Measurement Based Care Solutions: Questioning the Evidence

First, let’s get the terms straight. What we and others in the psychotherapy literature have called “systematic client feedback” (or just client or patient feedback) or “routine outcome monitoring (ROM),” the integrated care and psychiatric literature has called “measurement based care.”

 

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Outcomes Management Meets Measurement Based Care

Now that all three major accrediting bodies (Joint Commission, COA, CARF) require client-generated outcomes management, new companies purporting to provide evidence based web solutions to administer and score validated instruments are appearing at the pace of the book-of-the-month club main selection.

Hoping to cash in on the new requirements, these new, very well-funded companies, with bulging staffs and slick websites, claim to provide you with a measurement based care solution in an expansive evidence base firmly grounded in randomized clinical trials (RCT), the language of science.

 

"Evidence" for a Measurement Based Care Solution

This is all a scam. In my reading and preparation for submitting for publication our RCT conducted in three integrated care settings, I kept running across assertions about the evidence base of certain measurement based care solutions, but I couldn’t find any of the purported evidence with the measures (e.g., PHQ9, GAD7, DLA20, or custom created measures from validated instruments, etc.) that are promoted in this literature and contained in these new companies.

All the evidence cited and used to make the case for a measurement based care solution were from the Outcome Questionnaire 45 System (OQ; Lambert’s) and the Partners for Change Outcome Management System (PCOMS). In other words, while the measures often cited with measurement based care solutions were standardized and validated, no RCT has evaluated the use of the solutions to improve care. Measurement based care does have the oft-cited evidence base, but not with the measures with which it is most associated.

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And, not with the clinical process most espoused. Here is how measurement based care is typically described:

  1. A routinely administered symptom or outcome measure at each encounter;
  2. Practitioner review of data;
  3. Patient review of data; and
  4. Collaborative reevaluation of the treatment plan informed by data.

Does that process sound familiar? This is the PCOMS clinical process that I created from my clinical practice and that Dr. Jacqueline Sparks and I first articulated back in 2002. So what is advocated is the use of validated measures combined with the PCOMS clinical process. The only problem is that there is NO evidence and none of the measurement based care literature can cite an example of improved outcomes with the PHQ and GAD, let alone with the PCOMS process.

For example, a recent review advocating for measurement based care (Fortney et al., 2017) cited 15 RCTs supporting its use. None of the RCTs used the PHQ or GAD. None of them included collaboration with patients or more frequent administration. All but three of the studies were of the OQ System or PCOMS.

 

Don't Settle for Less Than a Truly Evidence Based Clinical Process

The OQ system and PCOMS are the only measurement based care solutions that are truly evidence based. And PCOMS is the only one with a documented, evidence based clinical process that includes clients as full partners, involving them in all decisions affecting their care.

 

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