapy: A White Paper to Inform Measure Development and Implementation. A. Advantages


Outcome measures can be used for clinical decision making and to engage consumers in care. As described in the examples above, routine outcomes monitoring can serve at least two purposes: (1) to help track consumer progress and identify individuals who fail to respond to treatment; and (2) to encourage consumer engagement in treatment.

Identifying individuals who fail to respond to treatment is particularly important. One study of over 6,000 individuals who received an average of four psychotherapy sessions in community-based treatment settings found that only about 35 percent improved and about 8 percent experienced worse symptoms or functioning (Hansen et al. 2002). Likewise, studies of children and youth receiving mental health care have found that as many as 24 percent get substantially worse during treatment (Warren et al. 2010). By drawing on data from outcome assessments, the measurement systems described in this paper are able to identify individuals experiencing treatment failure by comparing the trajectory of their progress with statistically generated expected results (Boswell et al. 2013). Some studies have suggested that such measurement approaches can identify 85-100 percent of individuals who get worse during treatment (Ellsworth et al. 2006; Lambert et al. 2002), which is better than relying on clinical judgment alone (Hannan et al. 2005). The information from assessments can also be combined with claims data to implement algorithms that identify individuals at risk for hospitalization (McAleavey et al. 2012).

Consumers can directly benefit from receiving feedback on outcome measures. Some clinicians and researchers have noted that even slight improvements in outcome measures can be encouraging for consumers and can help enhance therapeutic alliance (Youn et al. 2012). Some routine outcome monitoring systems include mechanisms to collect additional information from consumers at risk for poor outcomes. For example, a consumer who is not improving would be asked to report additional information about his or her social support and recent life events, which may provide critical contextual information to help the therapist adjust treatment (Boswell et al. 2013). Thus, repeated assessments may provide another tool for consumers to share information, engage in discussion about their treatment goals and progress, and make treatment decisions.

Outcome measures may overcome the limitations of structure and process measures. To some extent, the measurement of outcomes can be accomplished without regard to the specific content of the treatment being delivered. Outcome measurement shifts the focus from the content of the treatment, which may vary across consumers and time, to the result of the treatment. Nonetheless, measuring how psychotherapy was delivered in tandem with outcomes may help to provide insight into which components of therapy and common factors across psychotherapies produce positive results in typical care settings. Measures that focus directly on outcomes and inform clinical decision making as well as quality improvement may be more appealing than measures of specific processes of care. There may not be agreement on what constitutes high quality treatment, or when there is inadequate evidence that the specific structures and processes of care are strongly associated with outcomes.

In sum, outcome measures may have benefits at multiple levels of the health care system. The measurement of outcomes offers an approach for making care more patient-centered by enabling consumers (as well as other important individuals in their lives) to report information about their symptoms and functioning. For consumers, measures that focus on functional outcomes--such as relationships, employment, and engagement in the community--provide direct feedback that they can use for self-monitoring and making treatment decisions. Providers can use such measures to identify individuals who are not responding to treatment or may require adjustments to their treatment. Likewise, improvements in consumer outcomes may signal to consumers, providers, or health plans that more intensive or sustained treatment may have limited benefit to the individual or family. The tools used to monitor the progress of treatment can be adapted to the service setting and the population. Providers, health plans, and the broader health care system can use performance on these measures to monitor outcomes and identify opportunities for quality improvement as well as promising practices.

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