Measuring outcomes in adult outpatient psychiatry.

Despite growing pressure for accountability, mental health professionals continue to debate the value of routinely measuring treatment outcomes. This paper sought to move the outcomes measurement debate forward by reviewing some of the current limitations in outcomes methodology and by providing initial strategies to address them. Using these strategies, we evaluated outcomes for a large diagnostically diverse group of adult outpatients receiving treatment as usual (TAU) within an academic medical centre. Initial self-report and clinician-rated assessments were obtained from 5546 patients, and follow-up data were obtained from 1572 (28%) patients. Using the subset of patients with the follow-up data, we determined treatment effect sizes, rates of reliable improvement (and deterioration) and rates of clinically significant improvement for all patients and for specific diagnostic groups (depression, anxiety, substance abuse, mood disorders not otherwise specified, bipolar and psychotic conditions). TAU outcomes for depression and anxiety were also compared with benchmarks derived from the randomized controlled trial literature. Lastly, the impact of patient or sample characteristics on outcome was explored. Overall, these findings generally support the benefit of TAU over no treatment while also highlighting both the utility and limitations inherent in the current approaches to evaluating treatment outcomes. Suggestions for improving outcomes measurement are provided.

Benefits of an Outpatient Psychiatric TeleConsultation Unit: Results of a 1-Year Pilot.

BACKGROUND: A Psychiatric TeleConsultation Unit (PTCU) was created at the Massachusetts General Hospital (MGH) in response to critical changes in the health care delivery system. The PTCU's design was based on an understanding of the needs of primary care physicians (PCPs) at MGH, as derived from PCPs' responses to a survey and at focus groups. The PTCU was designed to supply psychiatric expertise to PCPs on a "1 phone call away" basis and to assist the MGH in supporting an increasingly large network of PCPs by expanding access to the MGH's psychiatric staff and services. METHOD: Open Monday through Friday, 9 a.m. to 5 p.m., the PTCU provided PCPs with immediate telephone access to a staff psychiatrist who answered diagnostic- and treatment-related questions, often while the patient was still in the PCP's office. If a referral for mental health services was required, the PTCU facilitated this using an electronic mail (e-mail)-based referral system. Data were gathered from April 1996 to April 1997. RESULTS: During its first year of operation, the PTCU served 107 PCPs and their 46,377 patients; its projected capacity was 470,000 patients. It provided 595 teleconsultations; half were primarily directed toward making a referral, one fourth were primarily directed toward diagnosis or treatment, and one fourth were for both referral- and diagnosis- or treatment-related reasons. 361 patients were referred via e-mail distribution lists to a network of 92 clinicians. In 72 teleconsultations (12%), referral for mental health services was prevented. The estimated savings from these prevented services far exceeded the PTCU's costs of providing all 595 teleconsultations. Projected yearly savings for the PTCU at full capacity were projected at $379,080, from prevented referrals for mental health services. Follow-up semistructured interviews of the first 81 PCP callers revealed that 71% were "extremely satisfied," 18% were "very satisfied," and only 2% were "not at all satisfied" with the PTCU. PCPs reported that the PTCU saved them time in 85% of teleconsultations. Teleconsultations related to diagnosis or treatment changed the PCP's diagnosis 20% of the time and changed the PCP's treatment plan in nearly two thirds of cases. Twenty percent of the teleconsultations were done while the patient was in the PCP's office. Ninety-four percent of the PCPs enthusiastically said they would use the PTCU again. CONCLUSION: Our PTCU increased the efficiency and efficacy of care provided by PCPs. Cost savings associated with a reduced frequency of unnecessary referrals were more than the costs of the PTCU in a capitated health care system.