Pushing the quality envelope: a new outcomes management system

This article is based on the authors' experience in designing and implementing outcomes management systems for large managed care organizations. Topics addressed include design of instruments, use of cost-effective technology, development of computerized decision-support tools, and methods for case-mix adjustment. The case-mix-adjustment models are based on a data repository of several thousand treatment cases with multiple measurement points across the course of treatment. Data from controlled and field studies are described. These data suggest that the outcomes management methods outlined in this article can result in significantly improved clinical outcomes and a more rational allocation of behavioral health care resources.

Group psychotherapy training and effectiveness

This study surveyed accredited programs in psychiatry, psychology, and social work, replicating and extending previous work in group training. Results detail the curriculum, group faculty/student participation, and predicted future therapy trends in four different formats of group treatment. The number of group courses in the curriculum, the number required, and the percent of students participating in these courses significantly varies among the three disciplines, indicating a discrepancy among those disciplines responsible for training in group therapy regarding the value and role of group training. Consensus does exist among the disciplines in forecasting that individual therapy will decrease and group treatment will increase, but what programs deliver in their training does not coincide with their predicted trends for group therapy use in the future. Ratings of the differential effectiveness of the four group modalities vs. individual are not consistent with empirical evidence. Results call for consensual clarity, accord of values and knowledge, and the integration of science, training, and practice across the three disciplines.

A survey of mental health care provider's and managed care organization attitudes toward, familiarity with, and use of group interventions

Managed Care has had a significant impact on delivery systems for mental health services. Direct and indirect persuasion to provide more cost-effective treatments has been one consequence. The cost-saving qualities and the effectiveness of group interventions have produced clear expectations for an increased use of therapy groups. This study compared perceptions and uses of group treatments on a national sample of managed care organizations and mental health providers. Because group psychotherapy encompasses such a broad definition, five specific types of group interventions were defined: problem-focused homogenous, process-oriented heterogeneous, psycho-educational, self-help, and short-term groups. Implications of differences and similarities between directors of managed care organizations and treatment providers are examined and discussed across five response categories (familiarity/training, perceived effectiveness, likelihood of reimbursement/referral, daily use, and expectation for future use).

Outcome Questionnaire: item sensitivity to change

Although high levels of reliability are emphasized in the construction of many measures of psychological traits, tests that are intended to measure patient change following psychotherapy need to emphasize sensitivity to change as a central and primary property. This study proposes 2 criteria for evaluating the degree to which an item on a test is sensitive to change: (a) that an item changes in the theoretically proposed direction following an intervention and (b) that the change measured on an item is significantly greater in treated than in untreated individuals. Outcome Questionnaire (Lambert et al., 1996) items were subjected to item analysis by examining change rates in 284 untreated control participants and in 1,176 individuals undergoing psychotherapy. Results analyzed through multilevel or hierarchical linear modeling suggest the majority of items on this frequently used measure of psychotherapy outcome meet both criteria. Implications for test development and future research are discussed.

Meta-analysis of medical self-help groups

Self-help groups (SHGs) may rival all other forms of treatment sometime within the next century (see Goodman & Jacobs article in "The Handbook of Group Psychotherapy," Wiley, 1994), though the "purist" model of SHGs seems inaccurate because many professionals are actually involved. Although traditional forms of group treatment have kept pace with empirical research (Fuhriman & Burlingame, "The Handbook of Group Psychotherapy," 1994), SHGs have not. In particular, medical SHGs, often promoted by hospitals as viable treatment alternatives, have no systemized database from which to draw conclusions about overall effectiveness compared to traditional group therapies. A preliminary assessment of this area is presented using a meta-analysis of articles culled from a comprehensive review of the literature from 1970 to 1997. Results indicate that although the posttreatment analysis produced no significant differences between active and control conditions, pre to posttreatment scores indicated that SHGs produced higher patient improvement when compared to the control condition. Future implications for research and use of medical SHGs are explored.

Pragmatics of tracking mental health outcomes in a managed care setting

Accountability, cost effectiveness, and continuous quality improvement are essential features of all managed health care systems. However, application of these principles to mental health treatments has lagged behind other health care services. In this article, administrative, practice, and technical issues are addressed through a joint effort between academically based researchers and administrators from two large managed health care organizations. Principles related to the measurement of outcome, instrument selection, and obstacles to the implementation of an ongoing program to assess mental health treatment outcomes are identified. Finally, principles for successfully changing mental health provider behavior toward outcome assessment and the implications of such for mental health delivery systems are discussed.

Reading disability subtypes and the test of memory and learning

For Study 1, 24 readers with dysphonetic dyslexia and 21 with dyseidetic dyslexia, classified by Boder criteria, were compared to 90 control group participants (45 matched for age and 45 for reading level) on the Composite Memory Index (CMI) score from the Test of Memory and Learning (TOMAL). CMI scores were significantly lower for children with dyslexia (p <.0001). Plotting average subtest score profiles for all reader groups revealed auditory sequential memory impairments for both types of readers with dyslexia, and multiple strengths for good readers. Dysphonetic and dyseidetic dyslexia profiles were nearly identical. For Study 2, average linkage cluster analysis was performed using principal components derived from subtests of the TOMAL. Homogeneous clusters of normal readers and children with reading disabilities emerged. Results indicated that qualitatively distinct subtypes of readers with dyslexia exist.

Evaluating the effectiveness of child and adolescent group treatment: a meta-analytic review

Utilizing 56 outcome studies published between 1974 and 1997, this meta-analysis specifically examines the effect of group treatment with children and adolescents (ages 4-18). Various types of group treatment were assessed, including preventative programs, psychotherapy, counseling, guidance, and training groups. Results indicate that group treatment was significantly more effective for children than wait-list and placebo control groups (effect size = .61). That is, the average child or adolescent treated by group treatment is better off than 73% of those in control groups. This meta-analysis strengthens and supports conclusions in the current literature and challenges others regarding the treatment of children and adolescents by group treatment. For instance, allegiance of the experimenter, setting of the therapy, socioeconomic status of the patient, and publication year of the study were variables that were significantly related to improvement, whereas diagnosis, content and source of the outcome measure were unrelated to improvement.

Outcome and process differences between professional and nonprofessional therapists in time-limited group psychotherapy

The outcome of clients who saw one of four "expert" professional group therapists selected by peer nomination or four "natural helper" nonprofessional nominated by students is contrasted in a 15-session psychotherapy group. Process measures tapping specific group and "common factors" were drawn from sessions 3, 8, and 14; outcome was assessed at pre, mid, posttreatment, and a 6-month follow-up. Results were examined by leader condition (professional vs. nonprofessional therapists) and time (group development). Virtually no reliable differences were found on measures of outcome primarily because of a floor effect on several measures. Therapist differences on the process measures tapping the "common factors" of therapeutic alliance, client expectancy, and perception of therapists were either nonsignificant or disappeared by the end of treatment. A complex picture of differences on one therapeutic factor (insight), common factor measures and subtle variation in the outcome data suggests a distinct pattern of change, however. Methodological limitations are also addressed including problems inherent in large-scale clinical-trial studies, ethical concerns raised by using nonprofessional leaders, and problems with generalizability, given the absence of significant psychopathology in group members.