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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.

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slide1

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

slide2

Background

2 possible forms of feedback in quality management

(1) Feedback on therapy outcome

(2) Feedback during the course of therapy

slide3

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
slide4

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
slide5

Background

Implication

  • to give relevant information to the clinicians during treatment.
  • Assumptions: - better acceptance by clinicians
  • - (more) effects on outcome
slide6

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

slide7

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?
slide8

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
slide9

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
slide10

Questionnaires

(2) Therapists perspective

  • Diagnosis (ICD-10)
  • Impairment Score IS
  • HAQ
  • Rating of changes
slide11

Design

Phase 1: Baseline

  • data collection at admission, after four weeks, and at discharge
  • no feedback
slide12

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
slide13

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

slide14

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

slide15

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
slide16

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

slide17

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
slide18

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

slide19

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

slide20

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%
slide21

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%
slide22

Accetance of feedback after 4 weeks (phase 3)

Does this feedback contain relevant information?

5%

34%

41%

20%

slide23

Accetance of feedback after 4 weeks (phase 3)

Can you use this information for further treatment?

14%

31%

41%

14%

slide24

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
slide25

Comparison of phase 1 (no feedback) and

  • phase 2 (feedback after discharge)
    • signal case rate
    • duration of treatment
    • patients‘ impairment
slide26

Comparison phase 1 - phase 2

Signal case rate

phase 1

36.7%

37.8%

phase 2

slide27

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)

slide28

Comparison phase 1 - phase 2

Psychological impairment (therapists perspective)

12

10

8

6

4

2

0

phase 1

phase 2

admission

discharge

slide29

Comparison phase 1 - phase 2

Psychological impairment (SCL-90-R, GSI)

3

2

1

0

phase 1

phase 2

admission

discharge

slide30

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

slide31

Comparison phase 1 - phase 2

Physical impairment

100

80

60

40

20

0

phase 1

phase 2

admission

4 weeks

discharge

slide32

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
slide33

Prognostic feedback after

4 weeks of treatment

slide34

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
slide35

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%

slide36

Relationship 4-weeks and outcome evaluation

Psychological impairment (therapists perspective)

admission

signal

no signal

discharge

slide37

Relationship 4-weeks and outcome evaluation

Psychological impairment (SCL-90-R, GSI)

3

2

1

0

admission

signal

no signal

discharge

slide38

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

slide39

Relationship 4-weeks and outcome evaluation

Physical impairment

100

80

60

40

20

admission

4 weeks

0

signal

signal

no signal

discharge

slide40

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)
slide41

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)