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Information feedback in inpatient psychotherapy: How is it received by the clinical team and what does it effect?

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.

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Information feedback in inpatient psychotherapy: How is it received by the clinical team and what does it effect?

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  1. 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

  2. Background 2 possible forms of feedback in quality management (1) Feedback on therapy outcome (2) Feedback during the course of therapy

  3. 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

  4. 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

  5. Background Implication • to give relevant information to the clinicians during treatment. • Assumptions: - better acceptance by clinicians • - (more) effects on outcome

  6. 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

  7. 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?

  8. 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

  9. Questionnaires (1) Patients perspective admission 4 weeks discharge • Scl-90-R • EB-45 • GBB • IIP • LQ • HAQ • EB-45 • GBB • HAQ • Rating of changes • Scl-90-R • EB-45 • GBB • IIP • LQ • HAQ • Rating of changes

  10. Questionnaires (2) Therapists perspective • Diagnosis (ICD-10) • Impairment Score IS • HAQ • Rating of changes

  11. Design Phase 1: Baseline • data collection at admission, after four weeks, and at discharge • no feedback

  12. 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

  13. 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 Standard Deviation 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 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 Evaluation of outcome: alarm signal - at least as many negative as positive changes - more than 30% negative changes Variables BSS: Impairmentscore THE: Therapists‘ rating of changes PAE: Patients‘ rating of changes LQ: Quality of life GBB: Giessener Beschwerdebogen (physical symptoms) SCL-90-R Scale 1: Somatization SCL-90-R Scale 2: Obsessive-compulsive SCL-90-R Scale 3: Sensitivity SCL-90-R Scale 4: Depression SCL-90-R Scale 5: General Anxiety SCL-90-R Scale 6: Hostility SCL-90-R Scale 7: Phobic Anxiety SCL-90-R Scale 8: Paranoid Ideation SCL-90-R Scale 9: Psychotizism SCL-90-R Scale GSI: General Severity Index IIP Scale 1: overly autocratic IIP Scale 2: overly competitve IIP Scale 3: overly cold IIP Scale 4: overly introverted IIP Scale 5: overly subassertive IIP Scale 6: overly exploitable IIP Scale 7: overly nuturant IIP Scale 8: overly expressive BSS LQ GBB SCL1 SCL2 SCL3 SCL4 SCL5 SCL6 SCL7 SCL8 SCL9 GSI IIP1 IIP2 IIP3 IIP4 IIP5 IIP6 IIP7 IIP8 • • • • • • • • • • • • • • • • • • • • • - - - + ++ 0

  14. 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 (median = 27) 24.0 8 ..................................................... 32 unsatisfied satisfied Comment of the patient Improvement: insight that there‘s no way without sports Deterioration: weight

  15. 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

  16. Patient: 119019209.01 GBB SD IR SR TO 28.0 62.0 22.0 admission 27.0 111.0 25.0 49.0 after 4 weeks 11.0 20.0 80.0 15.7 25.4 9.6 mean / cutoff 10.2 45.2 11.6 standard deviation 13.3 5.6 3.9 18.6 Diagnosis (ICD-10): F 61.0 (admission) F 32.1 Evaluation of change: very good course Variables GBB SD IR SR TO • PAE: Patients‘ rating of changes GBB: Giessener Beschwerdebogen SD: symptom distress IR: interpersonal relations SR: social role TO: total score OQ-45 • • • -- - • + ++ 0

  17. 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

  18. 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

  19. Acceptance of feedback in phase 2 (feedback after discharge) and phase 3 (feedback after 4 weeks)

  20. 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%

  21. 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%

  22. Accetance of feedback after 4 weeks (phase 3) Does this feedback contain relevant information? 5% 34% 41% 20%

  23. Accetance of feedback after 4 weeks (phase 3) Can you use this information for further treatment? 14% 31% 41% 14%

  24. 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

  25. Comparison of phase 1 (no feedback) and • phase 2 (feedback after discharge) • signal case rate • duration of treatment • patients‘ impairment

  26. Comparison phase 1 - phase 2 Signal case rate phase 1 36.7% 37.8% phase 2

  27. Comparison phase 1 - phase 2 Duration of treatment (days) 300 250 200 150 100 50 phase 1 mean = 121.2 (59.1) phase 2 mean = 127.2 (52.6)

  28. Comparison phase 1 - phase 2 Psychological impairment (therapists perspective) 12 10 8 6 4 2 0 phase 1 phase 2 admission discharge

  29. Comparison phase 1 - phase 2 Psychological impairment (SCL-90-R, GSI) 3 2 1 0 phase 1 phase 2 admission discharge

  30. 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

  31. Comparison phase 1 - phase 2 Physical impairment 100 80 60 40 20 0 phase 1 phase 2 admission 4 weeks discharge

  32. 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

  33. Prognostic feedback after 4 weeks of treatment

  34. 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

  35. Relationship 4-weeks and outcome evaluation Rate of signal cases after discharge : 36% Rate of signal cases after 4 weeks : 54% (N = 298) discharge signal no signal 55.9% 44.1% signal 4 weeks no signal 24.8% 75.2%

  36. Relationship 4-weeks and outcome evaluation Psychological impairment (therapists perspective) admission signal no signal discharge

  37. Relationship 4-weeks and outcome evaluation Psychological impairment (SCL-90-R, GSI) 3 2 1 0 admission signal no signal discharge

  38. Relationship 4-weeks and outcome evaluation Psychological impairment (OQ-45) 140 120 100 80 60 40 admission 20 4 weeks 0 discharge signal no signal

  39. Relationship 4-weeks and outcome evaluation Physical impairment 100 80 60 40 20 admission 4 weeks 0 signal signal no signal discharge

  40. 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)

  41. 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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