April 16, 1999

With health insurance costs continuing their relentless march upward, even in the face of the managed care revolution, patients and employers who purchase health insurance are demanding proof that they are getting good value for their investment. To help them and others in the health care system evaluate the quality and value of health services, APA has just developed a preliminary set of quality indicators that will allow them to gather information on and then assess crucial variables.

In a process begun in September 1997, the APA Task Force on Quality Indicators designed a framework for developing clinically based measures of quality that apply to several areas of mental illness and substance abuse treatment. The APA Board of Trustees endorsed the task force's report and recommendations at its meeting in Chicago March 13-14.

"There has been widespread recognition of the importance of practice guidelines and the need to standardize 'best practices' in medical care," said task force chair John Oldham, M.D. "A logical and clearly parallel step is the development of standards for measuring the care that health systems deliver. We also need methods to evaluate the quality of the health care delivery system."

Several other organizations, such as the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance, have begun using quality indicators as part of their accreditation processes. With APA's specialized knowledge, it is stepping in to emphasize the need for indicators that address clinically based concerns in mental health and substance abuse. APA is also working with these and other organizations that are designing indicators.

"Although many groups have developed report cards and other measures, they tend to overlook important clinical aspects of care for patients with mental disorders," explained Deborah Zarin, M.D., an APA deputy medical director and head of the Office of Quality Improvement and Psychiatric Services. "The APA practice guidelines are a rich source of information about appropriate treatment, and these [initial] quality indicators are an important step in disseminating that information to quality oversight groups."

Using the quality indicators report and the results of other APA quality improvement activities, the Association intends to continue to promote these clinical concerns to health care purchasers, health care systems, government agencies, managed care organizations, and accrediting groups.

The sample indicators are based in some instances on extensive research on particular disorders, while others are based more on psychiatrists' clinical experience and have "more limited research support," the task force points out.

For this initial phase of the project, the task force was "not expected to produce a comprehensive set of indicators, but rather to focus on major clinical concerns in mental health and substance abuse," its report notes.

The framework for each principle the task force identified consists of a recommendation or goal, an indicator that describes one component of quality patient care, a measure by which the indicator can be quantified, and a standard against which to measure whether the component of care is of adequate quality.

The task force cautions that while it chose specific indicators and measures for the purpose of its report, there are, in fact, many reliable measures that can be used to assess a particular recommendation or goal.

Task force members selected indicators based on the following principles:

• It reflects an important aspect of mental illness care.


• It will be useful in identifying opportunities for improving care


• It is quantifiable.


• It can, wherever possibly, be documented by an APA or other evidence-based practice guideline.


• It minimizes the potential for "gaming" the measure or for unintended adverse consequences.


• The eventual collection of indicators should reflect a balance representing all the major priority areas in mental health treatment.

While treatment outcome is a critical component of the quality of care, not all the indicators included in the APA project were designed to assess that dimension. Some apply to the "structure" of care; that is, whether a system-not an individual provider-has "resources or arrangements in place to deliver quality health care," the task force explains. Alternatively, an indicator may clarify an important aspect of the treatment process. Task members agreed "that a good evaluation program may include all three types, giving emphasis to outcome indicators where possible."

The task force suggests a framework for evaluation measures that includes access to effective medication, psychosocial treatment, and specialized services; quality of care, including evaluation, treatment, and prevention services; and perceptions of care by patients, families, and clinicians.

Concerning access to medication, for example, a recommendation/goal is that "patients with severe and persistent mental illness should have access to newer generations of antipsychotic medications as they become available," while an indicator of this is whether patients with schizophrenia have access to new antipsychotics.

Within the priority area of evaluating the quality of care, to take another example, appropriate medication use is a quality indicator dimension. Here the recommendation/goal is that "medications should be used in appropriate dosage and duration for those disorders for which they have been shown to be effective," and an indicator of whether this goal is being achieved is the use of "treatment with an antidepressant medication for patients with major depressive disorder, moderate or severe."

Achieving an "improved level of functioning and quality of life" with "minimization of social and economic cost" is a dimension under the report's section on evaluating outcomes. The recommendation/goal states, "Many patients with mental illness that significantly impairs functioning should be able to resume some degree of productive occupational or educational activity after receiving treatment known to be effective for their conditions." An indicator the task force cites to measure this is "resumption of productive activities by patients with severe and persistent mental illness when no longer in the acute phase of illness."

The report emphasizes that the task force's work is far from complete and is but one part of an array of APA efforts in this area that includes deriving additional indicators from APA's evidence-based practice guidelines, developing quality indicators specifically for the mental health care of children and adolescents, and continuing to develop diagnosis and assessment tools such as DSM-IV and the APA Handbook of Psychiatric Measures.

After voting in March to disband the task force now that its report has been completed, the Trustees agreed to replace it with a permanent Committee on Quality Indicators to continue this work.

The new committee, Oldham noted in his report to the Trustees last month, will have three primary missions. It will "develop strategies to disseminate the indicators, encourage additional research, and promote adoption of the indicators by quality oversight organizations that are implementing measurement programs."

Future efforts will be coordinated with APA's Steering Committee on Practice Guidelines, Oldham noted in an interview with Psychiatric News. The task force's report will appear on APA's Web site sometime this month.