February 5, 1999

By Rodrigo Muņoz, M.D.
APA President

Two issues have long been at the center of controversy about managed care: quality and costs. HMOs were supposed to increase the quality of health care and decrease costs. After several years of drastic reduction in services, both in terms of the number of people served and the treatments allowed, the system has been wrung dry. There is no evidence in 1999 that in this or any coming year health costs are going to decrease. In fact, most forecasts talk about substantial increases in health budgets. That leaves the issue of quality at center stage. We will know that quality is improving when we have instruments to measure it.

When Sam Guze, M.D., became chair of the APA Council on Research, he and Harold Pincus, M.D., the APA deputy medical director in charge of the Office of Research, announced that quality indicators could be developed-and should be developed-if we were to challenge assumptions based on minimal science. Herb Sacks, M.D., and Steve Mirin, M.D., who at the time were APA president and medical director-designate, respectively, took on the challenge by delegating the effort to develop the indicators to some of our best researchers, led by John M. Oldham, M.D. They included, in addition to Dr. Guze, Sara C. Charles, Helen L. Egger, Anthony F. Lehman, Denis J. Milke, Charles E. Riordan, Lloyd I. Sederer, Larry Y. Kline, Joseph Mawhinney, Richard C. Herman, and Molly T. Finnerty (all M.D.s). In addition to Dr. Pincus, the staff included Deborah Zarin, M.D., Claudia Hart, and Beatrice E. Edner. Kathleen K. McCann, M.D., consulted.

The task force worked at breakneck speed to produce in the most minimal period of a few months a report that easily compares with any of the most important documents produced by other areas of organized medicine.

As the indicators (defined as components of quality patient care) are developed, they are accompanied by a measure (mechanism or instrument to quantify the indicator) and a standard (levels of the measure that suggest that the component of care is of adequate quality).

Priority areas for the indicators are specific populations (children and adolescents, elderly, seriously and persistently mentally ill, developmentally disabled, abused women, head injured, HIV/AIDS patients) and diagnoses (depressive disorders, substance use disorders, dual diagnoses, schizophrenia, bipolar disorder, disruptive disorders, Alzheimer's disease, trauma/PTSD, personality disorders).

Dimensions of treatment include access, quality, perception of care, and outcome.

Here is an example of a quality performance indicator:

Appropriate Use of Medications in Major Depressive Disorder
Medications should be used in appropriate dosage and duration for those disorders for which they have been shown to be effective.

Indicator: Current provision of an antidepressant medication to patients with major depressive disorder, moderate or severe.

Measure: Percentage of patients in a given health plan with major depressive disorder, moderate or severe, receiving an appropriate dose of antidepressant medication.

Standard: Approximately 75 percent of the patients with major depressive disorder, moderate or severe, are in treatment.

In his presentation to the Board of Trustees this past December, Dr. Oldham stressed that this is a work in progress. The task force will be replaced by a permanent committee. This committee will work closely with the Steering Committee on Practice Guidelines to make the principles, strategies, and actual indicators available to all APA members.

The day is not distant when every psychiatric clinician will have the indicators at hand to challenge and educate those who talk about "quality" but do not know the meaning of the word.