Transcript TOP ALERTS - McGill Psychotherapy Process Research Group

Two decades of TOP research
It’s about improving treatment
not just measuring it
David R. Kraus PhD
Founder/CEO
October 7, 2009
Copyright © BHL, 2009
1
Treatment Outcome Package
Copyright © BHL, 2009
2
TOP Evolution
Version
# Items
# Subjects
Factors
1 -- 1993
250
432
15
2 -- 1995
112
2,217
15
3 -- 1996
93
5,288
13
4 -- 2003
58
19,801
12
GOAL: Meeting the requirements of the Core Battery Conference
Horowitz, L. M., Lambert, M. J., & Strupp, H. H. (Eds.) (1997). Measuring patient change in mood, anxiety, and
personality disorders: Toward a core battery. Washington, D. C.: American Psychological Association Press.
GENERAL
DISTRESS
QUALITY
OF LIFE
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SYMPTOMS
DEPRESSION
SUBSTANCE ABUSE
PSYCHOSIS
INSOMNIA / SLEEP
SUICIDE
VIOLENCE
ANXIETY
BIPOLAR
FUNCTIONAL
WORK
SOCIAL
SEXUAL
3
Treatment Outcome Package
Built from tens of thousands of clinical cases
Excellent construct validity
Excellent discriminant and convergent validity
e.g. TOP Depression Scale vs. BDI (r = .92)
Excellent sensitivity to change
Excellent predictive validity
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4
FREE SERVICES
The tool is free
Data collection is free
Real-time client reports are free
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5
BHL provides multiple pathways
to improving service quality with
EMPIRICALLY SUPPORTED INTERVENTIONS
Outcome-based Referrals sm
Client Feedback Reports
Benchmarking and CQI
Hospital Prevention
6
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Outcome-Based Referrals SM
patent pending
•150 Empirically Supported Treatments
•Accounting for 1 – 2% of outcome variance (Wampold, 2001)
•The therapeutic alliance
•Accounts for 5% of the variance
•But most of this variance is between therapists
•It is at the therapist level where results happen
•8.6% of variance across 10 RCTs (Crits-Christoph & Mintz, 1991)
•Estimates as high as 50% in other studies (Blatt, Sanislow, Zuroff, & Pilkonis, 1996; Elkin,
Falconnier, Martinovich, & Mahoney, 2006; Crits-Christoph, et al., 1991; Huppert, Bufka,
Barlow, Gorman, Shear, & Woods, 2001)
•Assigning cases based on skill sets
•Can increase outcome effect sizes by as much as 400%
•(Kraus & Castonguay, in preparation)
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7
Outcome-Based Referrals SM
patent pending
Definitions
“Effective therapist” – Average patient is reliably
improved
“Poor therapist” – Average patient is reliably
worse
Reliable Change (Jacobson & Truax, 1991)
RCI = (X2 − X1)⁄SEDIFF SEDIFF = (2(SE)2)1⁄2
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8
Outcome-Based Referrals SM
patent pending
Areas of Effectiveness
Therapists
0
4%
1
6%
2
9%
3
11%
4
12%
5
14%
6
12%
7
11%
8
9%
9
7%
10
3%
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EXPERTISE AREAS
Depression
Substance abuse
Mania
Panic
Psychosis
Violence
Suicide
Sleep
Social conflict
Sex
Work
Quality of life
(Kraus & Castonguay, in preparation)
9
Outcome-Based Referrals SM
patent pending
Correlations between therapist skills by domain
DEPRS
LIFEQ
MANIA
PANIC
PSYCS
SA
SCONF
SEXFN
SLEEP
SUICD
LIFEQ
.469
MANIA
.326
.044
PANIC
.491
.196
.240
PSYCS
.428
.171
.335
.369
SA
.264
.159
.211
.151
.239
SCONF
.350
.193
.150
.252
.367
.134
SEXFN
.310
.164
.118
.226
.218
.094
.310
SLEEP
.419
.208
.184
.384
.333
.149
.238
.160
SUICD
.531
.264
.229
.322
.454
.345
.309
.205
.290
VIOLN
.281
.102
.207
.232
.321
.228
.283
.222
.181
.421
WORKF
.331
.127
.258
.265
.253
.144
.251
.228
.213
.264
VIOLN
.241
DEPRS: Depression; LIFEQ: Quality of Life; PSYCS: Psychosis; SA: Substance Abuse; SCONF: Social Conflict;
SEXFN: Sexual Functioning; SUICD: Suicide; VIOLN: Violence; WORKF Work Functioning
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(Kraus & Castonguay, in preparation)
10
Outcome-Based Referrals SM
patent pending
Depression
2.5
2
1.5
1
0.5
0
pre
post
ALL THERAPISTS
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Cohen’s d effect size
0.91 – A large effect according
To Lipsey’s criteria (1990)
11
Outcome-Based Referrals SM
patent pending
Effect size
1.40
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Effect size
0.04
(Kraus & Castonguay, in preparation)
Effect size
-1.05
12
Outcome-Based Referrals SM
patent pending
Not all therapists are the same
3%
694 Clinicians
treating at least 10
depressed patients
30%
Some make their patients:
Reliably worse
No better or worse
Reliably better
67%
Reliable Change (Jacobson & Truax, 1991)
RCI = (X2 − X1)⁄SEDIFF SEDIFF = (2(SE)2)1⁄2
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(Kraus & Castonguay, in preparation)
13
Outcome-Based Referrals SM
patent pending
•Based on the philosophy of the “good-enough
mother” (Winnicott, 1953)
•At intake, TOP feedback includes a list of
therapists with proven, good-enough
therapeutic skills to handle this patient’s issues
•Clinics should assign cases based on these
recommendations
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14
Outcome-Based Referrals SM
patent pending
Improving service quality overnight
Avoid these and achieve
9% improvement
Rely on these and
achieve 54% increase
(Kraus & Castonguay, in preparation)
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15
Outcome-Based Referrals SM
patent pending
Good
Poor
Therapists Therapists
Effect size
(All therapists)
Effect size
(Good therapists)
Effect size
increase
Depression
67%
3%
0.91
1.41
54%
Quality of life
47%
5%
0.68
1.51
122%
Mania
0.7%
0.3%
Not enough data
Not enough data
N/A
Panic/Anxiety
43%
10%
0.42
1.17
179%
Psychosis
46%
9%
0.43
1.00
133%
Substance Abuse
50%
16%
0.47
1.14
143%
Social Conflict
45%
14%
0.48
1.46
204%
Sexual Functioning
29%
12%
0.27
1.48
448%
Sleep
54%
9%
0.57
1.20
111%
Suicide
58%
7%
0.64
1.30
103%
Violence
38%
16%
0.31
1.02
229%
Work Functioning
35%
7%
0.44
1.52
245%
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(Kraus & Castonguay, in preparation)
16
Outcome-Based Referrals SM
patent pending
Rankings vary depending on domain
Take the highest ranking Depression therapist
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Domain
Ranking
Depression
1
Quality of Life
3
Social Conflict
9
…
…
Violence
550
Mania
692
(Kraus & Castonguay, in preparation)
17
BHL provides multiple pathways
to improving service quality with
EMPIRICALLY SUPPORTED INTERVENTIONS
Outcome-based Referrals
sm
Client Feedback Reports
Benchmarking and CQI
Hospital Prevention
Copyright © BHL, 2009
18
Exceptional sensitivity to change
LSQ2
TOP–
DEPRS3
TOP–
FULL3
Improvement
20%
54%
91%
No change
72%
32%
5%
Deterioration
8%
14%
4%
2. Developed by UBH, the LSQ is a 30–item short form of the OQ–45. Doucette, A. (2006) From Ordinal
Observation to Linear Measurement, paper presented at the North American meeting of the Society for
Psychotherapy Research. N>140,000
3. Kraus, D. R., Seligman, D, Jordan, J. R., (2005). Validation Of A Behavioral Health Treatment Outcome And
Assessment Tool Designed for Naturalistic Settings: The Treatment Outcome Package. Journal of Clinical
Psychology, Vol 61(3), 285-314. N>20,000
4. Reliable Change (Jacobson & Truax, 1991) RCI = (X2 − X1)⁄SEDIFF SEDIFF = (2(SE)2)1⁄2
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Construct Validity
GFI
CFI
TLI
Confirmatory
Factor
Analyses
RMSEA
Brown, T. A. (2006). Confirmatory factor analysis for applied research. New York: Guilford.
Acceptable fit
>.90
>.90
>.90
<.08
Good fit
>.95
>.95
>.95
<.05
Mueller, R. M., Lambert, M. J. & Burlingame, G. M. (1998) Construct Validity of the Outcome Questionnaire:
A Confirmatory Factor Analysis, Journal of Personality Assessment, 70(2), 248-262.
OQ-Total Score
.827
.195
Not listed
Not listed
OQ-2 factor model
.824
.177
Not listed
Not listed
OQ-3 factor model
.822
.157
Not listed
Not listed
Kraus, D. R., Seligman, D., & Jordan, J. R. (2005). Validation of a Behavioral Health Treatment Outcome and
Assessment Tool Designed for Naturalistic Settings: The Treatment Outcome Package. Journal of Clinical
Psychology , 61(3), 285-314.
Kraus, D., Boswell, J., Wright, A., Castonguay, L., & Pincus, A. (submitted). Factor Structure of the
Treatment Outcome Package for Children. Journal of Clinical Psychology.
TOP Adult (12 factor)
.952
.947
.940
.035
TOP Child (13 factor)
.966
.973
.969
.035
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20
INDEPENDENT VALIDATION FROM
A PRIMARY COMPETITOR
A Psychometric Evaluation of the
Treatment Outcome Package TOP
Mark A. Blais, PsyD, Samuel J. Sinclair, PhD &
Hal Shorey, PhD
MGH-Psychological Evaluation
and Research Laboratory
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21
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22
Client Report
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23
Client Report
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24
Empirically Supported Feedback
Can therapists handle complex feedback?
Each TOP administration comes with detailed
assessment results.
There are no directives on how to, or whether to,
read the report.
So what happens if therapists are allowed to do as
they please?
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25
Case Vignettes
• Most therapist attitudes towards outcomes begins with
skepticism, even hostility.
• As a clinician I typically try to see the world through the
eyes of my patients.
• It is typically in one of these eye-opening experiences
that therapist attitudes towards outcomes change.
–
Sainz (2009) When metrics matter: The Case of Frank and the Treatment Outcome Package
• Often it is easier to be more honest about how bad things
are on a questionnaire (Carr & Ghosh, 1983; Erdman, Klein, & Greist, 1985; Hile & Adkins,
1997; Lucas, 1977; Searles, Perrine, Mundt, & Helzer, 1995; Turner et al., 1998)
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26
Empirically Supported Feedback
Client Improvement
Those that look
Those that don’t look
1
2
3
4
5
6
7
8
9
Number of clients with feedback
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27
Empirically Supported Feedback
Δ µ1
Δ µ2
σ1
σ2
T
df
α
Initial µ1
Initial µ2
2.6
4.1
11.2
10.1
2.4461
946
0.0146
24.2
25
Depression*
0.56
0.65
0.93
0.9
1.6639
1149
0.0964
1.88
2.06
Life quality***
0.12
0.28
0.87
0.84
3.1266
1121
0.0018
1.81
1.98
Mania***
Panic**
0.13
0.29
0.23
0.45
0.51
1
0.6
1.1
3.0473
2.5713
1143
1137
0.0024
0.0103
-0.16
1.65
-0.12
1.74
Psychosis
0.55
0.65
1.3
1.3
1.2968
1139
0.195
1.47
1.53
Substance
abuse
0.48
0.54
2.3
1.9
0.4489
1003
0.6536
1.15
1.12
Social conflict
0.33
0.31
1
1
0.3349
1123
0.7377
1.13
1.09
Sexual
functioning
Sleep
Suicide
0.2
0.37
0.55
0.18
0.43
0.54
0.88
0.79
1.7
0.87
0.8
1.4
0.3749
1.277
0.1081
1077
1146
1147
0.7078
0.2019
0.8452
0.48
1.13
1.41
0.49
1.24
1.39
Violence***
0.54
0.29
1.7
1.5
2.6263
1144
0.0087
1.04
0.93
Work
functioning*
0.2
0.29
0.79
0.98
1.6694
1078
0.0953
-0.11
-0.04
TOP total
score**
Group1 = First 5 clients with feedback; Group2 = Second 5 clients with feedback
Δ µ = Average pre-post change; Initial µ = Average pre-treatment score
* significant α <0.1; ** significant α <0.05; *** significant α <0.01
Copyright © BHL, 2009
28
BHL provides multiple pathways
to improving service quality with
EMPIRICALLY SUPPORTED INTERVENTIONS
Outcome-based Referrals sm
Client Feedback Reports
Benchmarking and CQI
Hospital Prevention
Copyright © BHL, 2009
29
EBT and CQI Support
•An outcome management system with fully
integrated quality improvement report cards.
•Integrated evidenced-based treatment libraries
that have been clinically proven to improve
outcomes.
30
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EBT and CQI Support
Kraus, D. Castonguay, L. (2006) Integrating Evidence Based Practices with
Outcomes Management. Paper presented at NASPR Annual Conference.
Adelman, R. (2008) Methods of Reconstruction with Adolescent Substance Abusers:
Combining REBT and Constructivism. In Raskin, J.D. & Bridges, S. (Ed.), Studies in
Meaning 3: Constructivist Psychotherapy in the Real World, New York: Pace
University Press.
Adelman. R. (2007) Reducing Anger in Adolescents: An REBT Approach, Center
City, Minnesota: Hazelden Press.
Adelman, R. (2006) The Angry Adolescent & Constructivist REBT. In Cummins, P.
(Ed.), Working with Anger: a Practical Constructivist Approach, London: John Wiley
& Sons.
Adelman, R. et. al, (2005) Reducing adolescent clients’ anger in a residential
substance abuse treatment facility. Journal on Quality and Patient Safety, 31, (6),
325-327.
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31
Agency X: raw, pre/post outcomes
all change scores are significant unless specified
1.5
1
0.5
0
Notno
sig
t
sig
-0.5
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Mania
Violence
Work
Sleep
Suicidality
Sex
Psychosis
Panic
Quality of Life
Interpersonal
Depression
-1
32
Provider Benchmarks
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33
BENCHMARK
Quartile Analysis
2
1
TOP quartile
0
-1
-2
mean
RANGE
OF RAW
DATA
Suicide
Bottom quartile
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34
Quartile analysis of
same data
“The National Leader in Outcomes Management”
Clients with excellent results are left two bars in each domain, followed
by clients with very poor results on right. Note, the second group of
Copyright ©suicide
BHL, 2009
clients are getting worse during the course of treatment.
35
Quartile analysis of
same data
Demographics
Category
Homeless
Male
Female
Single
Married
Divorced
Separated
Widowed
Christian
Hindu
Jewish
Muslim
No Religion
OtherReligion
White
Black
Asian
East Indian
Am.Indian
Hispanic
Mixed Race
Income $0+
Income $10+
Income $20+
Income $30+
Income $40+
Income $50+
Income $75+
Income$100+
Income$200+
Empl.FlTm
Unemployed
Average Age
Avg.# Chldrn
Copyright
©
Best
Outcomes
#
%
2
7%
9
35%
17
65%
13
46%
3
11%
10
36%
2
7%
0
0%
19
70%
0
0%
1
4%
0
0%
3
11%
4
15%
23
79%
0
0%
0
0%
1
3%
3
10%
2
7%
2
7%
15
60%
5
20%
3
12%
0
0%
0
0%
2
8%
0
0%
0
0%
0
0%
1
4%
16
57%
40
1.4
BHL,
2009
Medical
Worst
Outcomes
#
%
4
8%
29
67%
14
33%
28
57%
3
6%
17
35%
1
2%
0
0%
29
62%
0
0%
0
0%
0
0%
9
19%
9
19%
45
85%
0
0%
0
0%
1
2%
4
8%
3
6%
3
6%
13
34%
12
32%
6
16%
1
3%
0
0%
6
16%
0
0%
0
0%
0
0%
23
46%
19
38%
34
1.4
Category
HealthExclnt
HealthVryGd
HealthGood
HealthFair
HealthPoor
Physician/year
Physician/2Mo
Prescriptions
NoMedHosp
MedHospAvg
CaffeineAvg
NonSmokers
Avg.PsychHos
Avg.Therapists
ExerciseFreq
BackProblems
HeartDisease
Diabetes
Cancer
LungDisease
KidneyDisease
LiverDisease
Anemia
ImmuneDis.
Ulcer
Asthma
BloodPressure
Stressful Events
Best
Outcomes
#
%
2
7%
1
4%
12
44%
7
26%
5
19%
4
1
3
23
82%
Worst
Outcomes
#
%
6
14%
7
16%
20
47%
7
16%
3
7%
2
1
2
35
70%
1.1
6.2
3
10
36%
4
13
26%
3.8
1.8
3
2
10
3
4
5
4
2
2
3
1
4
3
5
2
2
13
3
5
4
4
1
1
5
4
5
5
4
26%
6%
10%
8%
8%
2%
2%
10%
8%
10%
10%
8%
12
4
29
5
1
1
10%
72%
13%
3%
3%
36%
11%
14%
18%
14%
7%
7%
11%
4%
14%
11%
18%
Education
Avg.Yrs.Sch.
ElementaryEd
HighSchoolEd
College2yr
College4yr
GraduateSchool
12
3
19
5
0
1
11%
68%
18%
0%
4%
Category
Avg.Severity
StdDev
Death
SeriousIll
IlnessofSelf
RelationEnd
RelationProb
SupportProb
Ed.Prob
FinancialProb
HousingProb
WorkProb
HealthProb
LegalProb
TraumaProb
DailyHassles
Best
Outcomes
#
%
29.7
23.7
7
35%
10
48%
7
35%
11
48%
14
64%
12
52%
6
27%
14
64%
11
52%
10
45%
8
36%
9
41%
5
24%
13
62%
Worst
Outcomes
#
%
21.6
19.1
14
13
12
11
13
14
8
24
13
17
13
18
7
12
36%
32%
31%
30%
35%
38%
21%
59%
34%
46%
33%
45%
19%
32%
Client Defined Goals
Avg.Sever#1
Avg.Year#1
Avg.Sever#2
Avg.Year#2
Avg.Sever#3
Avg.Year#3
7.5
7.4
7.9
7.7
7.4
10.1
7.6
7.8
6.7
9.8
6.8
9.3
Miscellaneous
AssistYes
AssistNo
TOPExclnt
TOPVeryGd
TOPGood
TOPFAir
TOPPoor
VoluntaryNo
LifeGood%
10
16
6
4
10
3
2
4
59
38%
62%
24%
16%
40%
12%
8%
14%
5
40
5
4
23
7
3
22
62
11%
89%
12%
10%
55%
17%
7%
44%
36
Quartile analysis of
same data
Category
DeprsMean
DeprsNormal
DeprsMild
DeprsMod.
DeprsSevere
Best
Outcomes
#
%
.9
36
64%
6
11%
5
9%
9
16%
Worst
Outcomes
#
%
.3
40
71%
3
5%
4
7%
9
16%
Category
QOLMean
QOLNormal
QOLMild
QOLMod.
QOLSevere
Best
Outcomes
#
%
1.4
16
50%
2
6%
11
34%
3
9%
Worst
Outcomes
#
%
-0.3
35
71%
0
0%
6
12%
8
16%
IntprMean
IntprNormal
IntprMild
IntprMod.
IntprSevere
0.6
27
1
3
1
84%
3%
9%
3%
-0.1
45
2
2
0
92%
4%
4%
0%
SexMean
SexNormal
SexMild
SexMod.
SexSevere
-0.3
30
0
0
1
97%
0%
0%
3%
-0.5
46
0
1
1
ManicMean
ManicNormal
ManicMild
ManicMod.
ManicSevere
0.0
49
3
1
3
88%
5%
2%
5%
-.3
51
2
1
0
94%
4%
2%
0%
SleepMean
SleepNormal
SleepMild
SleepMod.
SleepSevere
1.1
30
6
8
10
56%
11%
15%
19%
0.3
36
2
6
9
68%
4%
11%
17%
PanicMean
PanicNormal
PanicMild
PanicMod.
PanicSevere
1.5
29
7
7
13
52%
13%
13%
23%
.5
41
1
3
11
73%
2%
5%
20%
SuicdMean
SuicdNormal
SuicdMild
SuicdMod.
SuicdSevere
2.0
38
2
1
15
68%
4%
2%
27%
1.5
40
1
3
10
74%
2%
6%
19%
PsycsMean
PsycsNormal
PsycsMild
PsycsMod.
PsycsSevere
1.9
26
6
6
16
48%
11%
11%
30%
.9
40
2
3
11
71%
4%
5%
20%
96%
0%
2%
2%
Category
ViolnMean
ViolnNormal
ViolnMild
ViolnMod.
ViolnSevere
Best
Outcomes
#
%
1.3
38
69%
2
4%
3
5%
12
22%
Worst
Outcomes
#
%
0.8
41
77%
1
2%
3
6%
8
15%
WorkMean
WorkNormal
WorkMild
WorkMod.
WorkSevere
0.4
24
2
1
3
-0.2
38
3
3
2
80%
7%
3%
10%
83%
7%
7%
4%
Substance Abuse
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DrugWorry
DUI
ExcessDrink
NoDrugsUsed
Alcohol
Maijuana
Cocaine
Other Drugs
Hallucinogens
5
7
0.5
19
11
4
1
2
0
15%
21%
58%
33%
12%
3%
6%
0%
14
21
0.5
36
9
7
1
3
1
27%
40%
69%
17%
13%
2%
6%
2%
37
Summary of quartile analysis findings
Agency X: suicide
• Knowing what patients to watch out for:
– Involuntary treatment
– Males more than females
– Who endorse few problems and especially
state their quality of life is great
– … BUT, who ironically endorse clinically
significant suicidal ideation
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38
Empirically Supported Treatment
Manual
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BHL provides multiple pathways
to improving service quality with
EMPIRICALLY SUPPORTED INTERVENTIONS
Outcome-based Referrals sm
Client Feedback Reports
Benchmarking and CQI
Hospital Prevention
42
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Predictive Alerts on First
Assessment
• Hospitalization alerts
– Who will be hospitalized in next six months
– Could save US more than a half billion each
year by increasing appropriate out-patient tx
• On what recovery path is this patient?
– Rapid responder
– Slow responder
– Negative responder
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43
Predicting Hospitalizations
Stelk, W., & Berger, M. (2009). Predictive Modeling: Using TOP
Clinical Domain Items to Identify Adult Medicaid Recipients at Risk
for High Utilization of Behavioral Health Services in a Managed
Care Provider Network. 40th SPR International Annual Meeting.
Santiago de Chile.
BCBSMA Warehouse studies: Potential savings of $6.6M per year.
Key is identifying patients heading over a cliff, but before they start
through the revolving door.
Reasonable sensitivity (40%), especially when considering the
prediction of future behavior, and excellent specificity (99%).
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44
WellnessCheck®
Infrastructure
with
Hands-Free Outcomes sm
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45
Hands-Free Outcomes sm
Three simple steps to measurement:
1.
2.
3.
Sign informed consent to use patient’s email
Register patient on WellnessCheck.net®
BHL handles the rest with sophisticated patentpending No-PHI sm security protections
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Patented “One Click Assessments”
You have been asked by your doctor to complete an important
WellnessCheck.net assessment of your health. This process is highly
confidential and your doctor will receive a critical laboratory health
assessment report that he/she can go over with you at your next
appointment. Please do not reply to this automated email message from
WellnessCheck but communicate directly with your doctor if you have any
questions.
Click on the following link and answer the security question (answer given to
you by your doctor in a separate handout or verbal communication):
https://demo.wellnesscheck.net/oltop/t/welcome.jsf?accessId=NTcyMDI2OjE1O
DoxOTYwOjA6MTo2NzM3
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WELLNESSCHECK®
assess patient health & treatment outcomes online
A secure site for doctors and their patients
Log in
Free outcome tools
Free data collection engines
Free client feedback reports
WellnessCheck.net
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49
Three administration options:
•In office over web
•In office on paper (print and fax forms to BHL)
•At home administration
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50
Pharmaceutical Outcomes
51
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