Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care for Depression

1. Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care for Depression Experiences from the South-German QA project and the German Competence Network on Depression Martin Härter and Petra Sitta Stuttgart, 15.03. 2002

2. Regulations for QI SGB V § 135a (Abs. 1), 2000 Care providers have an obligation for quality assurance and improvement along standards of evidence based medicine. SGB V § 135a (Abs. 2) Health care providers are obligated toparticipate in external quality assurance measures, especially if improvement of outcome quality is intended. SGB V § 135a (Abs. 2) Hospitals and other health institutions should implement and improve internal quality management, that guarantees the quality of care by a system of precise procedures and systematic measures and helps to improve it continuously.

3. Quality Management Projects in Psychiatry and Psychotherapy I. Development of Inpatient Documentation Form (BADO) 1993 II. Quality Circles in Outpatient Care 1995 III. External Quality Assurance (Tracer Diagnoses) a) Depression (Baden-Württemberg) b) Schizophrenia (North Rhine Westphalia) 1997 IV. Improvement of Inpatient Quality Management 1998 V. Development of Guidelines (schizophrenia, affective disorders etc.) 1999 VI. Competence Networks a) Schizophrenia b) Depression c) Substance abuse d) Dementia 2000

4. Quality Assurance in Depression- Background - „Quality Assurance in Inpatient Treatment of Depression in Baden-Württemberg“ (Study Period: 1998-2000) Work Group: Dr. R. Metzger, Bad Schussenried (speaker since 1997) Prof. Dr. R.-D. Stieglitz, Basel (2. speaker, 1994-1999) PD Dr. Dr. M. Härter, Freiburg (2. speaker since 2000) Dr. Ch. Hornstein, Wiesloch PD Dr. F. Keller, Ulm Dr. G. Schell, Stuttgart Dipl.-Psych. S. Stabenow, Karlsruhe (1994-1999) Dipl. Psych. W. Wiegand, Zwiefalten Prof. Dr. M. Wolfersdorf, Bayreuth (speaker, 1994-1996) Initiator: Prof. Dr. M. Berger, FreiburgSupport: Landesärztekammer Stuttgart

5. Project 3Quality Management in Treatment of Depression Subprojects 3.5, 3.6 and 3.7 (Study Period: 2000-2004)

6. Aims • Improvement of diagnostic and therapeutic quality • Development of process and outcome quality indicators • Internal quality assurance and external comparison of hospitals (bench marking) • Implementation and evaluation of quality manage-ment structures • Transfer into regular care ?

7. Clinics South German QA project:n = 24 all psychiatric clinics in Baden-Württemberg Competence Network Depression:n = 10 5 clinics in North Rhine Westfalia 5 clinics in Baden-Würrtemberg and Bavaria

8. Quality indicators / Patient Characteristics • Sociodemographiccharacteristics(e.g. age, sex,marital status, level of • education, job situtation, living conditions, mother tongue) • Diagnostics(ICD-10, indication for inpatient treatment, reason for relapse/ disorder, • family history of mental disorder) • Severity of disorder(HAMD, CGI, AMDP, BDI, GAF, attempted suicide, risk to others) • Chronicity of disorder(duration, number of in- and outpatient treatments) Service Profiling Admission • Diagnostics (blood tests, ECG, EEG) • Pharmacotherapy (substance, dosage indication, duration etc.) • Psychotherapy (units of individual or group psychotherapy) • Other treatments (e.g. occupational therapy, music therapy) • Incidents (compliance, problems in psychotherapy, threats, attempted suicide) Process Course of treatment • Therapeutic effectiveness • Change of psychopatholoy (GAF, AMDP, CGI, HAMD, BDI etc.) • Patient satisfaction (ZUF- 8, BBA) • Duration of inpatient treatment • Changes (job situation, personal situation, living conditions etc.) Outcome Discharge

9. Assessment Tools

10. Study design Admission Day 1-3 Process (weekly) Discharge Day X ICD-10 Diagnosis of depressive disorder Yes No Exclusion from the study Patient:BDI Therapist in charge: DOCU-A/ HAMD Change in Diagnosis? Yes Therapist in charge: DOCU-P Patient:BDI, BBA, ZUF-8 Therapist in charge:DOCU-D/ HAMD

11. EXAMPLE

12. Patient Characteristics

13. Indication for inpatient treatment (%) (Multiple choice) Freiburg (2001), n= 383

14. Severity at Admission - CGI (%) Indication correct ?

15. EXAMPLE

16. Diagnostics (Freiburg 2001, n= 401) %

17. Medication 2000 1999

18. Psychotherapy

19. Clinical Global Impression Discharge (%) Problems ?

20. Psychopathology - Beck Depression Inventory Admission Discharge mean (SD) mean (SD) Freiburg 24,7 (11,6) 12,1 (11,1) (2001) N = 210 Baden-Württemberg 27,3 (11,2) 11,1 (9,8) (1999) N= 1587 Baden-Württemberg 25,7 (11,4) 10,7 (9,4) (2000) N= 1157

21. Duration of Inpatient Treatment

22. Evaluation of treatment by patients The most important for me was ....... Baden-Württemberg: n=473, categories >5%; BBA

23. Client Satisfaction Scale: ZUF-8

24. Client Satisfaction Scale: ZUF-8

25. Summary structural quality • indicators fo inpatient treatment • stronger control for indication (inpatient treatment) necessary process quality • comparison of diagnostic procedures (necessity?) • long mean duration of inpatient treatment • remarkable differences in medication and psychotherapy • relevance of psychotherapy for patients outcome quality • high effectiveness for inpatient treatment • relevant percentage of „unchanged“ patients (chronic depression) • high patient satisfaction

26. Quality Management Projects in Psychiatry and Psychotherapy Conclusions: + QA in psychiatry is possible + Attempt to implement QA area-wide / regional + Participation of all psychiatric hospitals in Baden-Württemberg + Development of documentation forms + Development and implementation of the concept of benchmarking - no project evaluation - representativity of data is limited (selection of patients?) - data only at admission and discharge - low establishment of QM-measures in clinics - clinical relevance ? - transfer in regular care ?

27. 3.5/3.6 Time schedule - Main study Step 3 Step 4 Step 5 Step 6 Intervention Baseline Initial Bench- markings Post -intervention treatment/evaluation Training; Involvement of QM-structures, areas of intervention (benchmarking based) Continuous training Ongoing benchmarkings Exp. group: 5 hospitals T0 T1 T2 T0 T1 T2 n=150 pat./hospital n=150 pat./hospital Contr. group: 5 hospitals T0 T1 T2 No intervention T0 T1 T2 n=150 pat./hospital n=150 pat./hospital 2002 2003

28. Quality Management Projects in Psychiatry and Psychotherapy Preliminary Conclusions: + planned total-survey in clinics + reduced and adapted documentation materials + testing the effect of QM-structures - motivation of staff, documentation load for physicians - data for clinical decision making ?

29. Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care for Depression Experiences from the South-German QA project and the German Competence Network on Depression PD Dr. phil. Dr. med. Martin Härter and Petra Sitta, Dipl. Psych. Martin_Haerter@psyallg.ukl.uni-freiburg.de

30. Selected Publications • Härter, M., Vauth, R., Tausch, B. & Berger, M. (1996). Ziele, Inhalt und Evaluation von Trainingsseminaren für Qualitätszirkelmoderatoren. Zeitschrift für ärztliche Fortbildung und Qualitätssicherung, 90, 394-399. • Reuter, K., Mager, A., Härter, M., Kern, I. & Berger, M. (1999). Qualitätszirkel in der stationären Versorgung. Ein Pilotprojekt an der Universitätsklinik Freiburg. In M. Härter, M. Groß-Hardt & M. Berger (Hrsg.), Leitfaden Qualitätszirkel in Psychiatrie und Psychotherapie (S. 91-102). Göttingen: Hogrefe. • Härter, M., Stieglitz, R. & Berger, M. (1999). Qualitätsmanagement in der psychiatrisch-psychotherapeuti-schen Versorgung. In M. Berger (Hrsg.), Psychiatrie und Psychotherapie (S. 1001-1014).München: Urban & Schwarzenberg. • Klimpel, M., Schüpbach, H., Groß-Hardt, M. & Härter, M. (2000). Implementierung von Qualitätszirkeln im Krankenhaus aus arbeits- und organisationspsychologischer Sicht. Gesundheitsökonomie und Qualitäts-management, 5, 157-162. • Härter, M., Bermejo, I., Aschenbrenner, A. & Berger, M. (2001). Analyse und Bewertung aktueller Leitlinien zur Diagnostik und Behandlung depressiver Störungen. Fortschritte der Neurologie und Psychiatrie, 69, 390-401. • Tausch, B. & Härter, M. (2001). Perceived effectiveness of diagnostic and therapeutic guidelines in primary care quality circles. International Journal forQuality in Health Care, 13 (3), 239-246. • Keller, F., Härter, M., Metzger, R., Wiegand, W. & Schell, G. (2001). Prozess- und Ergebnisqualität in der stationären Behandlung ersterkrankter und chronisch depressiver Patienten. Krankenhauspsychiatrie, 12, S50-S56. • Härter, M. & Stieglitz, R.-D. (in Druck). Qualitätsmanagement in Psychiatrie und Psychotherapie. In H.J. Freyberger, R.-D. Stieglitz & W. Schneider (Hrsg.), Kompendium der Psychiatrie, Psychotherapie und Psychosomatischen Medizin. Basel: Karger.