Assess outcomes meaningful to patients to improve care equity and quality

Dealing with inequality in access and achieving optimal outcomes for all are central to those engaged in the care of people with mental health problems.¹

To compare care quality and access across different settings and patient groups, we need large amounts of data, speakers agreed. But size is not all that counts. They also pointed out that data need to be representative of the wider population, obtained in real-world circumstances, accurate, unbiased, secure and – perhaps above all – clinically meaningful.

What matters is how well and fairly we achieve the outcomes that patients most want

At the end of the day, the key outcomes are what patients themselves want, said Gray Norquist, chair of the APA Council on Quality Care. Questioning the frequent focus on monitoring procedures, he emphasized that it is not just doing things that matters, but doing things that make a difference.

Crossing the quality chasm

Echoing an earlier call for ways to assess and reduce health disparities, Juliet Beni Edgcomb (University of California Los Angeles, USA) asked whether electronic health records (EHR) had actually fulfilled the promise of providing a large repository of relevant clinical data while also offering tools to guide decision making at the bedside.

Her conclusion was not encouraging. The fact that there is still a variety of systems in operation, with no common data architecture, means that it is difficult to collate and compare information across institutions. Some clinicians feel that the required documentation is too great a burden to tolerate, resulting in missing data. Others fear loss of clinical autonomy.

And there is evidence – though this is from the context of emergency medicine – that clinicians document in the EHR more investigations than they have actually conducted.²

Where data are incomplete, inaccurate or subject to bias, the danger is that electronic health records – far from improving equity in care – serve only to perpetuate disparities, she warned.

We need to drive our practice towards both better quality and greater equity

Examples of shortfalls in quality

To illustrate what still needs to be done in the field of mental health, Dr Edgcomb cited two recent examples:

• Guidelines recommend that patients with substance use disorders who also have depression should receive concurrent treatment for both conditions, yet treatment of depression in such patients is of poorer quality than in patients with no substance misuse.³
• In the United States, national adherence rates for two measures related to the timeliness of care for children with mental health problems were below 50% in a recent study, and performance quality had not improved over the previous five years.⁴

The establishing of the Accrual to Clinical Trials (ACT) network,⁵ the national Patient-Centered Clinical Research Network (PCORNet),⁶ and the APA’s PsychPRO registry⁷ – which aims to optimize outcomes using tools to chart and benchmark care - represent further efforts to monitor and promote both quality and equity in the treatment of those with physical or mental health problems. All will wish success to such endeavors.