What if a doctor prescribed medication for a patient with high blood pressure and, when the patient came back in for checkups, the physician neglected to measure the blood pressure again? Most people would question the quality of care that patient was receiving, because the doctor had no way of knowing whether the prescribed treatment was working or whether it needed to be adjusted.
Using quantifiable measures such as blood pressure to drive clinical decision-making is part of standard medical practice. However, except for drug testing, behavioral health care cannot be physically measured. Patients in treatment for drug or alcohol use disorders routinely have their urine tested, with a negative test suggesting treatment success. But urine testing does not predict who is at risk for relapse. Therapeutic drug monitoring is often used to determine whether blood levels of antipsychotic medications are in the therapeutic range but does not provide information about whether the drug is effective or whether it caused side-effects.
Measurement-based care (MBC) uses validated symptom scales completed by patients and reviewed by clinicians during therapeutic encounters. In a recently released Issue Brief, titled, “Fixing Mental Health Care in America: A National Call for Measurement Based Care in Behavioral Health and Primary Care” (http://bit.ly/2oKaExq), experts at The Kennedy Forum stated, “Measurement-based care will help providers determine whether the treatment is working and facilitate treatment adjustments, consultations or referrals for higher intensity services when patients are not improving as expected.”
MBC is not considered standard for all treatment centers. Clinical judgment is the current method most often used to detect changes in symptom severity and treatment response, although this method has been shown to be accurate only about 20 percent of the time. MBC has been shown to significantly improve outcomes in behavioral health care patients.
A more accurate way to measure symptoms of mental illness is to ask for feedback from patients. Symptom rating scales can be used to measure abstract concepts, such as thoughts, feelings, pain and psychiatric symptoms. Most such scales consist of multiple questions that measure one or more aspects of a specific concept. An entire field of social science specializes in the development, testing and analysis of such scales, called psychometrics. Psychometrics help to ensure that a scale:
- Accurately measures what it is intended to measure
- Is consistently reliable
- Applies to the population for which it is being used
- Is practical to administer
- Has predictive value, so that risk of adverse outcomes can be highlighted and prevented
Typically, scale development takes many years. First, the social scientist must decide what is to be measured and clearly define it. Second, he or she develops relevant questions and tests the scale in a pilot study. Third, the scientist analyzes pilot data using various statistical analyses that will help him or her to determine validity, reliability and which questions to keep. Fourth, the scientist revises and retests the scale. Even scales with good psychometrics are only effective on the population on which they are tested. Translating a standard scale to another language or format, for example, would require further pilot testing before it could be used.
Fortunately, there are many established measures of symptom severity for mental disorders, such as depression, anxiety, posttraumatic stress disorder and most other conditions described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Other important factors also must be measured to evaluate treatment outcomes, such as role functioning, quality of life, readiness for change and the quality of the therapeutic relationship between patients and their providers. Behavioral health patients will likely have several different questionnaires to complete at each visit in the future.
The Kennedy Forum and its partners vetted many rating scales to help measure patient outcomes. The Forum’s experts recently published the most psychometrically sound scales that they felt were suitable for widespread adoption. They included symptom ratings, functional status, substance use and screening tools for children, adolescents and adults. Several other national organizations are working on how MBC can be implemented as a standard for all behavioral health care providers, including:
- The National Quality Forum, which works toward quality improvements in health care
- The American Psychiatric Association’s Council on Quality Care, which helps set standards of care in psychiatry
- The Joint Commission, which accredits and certifies health care institutions and programs based on standardized criteria
Measuring behavioral health care outcomes makes sense for providers, patients and payers for several reasons. Providers will receive valuable feedback on their treatment plans, affording them continuous opportunity for improvement. Results may also alert providers to changes in their patients’ conditions that may otherwise go undetected. Patients will theoretically receive better care and not have to continue treatment that is not helping them. Payers will be able to hold providers accountable for the effectiveness of treatments that they are mandated to cover.
Once MBC is implemented, providers, patients and payers will be able to ensure that treatment outcomes measure up to stated goals. Data can be tracked and compared to benchmark treatment standards. Best practices can then be leveraged and shared to improve behavioral health care nationwide. With the current epidemics of mental illness, addiction and suicide in the United States today, such improvements can’t happen soon enough.