the quality star – an algorithm for the evaluation of mental health services

THE QUALITY STAR – AN ALGORITHM FOR THE EVALUATION OF MENTAL HEALTH SERVICES

Bo Ivarsson, Lars Erdner and Ulf Malm

THE PRESENTATION:• Background, history

• Instruments and Procedure

• Results, examples

• Development

1994: Situation??

1) PATIENT PARTICIPATON ? Too little and in vague forms

2) QUALITY FOLLOW-UP ? Only production statistics.

No broadly accepted outcome measures

1994: Optimal Treatment Project !

1) PATIENT PARTICIPATON !”Shared decision making, Empowerment…

2) OUTCOME QUALITY CONTROL BY YEARLY FOLLOW-UP! …systematic use of simple effectiveness measures yearly

1995: Presentation of concept; Donabedian logic Quality technology as an engine to organize better care and serivice for schizophenia – the most expensive desease in the world

Kvalitetsteknologi som motor för att organisera bättre vård och service vid schizofreni - världens dyraste sjukdom Bo Ivarsson R&D officer, Psych services Borås hospital Ulf Malm Ass. professor, Sahlgrenska university hospital Gothenburg Karl-Otto Svärd Swedish Psychiatric Association, Head Psych dept. Karlstad

1997-99: Tests in routine services 1999: Decision on Routine Implementation Starting 2000 in Western region and part of Stockholm. Global measures obligatory for comparability, local additions wellcome Included in routine clinical programme.

2001: Presentation of established algorithm”Kvalitetsstjärna – metod för regelbunden patientuppföljning som motor.”Bo Ivarsson and Ove Sonesson. Socialmedicinsk tidskrift nr 4/2002

“The Quality Star – A Tool for Regular Outcome Monitoring” Lars Erdner and Bo Ivarsson. In: ENTER conference monograph London 2000 Paris 2001, Ed.: Mervyn London, Cambridge UK 2002

Consumer Satisfaction with Services

Subjective Quality of Life

Symptom Global

Recommened Quality Dimensions for Regular monitoring & Dialogue with Users

Patient's Perceived Distress

(Resource usage)

Family BurdenSyndome Specific Axis

Social Functioning




• Development


Patient's Perceived Distress Subjective Quality of Life

Symptom Global Social Functioning

Syndome Specific Axis Family Burden (Resource usage)

Consumer Rating Satisfaction Scale Self Assessment Form

Questions on 11 areas

1. Availability of assistance when in need of help? 2. General atmosphere wherever your contact with the psychiatric care? 3. General attitude and approach of the staff? 4. Availability of counseling and other treatment alternatives other than medication? 5. Consistency of staff, i.e. being able to see the same staff member throughout? 6. Availability of information regarding for example planning of treatment, decisions made, diagnostic considerations etc? 7. Opportunities for you to take part in decision-making? 8. If you have been prescribed medication, how did you experience that? 9. Opportunities of being offered psychosocial interventions? 10. The result of your treatment so far? 11. Consider your contacts within the psychiatric health system an assurance of a future feeling of satisfaction with your life and a general sense of well-being?

Question domains

Example:

If you think you have had rather poor opportunities to get help when needed, circle in the following manner:

1. How did you find the availability of assistance when in need of help?

Very poor

Poor Fairly poor

Neither good nor

bad(can't tell)

Fairly good

Good Very good

Example:

If you think you have had rather poor opportunities to get help when needed, circle in the following manner:

1. How did you find the availability of assistance when in need of help?

Very poor

Poor Fairly poor

Neither good nor

bad(can't tell)

Fairly good

Good Very good

-3 -2 -1 0 +1 +2 +3

How much have you been bothered by Your psychiatric problems during the last month?

How to fill out the form!

A cross at the bottom end of the line represents the worst possible situation including experiencing extremely difficult psychiatric problems. A cross at the top end represents a situation where You have not experienced any psychiatric problems at all during the last month.

Put a cross on the line that shows to what extent You have been troubled by psychiatric problems during the last month.

I have not experienced any psychiatric problems at all

My psychiatric problems have troubled me extremely much

VAS-scale Visual Analogue Scale

How do you find your life situation right now?

How to fill out the form! A cross at the bottom end of the line represents the worst possible life situation. A cross at the top end represents the best possible life situation for You. Put a cross on the line where You think that your life is at the moment.

Best possible life situation

Worst possible life situation

How big a burden have You experienced (felt) the last month due to Your next of kin’s psychiatric problems?

How to fill out the form!

Imagine that a cross at the bottom end of the line represents the greatest possible burden for You and that a cross at the top end represents the best possible situation without any feeling of burden at all.

Put a cross on the line where You think that you life is at the moment.

No burdening feeling

The greatest possible feeling of burden

Global funktionsskala (GAF-skalan)

100 Synnerligen god funktionsförmåga inom vitt skilda områden, livsproblem förefaller aldrig | bli ohanterliga, andra söker sig till personen pga av hans eller hennes många positiva | egenskaper.91 Inga symtom.

90 Frånvaro av symtom eller minimala symtom (t ex lätt nervositet inför en tentamen), god | funktionsförmåga i alla avseenden, intresserad av och engagerad i ett antal olika aktiviteter, | socialt kapabel, allmänt sett tillfreds med tillvaron, endast vardagliga problem eller bekymmer81 (t ex tillfälliga konflikter med anhöriga).

80 Om några symtom föreligger så rör det sig om övergående och förväntade reaktioner på | psykosociala stressfaktorer (t ex koncentrationssvårigheter efter familjegräl); endast obetydliga | funktiossvårigheter med avseende på sociala kontakter, arbete eller skola (tex tillfälligt på71 efterkälken med skolarbetet).

70 Vissa lindriga symtom (t ex nedstämdhet och lindriga sömnbesvär) ELLER vissa funktions- | svårigheter med avseende på sociala kontakter, arbete eller skola (t ex tillfälligt skolk, stulit | från annan familjemedlem), men i stort sett tämligen välfungerande, har några etablerade,61 betydelsefulla personliga relationer.

60 Måttliga symtom (t ex flacka affekter och omständligt tal, enstaka panikattacker) ELLER måttliga | funktionssvårigheter med avseende på sociala kontakter, arbete eller skola (t ex har endast få51 vänner, har konflikter med kolleger eller arbetskamrater).

50 Allvarliga symtom (t ex självmordstankar, svåra tvångsritualer, frekventa snatterier) ELLER | allvarliga funktionssvårigheter med avseende på sociala kontakter, arbete och skola (t ex inga41 vänner alls, oförmögen att behålla ett arbete).

40 Viss störning i realitetsprövningen eller av kommunikationsförmågan (t ex uttrycker sig tidvis | ologiskt, oklart eller irrelevant) ELLER uttalade funktionssvårigheter i flera avseenden, såsom | arbete eller studier, familjerelationer, omdöme, tankeförmåga eller sinnesstämning (t ex en | deprimerad man som undviker sina vänner, försummar familjen och är oförmögen att arbeta; ett barn31 som ofta ger sig på yngre barn, misslyckas i skolan och är trotsigt hemma).

30 Beteendet avsevärt påverkat av vanföreställningar eller hallucinationer ELLER allvarlig | störning av kommunikationsförmågan eller omdömet (t ex stundtals osammanhängande, beter | sig gravt inadekvat, ständiga suicidtankar) ELLER oförmögen att fungera i snart sagt alla21 avseenden (t ex ligger till sängs hela dagen; inget arbete, ingen bostad, inga vänner).

20 Viss risk för att individen tillfogar sig själv eller andra skada (t ex suicidhandlingar utan | uppenbar dödsförväntan; ofta våldsam; maniskt uppskruvad) ELLER stundtals oförmögen till | elementär personlig hygien (t ex kladdar med avföring) ELLER grav störning av kommuni-11 kationsförmågan (t ex mestadels osammanhängande eller mutistisk).

10 Ständig risk för att individen tillfogar sig själv eller andra allvarlig skada (t ex återkommande | våldsamhet) ELLER ständigt oförmögen till elementär personlig hygien ELLER allvarlig

1 suicidhandling med uppenbar dödsförväntan.

GAF-S GAF-F

”Split-GAF” derived from DSM IV-TR is used to indicate Symptom severity and

Psycho-social functioning respectively





GAF-S GAF-F





For schizophrenia:Symptom screening for Adverse Effects of Medication

UKU-Side Effect Rating Scale 1.1 Concentration difficulties 1.2 Asthenia/Lassitude/Increased fatigability 1.3 Sleepiness/Sedation 1.4 Failing memory 1.5 Depression 1.6 Tension/Inner unrest 1.7 Increased duration of sleep 1.8 Ruduced duration of sleep 1.9 Increased dream activity 1.10 Emotional indifference 2.1 Dystonia 2.2 Rigidity 2.3 Hypokinesia, Akinesia 2.4 Hyperkinesia 2.5 Tremor 2.6 Akathisia 2.7 Epileptic seizures 2.8 Paresthesias Etc.





Material for DIALOGUEDIALOGUE with user

Software supporting over-time developmentfor user – staff dialogue

Regular export to common data-base for comparisons between services




• Development

Sahlgrenska Univ. 156

Kungälv 143

Skaraborgs Sjh 38

NU-sjukvården 241

Södra Älvsborg 226

Lysekil 73

Norra Stockholm 216

Halmstad 98

Varberg 39

Ljungby 347

Nord Uppland 33

Total 1610

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6No of Ratings 922 285 189 139 62 13

Material from someof the participatingCentres - 1610 ratings

Kungälv 1 och 5

0

20

40

60

80

100ConSat

VAS - Livskvalite

GAF Funktion

VAS - AnhörigbördaUKU Symtom

GAF Symtom

VAS - Upplevda besvär

År 1

År 5

Schizophrenia spectrum group – 5 years follow upKungälv service

Ljungby 1 och 5

0

20

40

60

80

100ConSat S

VAS - Livskvalite S

GAF Funktion

VAS - AnhörigbördaUKU Symtom

GAF Symtom

VAS - Upplevda besvär S

År 1

År 5

Schizophrenia spectrum group – 5 years follow upLjungby service

ConSat Q o Life GAF- F Relatives Adv Effects GAF S DistressSÄS 73 62 48 76 92 50 67SkaS 79 72 55 86 87 45 77Halmstad 72 58 49 65 94 53 60Kungälv 79 67 50 76 87 55 60Ljungby 77 74 47 86 88 50 70Lysekil 73 58 51 94 90 52 59NU 68 53 50 55 85 50 58Ryhov 83 47 45 32 82 45 23Stockholm 76 64 50 81 87 50 78

Analysing differences: User subjective dimensions

Ljungby versus Other services (examples SÄS and Ryhov)

ns

0

10

20

30

40

50

60

70

80

90

100

< 3 mån 3 - 18månader

1,5 - 3 år Mer än 3år

Percentiles 85

Median

Percentiles 15

<3 months 3-18 m 1,5-3 y 3< years

Quality of Life related to Years in contact with Service

3 year figures differ significantly from shorter duration

Consum Satisf

Quality of Life

GAF- Function

Relatives' Burden

Adverse Effects

GAF Symptom

Perceived Distress

Service x Diagnosis x x x Sex x x x Age x x Symtom - years x Dysfunction - years Help - years x Psychiatric contact –yrs x In present service -yrs x Diagnosis -years x

Independent variables explaining Quality Star Out-come measures

0

20

40

60

80

100TILLFREDS

LIVSKVALIT

GAF2

ANHÖRIGB

RESURS

SPECAX

GAF1

UPPLBESV

PercUTOT

MedianTot

PercNTOT

Schizophrenia

TILLFREDSSTÄLLESE

0

20

40

60

80

100TILLFREDS

LIVSKVALIT

GAF2

ANHÖRIGB

RESURS

SPECAX

GAF1

UPPLBESV

PercUTOT

MedianTOT

PercNTOT

Personality disorders

Median

20 percentile

80 percentile

TILLFREDSSTÄLLESE

0

20

40

60

80

100TILLFREDS

LIVSKVALIT

GAF2

ANHÖRIGB

RESURS

SPECAX

GAF1

UPPLBESV

PercUTOT

MedianTOT

PercNTOT

0

10

20

30

40

50

60

70

80

90

TILLFREDS

LIVSKVALIT

GAF2

ANHÖRIGB

RESURS

SPECAX

GAF1

UPPLBESV

PercU30

Median30

PercN30

Depression

DifferencesBetween twoservices

Median20 percentile80 percentile




• Development

1. Adding background data into the method /parallell with National Quality Registers/

2. Negociating common webb-based system together with National Quality Registers

3. Deciding resource usage axis content. Measure? Days-in-care is one option. Any suggestions are welcome!

Thanks for Your Attention ! Powerpoint presentation available on webb-site:

[email protected]@[email protected]

http://forum.carelink.se/pages/newsbillNews.asp?DeptID=15&ProjID=21&Pages=159

the quality star – an algorithm for the evaluation of mental health services

Documents

quality star

quality followup

outcome quality control

global measures obligatory

history instruments

procedure results

routine services

need of help