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					       Information feedback in inpatient
                   psychotherapy:

    How is it received by the clinical team and what
                     does it effect?



             Stephanie Bauer & Hans Kordy
     Center for Psychotherapy Research, Stuttgart



Expert Workshop on Quality Management and Outcome Monitoring
                  Stuttgart, March 16th 2002
                    Background

2 possible forms of feedback in quality management


(1) Feedback on therapy outcome

(2) Feedback during the course of therapy
                     Background

(1) Feedback on therapy outcome

•   Discussion of therapy outcome with the thera-
    peutic team after discharge

•   identification of potential shortcomings after
    discharge
•   no direct relevance for the discussed treatment
•   no possibility to avoid shortcomings
•   reduced willingness and motivation of therapists
                         Background
•   assumption that present systems have positive
    effects on future treatments, i.e. long term effects
    (learning from mistakes)
•   no empirical support for that assumption
•   Experts demand to put growing emphasis on the
    “quality assurance of quality assurance”
    (“Sachverständigenrat für die Konzertierte Aktion im
    Gesundheitswesen” 2000/01).

•   the development of every new quality management
    system should be attended by evaluation studies
•   demonstration of the effectiveness prior to the
    implementation in the clinical routine
                     Background

Implication

• to give relevant information to the clinicians during
  treatment.

• Assumptions: - better acceptance by clinicians
               - (more) effects on outcome
                       Background

(2) Feedback during therapy


 •    Discussion after the first period of therapy with
      the therapeutic team

     a) feedback on status and changes since admission
     b) information on the expected outcome
                      Questions

(1) Acceptance of (different forms of) feedback?


(2) Do different forms of feedback effect therapy
    outcome?


(3) Do different forms of feedback effect duration of
    treatment?
                        Design


•   context of routine quality management in a clinic
    for psychosomatics and psychotherapy

•   12 therapeutic teams (4 –10 persons)

•   data collection since Jan 2000:
    4 - 10 quality management sessions per team
                    Questionnaires

(1) Patients perspective


  admission            4 weeks         discharge

• Scl-90-R          • EB-45          • Scl-90-R
• EB-45             • GBB            • EB-45
• GBB               • HAQ            • GBB
• IIP               • Rating of      • IIP
• LQ                  changes        • LQ
• HAQ                                • HAQ
                                     • Rating of
                                       changes
                         Questionnaires

(2) Therapists perspective

 • Diagnosis (ICD-10)
 • Impairment Score IS
 • HAQ
 • Rating of changes
                        Design

Phase 1: Baseline

•   data collection at admission, after four weeks, and
    at discharge

•   no feedback
                        Design

Phase 2: Feedback after discharge

•   information on status at admission, status at
    discharge, and changes
•   evaluation of treatment outcome according to the
    algorithm of the Stuttgart-Heidelberg model
•   Quality circles: discussion of treatments with the
    therapeutic team after discharge
Overview and evaluation of treatment outcome                                                                                                               Patient: 111033992032

                            BSS       LQ      GBB      SCL 1 SCL 2 SCL 3 SCL 4 SCL 5 SCL 6 SCL 7 SCL 8 SCL 9 GSI                IIP 1   IIP 2   IIP 3   IIP 4   IIP 5      IIP 6   IIP 7   IIP 8

Admission                         3   23        37,0    0,3      0,8    1,6   0,9    0,3    0,7    0,1       2,0   0,4    0,8    18,0    19,0    19,0    17,0       22,0    22,0    20,0    19,0

Discharge                         3   40        51,0    1,5      2,4    2,3   2,0    1,3    1,3    0,6       1,5   1,4    1,6    14,0    11,0    20,0    23,0       20,0    21,0    18,0    15,0

 Mean / Cutoff score
                                  5   28        15,7    0,4      0,5    0,4   0,4    0,3    0,3    0,1       0,4   0,2    0,3    8,8     9,6     9,6     10,1       11,5    11,6    12,3    9,8

 Standard Deviation               0   0         13,3    0,3      0,4    0,4   0,4    0,3    0,3    0,2       0,4   0,2    0,3    5,2     5,4     5,4     5,8        6,0     5,3     4,9     4,9

                                                                         Diagnosis (ICD-10): F 43.21
                                                                         (discharge)         F 60.7
 Variables                                                               Evaluation of outcome:     alarm signal
                                                                                                   - at least as many negative as positive changes
 BSS: Impairmentscore                                                                              - more than 30% negative changes
 THE: Therapists‘ rating of changes
 PAE: Patients‘ rating of changes
 LQ: Quality of life
                                                                                                                                  •
                                                                              •
                                                                       BSS
 GBB: Giessener Beschwerdebogen            (physical symptoms)


                                                                                                       •
                                                                       LQ
 SCL-90-R Scale 1: Somatization                                        GBB
 SCL-90-R Scale 2: Obsessive-compulsive                                SCL1   •
 SCL-90-R Scale 3: Sensitivity                                         SCL2
                                                                       SCL3
                                                                              •                        •                                                        •
                                                                                                       •
 SCL-90-R Scale 4: Depression
 SCL-90-R Scale 5: General Anxiety                                     SCL4
                                                                       SCL5
                                                                                                                                                                •
 SCL-90-R Scale 6: Hostility
                                                                       SCL6
                                                                                                       •
 SCL-90-R Scale 7: Phobic Anxiety
                                                                       SCL7
                                                                                                       •
 SCL-90-R Scale 8: Paranoid Ideation
                                                                       SCL8
                                                                                                                                                                •
 SCL-90-R Scale 9: Psychotizism
                                                                       SCL9
                                                                                                                                 •
 SCL-90-R Scale GSI: General Severity Index
                                                                       GSI
 IIP Scale 1: overly autocratic
                                                                       IIP1
                                                                                                                                                                •
 IIP Scale 2: overly competitve
                                                                       IIP2
                                                                                                                                 •
 IIP Scale 3: overly cold
                                                                       IIP3
                                                                                                       •
 IIP Scale 4: overly introverted                                       IIP4
                                                                                                       •
 IIP Scale 5: overly subassertive
 IIP Scale 6: overly exploitable
                                                                       IIP5
                                                                       IIP6
                                                                                                                                 •                              •
 IIP Scale 7: overly nuturant                                          IIP7
                                                                                                                                                                •
 IIP Scale 8: overly expressive                                        IIP8
                                                                              --                         -                       •0                             +                             ++
Information of treatment Admission - Discharge                sex: male                         age: 46      Patient: 111033992032




       Duration of treatment:                 98 days

       Individual therapy:                    5.8 (hours)

       Additional therapies:                  1.5 (hours) Atemtherapie




       Helping Alliance                            admission                   discharge

                                    patient               2.1                          0.8

                                    therapist             -0.6                        -0.3

                                                       -3 ....................................... +3
                                                     low                                         high




       Patient Satisfaction                                            24.0
                                             8 ..................................................... 32
                 (median = 27)           unsatisfied                                             satisfied




       Comment of the patient                   Improvement: insight that there‘s no way without sports

                                                Deterioration: weight
                         Design

Phase 3: Feedback after 4 weeks of treatment

 •   information on status at admission, status after 4
     weeks, and changes
 •   evaluation of changes since admission according
     to the algorithm of the Stuttgart-Heidelberg model
 •   Quality circles: discussion of the first month of
     treatment
 •   feedback in written form between the quality
     management sessions
                                                                               Patient: 119019209.01
                                   GBB           SD                 IR        SR            TO

   admission                       28.0         62.0               22.0       27.0         111.0

   after 4 weeks                   25.0         49.0               11.0       20.0          80.0

   mean / cutoff                   15.7         25.4               10.2       9.6           45.2

   standard deviation              13.3         11.6                5.6       3.9           18.6

                                     Diagnosis (ICD-10):       F 61.0
                                     (admission)               F 32.1
                                     Evaluation of change: very good course



Variables

PAE: Patients„ rating of changes     GBB                                  •
GBB: Giessener Beschwerdebogen       SD                                              •
SD: symptom distress                 IR
                                                                                                    •
IR: interpersonal relations          SR                                              •
SR: social role

TO: total score OQ-45
                                     TO
                                           --              -              0
                                                                                     •
                                                                                     +             ++
                        Design

Phase 4: Feedback and prognosis after 4 weeks

•   information on status at admission, status after 4
    weeks, and changes
•   prognostic information on the expected treatment
    outcome
•   Quality circles: discussion of the first month of
    treatment and the expected outcome
•   feedback in written form between the quality
    management sessions
 Phase 1:   Jan 00 – Dec 00
            n = 209
            evaluation n = 151


Phase 2:    Jan 01 – Jul 01
            n = 130
            evaluation n = 90
            feedback n = 84


Phase 3:    Aug 01 – May 02
            n = 132
            evaluation n = 110
            feedback n = 93

Phase 4:    Jun 02 – Dec 02
  Acceptance of feedback in phase 2
(feedback after discharge) and phase 3
       (feedback after 4 weeks)
    Accetance of feedback after discharge (phase 2)

•   in 84% the therapists agree with the feedback

       - in good / very good outcomes: 92%

       - in signal case outcomes: 71%
    Accetance of feedback after 4 weeks (phase 3)

•   in 83% the therapists agree with the feedback

       - in good / very good courses (n = 24): 71%

       - in signal cases (n = 40): 90%
     Accetance of feedback after 4 weeks (phase 3)

Does this feedback contain relevant information?


  not at all       5%


       few                               34%


     much                                      41%


very much                     20%
     Accetance of feedback after 4 weeks (phase 3)

Can you use this information for further treatment?



 not at all                14%


    a little                                31%

    much                                              41%


very much                  14%
                       Summary

•   high acceptance for both forms of feedback

•   after discharge: higher acceptance for no signal
    feedback

•   after 4 weeks: higher acceptance for signal
    feedback

•   feedback after 4 weeks is considered as relevant
    and useful for further treatment in more than 50%
    of the treatments
Comparison of phase 1 (no feedback) and
  phase 2 (feedback after discharge)

  •   signal case rate
  •   duration of treatment
  •   patients„ impairment
            Comparison phase 1 - phase 2
Signal case rate


 phase 1                                   36.7%


 phase 2                                   37.8%

           0       10   20     30     40       50
             Comparison phase 1 - phase 2
Duration of treatment (days)
 300

 250

 200


 150

 100


 50




            phase 1               phase 2
       mean = 121.2 (59.1)   mean = 127.2 (52.6)
           Comparison phase 1 - phase 2
Psychological impairment (therapists perspective)
12

10

8

6

4

2

0




        phase 1            phase 2         admission
                                           discharge
           Comparison phase 1 - phase 2
Psychological impairment (SCL-90-R, GSI)


3


2


1


0




        phase 1           phase 2          admission
                                           discharge
           Comparison phase 1 - phase 2
Psychological impairment (OQ-45)


140

120

100

80

60

40

20

 0



        phase 1                    phase 2   admission
                                              4 weeks
                                             discharge
           Comparison phase 1 - phase 2
Physical impairment
100


80


60


40


20


 0

        phase 1                phase 2    admission
                                          4 weeks
                                          discharge
                       Summary

•   no differences in duration of treatment between the
    “no feedback” and the “feedback after discharge”
    group

•   no differences in patients‟ impairment and signal
    case rate between the “no feedback” and the
    “feedback after discharge” group
Prognostic feedback after
  4 weeks of treatment
                  Prognostic Feedback
Condititon

• Relationship between alarm signals after 4 weeks
  and after discharge

• Identification of early indicators of further course
  and therapy outcome

• i.e. initial status and/or status after the first period
  of therapy and/or the changes between both must
  be related to further course or outcome
    Relationship 4-weeks and outcome evaluation

Rate of signal cases after discharge : 36%      (N = 298)
Rate of signal cases after 4 weeks : 54%

                             discharge
                    signal          no signal


                    44.1%           55.9%
           signal

 4 weeks

      no signal     24.8%           75.2%
   Relationship 4-weeks and outcome evaluation
Psychological impairment (therapists perspective)




                                            admission
       signal             no signal          discharge
    Relationship 4-weeks and outcome evaluation
Psychological impairment (SCL-90-R, GSI)


3




2




1



0
                                           admission
       signal             no signal         discharge
      Relationship 4-weeks and outcome evaluation
Psychological impairment (OQ-45)

140

120

100

80


60


40

20                                           admission
                                             4 weeks
 0
         signal           no signal           discharge
      Relationship 4-weeks and outcome evaluation
Physical impairment

100


80


60


40


20
                                            admission
 0                                          4 weeks
         signal
          signal          no signal          discharge
                         Summary

•   higher risk for signal cases after 4 weeks to be signal
    cases at discharge
•   signal cases after 4 weeks finish therapy in a worse
    state than the nonsignal cases (from patients‟ and
    therapists‟ perspective)
•   both groups show positive course in the second part of
    therapy, especially those evaluated as “signal” after 4
    weeks
•   patients status after 4 weeks seems to be the relevant
    information
•   negative correlation between change 1 (admission to 4
    weeks) and 2 (4 weeks to discharge)
                Chances and limitations

•   Feedback during therapy opens up a good
    opportunity to get into discussion with the clinical
    team
•   computerized data assessment will allow
    immediate feedback
•   probably limited possibility to guide decisions (e.g.
    concerning the length of treatment)

				
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