Patient, family and provider views of measurement-based care in an early-psychosis intervention programme

A mixed-methods study exploring the benefits, drawbacks, and utilization of data in care: Findings from the EPI-CAL early psychosis learning health care network

Using data collected in routine care delivery to inform treatment is a key feature of a learning health system (LHS). In this study, we explored the experiences of service users and providers adopting measurement-based care (MBC) in early psychosis (EP) specialty care settings. Qualitative interviews were conducted with 32 providers and 12 service users across 18 programs in the Early Psychosis Intervention Network of California (EPI-CAL). These findings were compared with quantitative data from Beehive, EPI-CAL's data collection and review application. Regarding the clinical benefits of MBC in EP, three broad themes were identified - supporting safety monitoring and response, the assessment process, and delivery of psychotherapy. Outside of direct clinical care, Beehive was considered to support clinical supervision and external reporting, while service users reported data collection facilitated self-reflection. In the quantitative Beehive application data collected from 23 EP programs, high utilization of the safety alert system was evident (349 alerts in total, of which 338 [96.85 %] were resolved at a median of 2.03 days). However, service users' key survey data was only reviewed by assigned providers in 32.22 % (142 of 441) of cases. While providers and service users saw many benefits to Beehive, utilization was highly inconsistent outside of the alert system. Going forward, further consideration of how best to support EP providers to consistently use data in care is necessary to maximize the utility of the LHS approach and positively impact outcomes.

Organizational factors impacting the implementation of a digital mental health tool in Alberta's mental health care of youth and young adults

With mental health concerns on the rise among youth and young adults (age 12-24), increased mental health options include virtual care, apps and online tools, self-management and tracking tools, and digitally-enabled coordination of care. These tools may function as alternatives or adjuncts to face-to-face models of care. Innovative solutions in the form of digital mental health (dMH) services not only provide support, resources and care, but also decrease wait times and waitlists, increase access, and empower youth. However, organizational factors may impact the extent of dMH interventions are that accepted, used, and sustained in clinical settings. This qualitative study explores organizational barriers and facilitators surrounding the implementation of a digital platform (Innowell), which uses measurement-based care (MBC) to track youth progress and outcomes. Data was collected from 154 mental health care providers participating in 23 focus groups across Alberta, drawing on school and community settings, specialized mental health services, and primary care networks. A thematic analysis revealed the following: barriers included incompatibility with current systems and workflows, lack of inter-organizational collaboration, time commitment, perceived sustainability and lack of digital literacy. Facilitators included positive attitudes towards using dMH to optimize clinical practices by empowering youth and improving continuity of care, transitions in care, and quality of care, as well as workplace culture and leadership. The study highlights a critical need for decision makers and clinical leaders to address organizational factors by integrating training and support, establishing interoperability between digitized and in-person healthcare systems, and leveraging support for MBC and youth-centred care.

Putting measurement-based care into action: a multi-method study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

BACKGROUND

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for young people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

METHODS

We used a multi-method approach to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report (treatment as usual, TAU) and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the personalized feedback report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

RESULTS

The total sample showed significant improvements in shared decision-making and in their intent to complete the program. Post hoc analyses revealed significant increases in the personalized feedback group, and non-significant changes in the TAU group, although group-by-time interactions did not reach statistical significance. The feedback report group engaged in significantly more sessions of Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

CONCLUSIONS

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase treatment attendance in psychosocial interventions. We posit that this process facilitates recovery-oriented care, strengths-focused treatment planning, enhances intrinsic motivation, and strengthens the therapeutic alliance.

Critical Realism in Symptom Science - A Scoping Review

There has been an increasing interest in research positioned within critical realism (CR). This analysis aimed to determine how CR has been applied in symptom science through a scoping review of the literature. Fifty-two articles were identified through searches in seven databases and search engines, and grey literature. Quantitative and qualitative analyses were performed using Excel and ATLAS.ti 8.0. Review findings indicate that CR has been used to examine two key aspects of symptoms - symptom experiences and symptom interventions. The details of how CR was operationalized are presented. This first scoping review highlights how a critical realist lens would help examine individual and contextual factors that influence symptom experiences, response to interventions, and outcomes.

Youth, caregiver, and clinician perspectives of youth Patient-Reported Outcome Measures (PROMs) in a psychological training clinic: lessons from early adopters

This study examines the applicability and utility of youth Measurement-Based Care (MBC) in a community-based psychological training clinic. Considering the complexity of youth compared to adult MBC, there is an increasing need to expand the evidence base. This study investigated how doctoral students in clinical psychology managed the selection and usage of Patient Rated Outcome Measures (PROMs) for youth and their parents. Additionally, this study evaluates youth attitudes toward MBC and PROMs and overall appropriateness and completion rates. Youth (N = 79) from 1 to 17-years-old with various mental health disorders (i.e., depression, anxiety, ADHD) completed evidence-based psychotherapy. Clinicians (N = 21) were trained to have therapy clients and their caregivers' complete weekly measures digitally as an integrated part of standard care. All clinicians, youth clients, and their parents reported attitudes supporting the utility of youth PROMs and MBC. Compared to adult clients (N = 81), youth clients were significantly less adherent in regularly completing their weekly measures. These results demonstrate the usage of MBC and utility of implementing this practice for youth clients in a training clinic. Together, there is a need for improving the specificity of training for clinicians who will administer MBC for youth above and beyond what is indicated for adult clients.

Talking 'Bout Better outcomes for Adolescent Depression: Youth and Caregiver Perspectives on an Integrated Care Pathway for Depression

BACKGROUND

Depression is a common condition among adolescents, with rates continuing to rise. A gap exists between evidence-based recommendations for the treatment of depression and clinical practice. Integrated Care Pathways (ICPs) can help address this gap, but to date no study has examined how young people and their caregivers experience ICPs and whether these pathways are an acceptable form of care. This study used focus groups with adolescents, caregivers, and service providers to examine experiences of an ICP.

METHODS

Six individual interviews with service providers, four focus groups with youth, and two focus groups with caregivers were completed. Data was analyzed consistent with Braun & Clarke's Thematic Analysis Framework within an interpretivist paradigm.

RESULTS AND CONCLUSION

The study demonstrated that ICPs are acceptable to youth and their caregivers and that ICPs facilitate shared decision making between youth/caregivers and care providers. Findings also indicated that youth are willing to engage with ICPs particularly when there is a trusted clinician involved who helps interpret and tailor the ICP to the young person's experience. Further questions include how to best integrate these into the overall system and how to further tailor these pathways to support youth with diagnostic complexity and treatment resistance.

Therapists' and patients' experiences of using patients' self-reported data in ongoing psychotherapy processes-A systematic review and meta-analysis of qualitative studies

OBJECTIVE

Using patient-generated quantitative data in psychotherapy (feedback) appears to enhance treatment outcome, but there is variability in its effect. Different ways and reasons to implement routine outcome measurement might explain such variability. The goal of this review is to address the insufficient knowledge on how these data are used by therapists and patients.

METHODS

The present study is a systematic review and meta-analysis of qualitative reports of therapists' and patients' experiences using patient-generated quantitative data during ongoing psychotherapy.

RESULTS

Four main categories of use were identified: (1) uses of patients' self-reported data as nomothetic/objective markers for assessment, process monitoring, and treatment planning; (2) intrapersonal uses that enhance self-awareness, initiate reflection, and influence patients' mood or responses; (3) uses that prompt interactional processes by facilitating communication, supporting exploration, creating ownership in patients, changing treatment focus, enhancing therapeutic alliance, or disturbing the psychotherapy process; and (4) patients responding for specific purposes due to uncertainty and interpersonal motives, or strategic responding to achieve a desired result.

CONCLUSION

These results demonstrate that patient-reported data, when used in active psychotherapy, is very clearly not just an objective measurement of client functioning: the inclusion of patient-data has the potential to influence psychotherapy in numerous ways.

Putting measurement-based care into action: A mixed methods study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

Background

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

Methods

We used a quasi pre-post comparison design with mixed methods to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

Results

People who received a personalized feedback report reported significant improvements in shared decision-making and had greater improvements over time in their intent to attend future treatment sessions. They engaged in more sessions for Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

Conclusions

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase engagement in psychosocial interventions. We posit that this process facilitates strengths-focused discussions, enhances intrinsic motivation, and strengthens the therapeutic alliance.

Perceptions of mental health providers of the barriers and facilitators of using and engaging youth in digital mental-health-enabled measurement based care

Objectives

Increased rates of mental health disorders and substance use among youth and young adults have increased globally, furthering the strain on an already burdened mental health system. Digital solutions have been proposed as a potential option for the provision of timely mental health services for youth, with little research exploring mental health professional views about using such innovative tools. In Alberta, Canada, we are evaluating the implementation and integration of a digital mental health (dMH) platform into existing service pathways. Within this paper we seek to explore mental health professionals' perceptions of the barriers and facilitators that may influence their utilization of digital MH-enabled measurement-based care (MBC) with the youth who access their services.

Methods

A qualitative, descriptive methodology was used to inductively generate themes from focus groups conducted with mental health professionals from specialized mental health services and primary care networks in Alberta.

Results

As mental health professionals considered the barriers and facilitators of using dMH with youth, they referenced individual and family barriers and facilitators to consider. Providers highlighted perceived barriers, including: first, cultural stigma, family apprehension about mental health care, and parental access to dMH and MBC as deterrents to providers adopting digital platforms in routine care; second, perceptions of increased responsibility and liability for youth in crisis; third, perception that some psychiatric and neurodevelopmental disorders in youth are not amenable to dMH; fourth, professionals contemplated youth readiness to engage with dMH-enabled MBC. Participants also highlighted pertinent facilitators to dMH use, noting: first, the suitability of dMH for youth with mild mental health concerns; second, youth motivated to report their changes in mental health symptoms; and lastly, youth proficiency and preference for dMH options.

Conclusions

By identifying professionals' perceptions of barriers and facilitators for youth users, we may better understand how to address misconceptions about who is eligible and appropriate for dMH through training and education.

Using a Quality Improvement Approach to Implement Measurement-Based Care (MBC) in Outpatient General Psychiatry

BACKGROUND

Measurement-based care (MBC) is the clinical practice of using patient-reported symptom measurement to inform treatment decisions. MBC has been shown to improve patient outcomes and quality of care in outpatient psychiatry. Despite these benefits, MBC is not routinely used in most psychiatric outpatient settings. This quality improvement (QI) project aimed to achieve 75% completion of symptom scales using an online MBC platform in a general psychiatry clinic in Toronto, Canada, by June 2022.

METHODS

The QI team used the Model for Improvement methodology. The main outcome measure was completion of symptom scales using an online MBC platform. Process measures included counts of invitations to join the MBC platform, counts of online MBC account creation, and counts of symptom scale assignment by clinicians. Balancing measures included administrative task completion and physician workload assessment. Stakeholder interviews explored barriers and facilitators to MBC utilization.

RESULTS

Completion of symptom scales increased from 7/65 (10.8%) preintervention to 40/70 (57.1%) during the 26-week intervention. Clinician reminders and coaching clinicians about how to incorporate MBC into the care process facilitated uptake of MBC. Stakeholders identified several barriers to implementation, particularly physician attitudes toward MBC and perceived administrative burden.

CONCLUSION

Completion of symptom scales increased over the course of this QI initiative. Successful implementation of MBC in general psychiatry outpatient settings requires the availability of a broad range of measurement scales given the diversity of mental health diagnoses. Implementation must also consider health equity, including access to technology and availability of symptom scales in multiple languages.

Measurement-based care for suicidal youth: Outcomes and recommendations from the Services for Teens At Risk (STAR) Center

Measurement-based care has demonstrable benefits, but significant implementation barriers slow dissemination in real-world clinical settings, especially youth behavioral health care. Here, we describe use of measurement-based care in a specialty clinic offering a continuum of outpatient care for suicidal youth. We characterize strategies used to facilitate measurement-based care in this population and ways in which challenges to implementation have been addressed. We examined adherence to measurement-based care procedures relative to treatment engagement data from electronic medical records, as well as data from clinicians regarding acceptability and utility of measurement-based care. Results suggest that measurement-based care is both feasible and acceptable for use with suicidal youth. Here we provide future directions in measurement-based care in this, and other, behavioral health settings.

Educating Mental Health Trainees About Measurement-Based Care: A Scoping Review

OBJECTIVE

Measurement-based care (MBC) refers to the routine use of symptom rating scales to guide treatment decisions. Although effective, it is an underused approach to enhance patient care. A significant barrier to integration of MBC is insubstantial foundational training. This scoping review aims to survey the literature on MBC educational curricula for mental health trainees.

METHODS

Investigators searched Ovid Medline, PsycINFO, Embase, Cochrane Central, and Ebsco CINAHL through June 2021 to select records that described studies of MBC educational programs for undergraduate, graduate, or postgraduate learners in mental healthcare.

RESULTS

From 1270 unique records, 1263 were excluded in abstract/title and full-text screening. This scoping review included seven articles, of which most were empirical or case studies and took place in the USA. These curricula involved many delivery formats, including lectures and in-service training. Measured learner outcomes include those that are learner-focused (i.e. learner reaction, or attitudinal/behavioral change) and organizational-focused (i.e. increased clinical use of MBC). Mechanisms of positive outcomes are posited to include enhanced stakeholder support and continual curriculum improvement.

CONCLUSIONS

MBC curricula can be taught in various formats to diverse learners in mental healthcare. Contextual factors, such as dedicated resources, MBC champions, supervisor training, online measurement feedback systems, simple measures, and gathering and disseminating feedback may facilitate curricular success by fostering stakeholder support and continual program improvement. To address literature gaps, future research in MBC education should involve educational frameworks in designing curriculum and address the use of quality improvement approaches in the implementation of MBC education.

Barriers and facilitators to technology-enhanced measurement based care for depression among Canadian clinicians and patients: Results of an online survey

BACKGROUND

Measurement-based care (MBC) is an evidence-based approach that can improve management of depression, but its use in clinical settings remains low. The use of digital technology, or technology-enhanced MBC (eMBC), may address some of the barriers to implementation of MBC by enabling patients to easily complete outcome assessments. This study aims to identify the perceived facilitators and barriers to MBC and eMBC from both patient and provider perspectives in Canada.

METHODS

The study recruited 108 clinicians and 131 patients with a self-reported diagnosis of depression to participate in an online survey about the acceptability of both MBC and eMBC.

RESULTS

Most clinicians (90/108, 83.3 %) agreed that MBC is important for clinical judgement, and felt trained to interpret their scores; however, only 43/108 (39.8 %) use MBC routinely. Clinicians (95/108, 88.0 %) felt they would be more likely to use MBC if it was automated and available to use electronically. Most patients (117/131, 89.3 %) felt MBC would be helpful for their treatment and were willing to use a mobile app to track their symptoms.

LIMITATIONS

Recruitment was done online and, hence, this study may not capture the perspective of patients who are not already familiar with using online programs to complete questionnaires.

CONCLUSIONS

Clinicians and patients in Canada would be willing to utilize MBC and eMBC in their psychiatric care, but barriers to implementation include perceptions about efficiency, ease of use, and accessibility. These results highlight the importance of engaging both clinicians and patients to effectively implement MBC and eMBC for depression.

Factor Structure of the Brief Addiction Monitor in a Non-Veteran Substance Use Disorder Outpatient Treatment Sample

Background

The Brief Addiction Monitor (BAM) was developed as a comprehensive substance use disorder (SUD) outcome metric to fill a gap in quality measurement. Research to date has only examined the psychometric performance of this measure in veteran SUD populations. The purpose of the current research is to examine the factor structure and validity in a non-veteran SUD population.

Methods

Non-veteran patients admitted to a SUD treatment program (N = 2,227) completed BAM at intake. After confirmatory factor analysis (CFA) was performed to evaluate the measurement model validity of previously defined latent structures, exploratory factor analysis (EFA) was used to assess the factor structure and psychometric properties of the BAM within the full sample and within subgroups, specifically racial, referral source (mandated vs. not), and primary SUD diagnosis.

Results

Exploratory factor analyses in the full sample supported a 4-factor model (representing Stressors, Alcohol Use, Risk Factors, and Protective Factors) derived from 13 items. Subsequent EFAs conducted separately in each subgroup revealed variability in the number of resulting factors and pattern matrices. The internal consistency also varied among factors and between subgroups; in general, reliability was greatest for the Alcohol Use scale and either poor or questionable for pattern matrices resulting in scales reflecting Risk or Protective Factors.

Conclusion

Findings from our study suggest that the BAM might not be a reliable and valid instrument for all populations. More research is needed to develop and validate tools that are clinically meaningful and allow clinicians to track recovery progress over time.

The Implementation of Measurement-Based Care in the Context of Telemedicine: Qualitative Study

BACKGROUND

The Measurement Based Care in Mental Health Initiative launched by the Department of Veterans Affairs in 2016 is an example of an evidence-based practice that uses patient-reported outcome measures (PROMs) to improve patient outcomes. The acceptance of measurement-based care (MBC) among Veterans Affairs providers is relatively high. However, there are barriers to MBC for telehealth providers. Health information technologies might afford opportunities to address some of the barriers related to the uptake of MBC.

OBJECTIVE

This paper reports on an implementation effort to integrate MBC into mental health care telehealth practice using eHealth solutions.

METHODS

Qualitative data were generated from 22 semistructured interviews with psychiatrists (n=4), psychologists (n=3), social workers (n=3), nurses (n=6), a pharmacist (n=1), and administrative staff (n=5) who provide telemental health care through a community-based outpatient clinic in the rural Midwestern United States. The interviews were conducted during the pilot phase of an implementation initiative to increase the adoption of MBC by revising clinic workflows to integrate the use of eHealth technologies. Data were analyzed using thematic analysis.

RESULTS

Time burden and workflow issues were the most common barrier to provider adoption of MBC; sharing and reviewing pencil-and-paper measures and results in the same room was no longer possible in novel telehealth workflows necessitated by the COVID-19 pandemic. Providers voiced concerns about how long it would take to collect, adequately score, interpret, share, and document the PROMs during the telehealth visit. Concerns about time might also correspond to a gap in providers' familiarity with these assessments, greater comfort in assessing symptoms through clinical interviews, and being accustomed to using the assessments as screening tools more so than longitudinal outcome measures. Capacities associated with eHealth technologies may address workflow concerns and promote providers' understanding and use of the measures as tracking tools.

CONCLUSIONS

The need to use limited appointment time well was a top priority for telemental health providers. eHealth technologies provided operative supports that protect time in appointments by shifting when and how PROMs are collected. Bolstering providers' familiarity with how to use PROMs in the course of treatment may impact providers' buy-in by encouraging them to reconsider how sharing and acting on PROMs could be time well spent.

Conceptualising fairness: three pillars for medical algorithms and health equity

OBJECTIVES

Fairness is a core concept meant to grapple with different forms of discrimination and bias that emerge with advances in Artificial Intelligence (eg, machine learning, ML). Yet, claims to fairness in ML discourses are often vague and contradictory. The response to these issues within the scientific community has been technocratic. Studies either measure (mathematically) competing definitions of fairness, and/or recommend a range of governance tools (eg, fairness checklists or guiding principles). To advance efforts to operationalise fairness in medicine, we synthesised a broad range of literature.

METHODS

We conducted an environmental scan of English language literature on fairness from 1960-July 31, 2021. Electronic databases Medline, PubMed and Google Scholar were searched, supplemented by additional hand searches. Data from 213 selected publications were analysed using rapid framework analysis. Search and analysis were completed in two rounds: to explore previously identified issues (a priori), as well as those emerging from the analysis (de novo).

RESULTS

Our synthesis identified 'Three Pillars for Fairness': transparency, impartiality and inclusion. We draw on these insights to propose a multidimensional conceptual framework to guide empirical research on the operationalisation of fairness in healthcare.

DISCUSSION

We apply the conceptual framework generated by our synthesis to risk assessment in psychiatry as a case study. We argue that any claim to fairness must reflect critical assessment and ongoing social and political deliberation around these three pillars with a range of stakeholders, including patients.

CONCLUSION

We conclude by outlining areas for further research that would bolster ongoing commitments to fairness and health equity in healthcare.