Why measuring quality of mental health care is still an unmet challenge and how to meet it

Quality improvement programs aim to reduce clinical decision variability due to lack of knowledge or subjectivity as well as the gap between guidelines and real world practices. In psychiatry, the attempt to disseminate these initiatives has generated two opposite reactions: on the one hand, some researchers have been fascinated with the idea of moulding clinical practice based exclusively on research findings, considering all deviations from scientific evidence as an inappropriate action; on the other, several clinicians have regarded the entire process of quality improvement as biased by reductionism, and as an expression of disdain of the value of their own experience. Substantial gaps between evidence and practice, and non-attainment of optimal health outcomes, are well documented in the whole field of medicine, even in high-income countries and across disciplines. A seminal review of studies on quality of primary care conducted in UK, Australia and New Zealand in 2001 concluded that “in almost all studies the process of care did not reach the standards set out in national guidelines or set by the researchers themselves”1. In the US, a more recent analysis of 48 state and regional measure sets found that they included more than 500 different measures, only 20% of which were used by more than one program; a study of 29 private health plans identified approximately 550 distinct measures, which had little overlap with the measures used by public programs2. In the UK, the translation of guidelines into legal standards of care in the field of surgery and anesthesiology has been found not to have a sufficient endorsement by the relevant professional bodies3. In the Netherlands, a study performed in two different regions proved that several professionals and patients experienced barriers in guideline implementation in the field of obstetrics and gynecology4. In psychiatry, quality of care programs have to face even more significant problems in terms of feasibility: heterogeneity of services in the various countries or regions; high professional burden; uneven provision of resources; inequality in the access to care; lack of support or rewards for services or professionals undertaking initiatives based on quality improvement; factors beyond the control of clinicians that interfere with treatment outcomes; the necessity to integrate interventions provided in different settings5. Evidence collected from non-research clinicians and clinical consensus may play a particularly salient role in this regard. Trying to understand the reasons for current discrepancies between routine practice and guideline recommendations, and promoting a shared culture of quality that pays appropriate respect to the clinicians’ experience6, are fundamental ingredients for the success and dissemination of quality of care initiatives7. Routine outcome monitoring, performed at the local level, including both objective and subjective variables, has been thought to have the potential to facilitate quality assurance programs. So far, however, there have been inconsistent findings even from studies performed in similar contexts, and systematic reviews have been inconclusive on the regular feedback and use of those data for improving patient outcomes or management8. Any effort to implement quality indicators should not overlook a number of ethical and theoretical questions. What is the role of ethical values in shaping practices? We know that the mechanisms involved in the collection of evidence are rather complex and sometimes include economic interests. The concepts themselves of “effectiveness” and “quality of care” might differ markedly between clinicians and administrators. Furthermore, some aspects of treatment are more easily measurable and likely to be standardizable (e.g., drug treatments) than others (psychosocial treatments or psychodynamic therapies), with important consequences on the amount of evidence that is available. What course of action should a clinician take when confronted with different levels of evidence? What are the limits of evidence? What should be done in clinical situations for which there is no scientific evidence? On the other hand, we should not forget that providing evidence-based treatments and quality measurements is indeed an ethical imperative. It means not only respecting patients’ rights and mental health workers’ competences, but also professionals’ right and duty to be updated on and to appropriately discuss emerging practices. Furthermore, in order to be effective, quality assessment programs should be solidly rooted in the frame of the specific context, which involves: a) gathering information on the core values and norms underlying ideologies and assumptions within an organization; b) identifying the level of commitment and motivation for improvement of professionals and support by leaders; c) clarifying the extent to which the implementation of the programs is likely to actually improve the quality of care provided rather than impairing the process (for example, by subtracting resources dedicated to the direct care of patients in favor of bureaucratic practices); d) involving service users in the identification of emergent service needs9; e) remaining vigilant to the risk that local adaptation alters a given recommendation to better adjust it to real practice. This latter issue has become quite pressing: adherence to specific programmatic standards – frequently referred to as fidelity of implementation – is necessary to produce the expected outcomes. However, this issue too is not a simple one. It is much easier to manualize interventions in research settings than in the real world. Some evidence suggests that the best outcomes are obtained by therapists who demonstrate flexibility by adapting interventions to their individual clients’ needs10. The degree to which interventions should involve flexible modification and integration to be effective when applied in everyday clinical work remains a matter of debate. In conclusion, all actors involved in mental health planning, organization and routine care processes are called upon to work towards obviating the risk that, due to negligence or a lack of coordination or consideration of the local context, even the most advanced mental health care models miss the opportunity to significantly improve routine care practices. Mirella Ruggeri Section of Psychiatry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy