A conceptual outcomes framework for the treatment of schizophrenia
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Current Issues in Pharmacoeconomics 2--------------------------------------------------
A conceptual outcomes framework for the treabnent of schizophrenia
What are 'outcomes' of treatments and services for people with schizophrenia, and how can an outcomes framework be used to improve care, asks Professor Anthony Lehman from the University of Maryland, US.* Outcomes have multiple dimensions and need to be considered in their proximal and distal contexts, says Professor Lehman, illustrating this point with two different treatment examples.
The first example concerns conventional anti-psychotic medications. The proximal outcomes of medication are reduced positive symptoms and the occurrence of medication-related adverse effects. Medication may include effects on 'ancillary symptoms' including depression, anxiety and dysphoria - while there is much hope that new atypical antipsychotics may be more effective in ameliorating these symptoms, there is evidence that with conventional medications distal factors such as quality of life (QOL) may have more impact on negative and 'ancillary' symptoms.
Professor Lehman says that proximal clinical effects may lead to distal effects such as changes in functional status, QOL, family weB-being and public safety, and that both proximal and distal outcomes may contribute to a reduction in the costs of treatment.
The second example considers vocational rehabilitation. The proximal outcomes of vocational rehabilitation are patients with employment and income, with downstream distal outcomes affecting QOL, family well-being, and social participation. These effects of vocational rehabilitation feed back into clinical status and are associated with reduced hospital admissions.
Distal outcomes not targeted
Professor Lehman says that, unlike acute disorders with primarily proximal outcomes, the distal outcomes of chronic disorders 'are generally not targeted'. He recommends a number of steps to implement outcomes assessment in clinical practice:
identify patient needs, and secure agreement between the patient and provider as to which of these needs can be addressed by treatment
establish treatment and service goals (which may exist in clinical, rehabilitative, humanitarian and public welfare domains), with emphasis on those that can be realistically addressed in negotiations between patient, provider and family
monitor quality-improvement programmes of both proximal and distal outcomes - an ongoing monitoring process geared to individuals with the goal of providing 'consumer-oriented' treatment
manage outcomes at the service system level, including the 'allocation of resources within service systems based upon patients' priorities'.
PhannacoEconomics & Outcomes News 11 Dec 1999 No. 242
Such an approach, says Professor Lehman, may include provider 'report cards' that incorporate effectiveness in distal outcomes. * supported by an educational grant from Eli Lilly Lehman AF. Developing an outcomes-oriented approach for the treatment of schizophrenia. Journal of Clinical Psychiatry 60 (Suppl. 19): 30-35, 1999
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