[PC-BH-Integration] outcome tools

Thu Sep 3 11:12:54 EDT 2009

David,
Please don't take my comments personally or as a criticism of how you've
sent your life. I am just trying to discuss the data, what it tells us, and
how it can move the field forward. For the record, I am not a competitor. I
used to be in the outcomes business and published a fair amount some years
ago. I was a competitor years ago. It has been many years since I was
involved in competitive bidding on any outcomes project. However, I continue
to be interested in outcomes. I happen to think outcomes can be useful
clinically.

Your reponse does not address the the points I made in my prior email,
specifically:
1. Your statement of >90% improvement in not consistent with outcomes data,
whether RTC data or naturalistic data. I stand by my statement: this is a
Red Flag. Just because you go to the fun house and the mirror makes you look
thin, this perception doesn't mean that you are thin: the mirror may not be
accurate. If TOPS reports > 90% improvement, why measure at all? Why does
this improvement rate make the TOPS better than every other standard
instrument that show  far less change?
2. You review LSQ outcomes data is wrong: you will find that improvement is
generally about 60% (improvement in the Jacobson and Truax lexicon involves
both a) clinical improvement ("clinically significant" change) plus b)
recovery (clinically significant change plus return to functioning in the
normal range)-- not the 20% you report. I had an article on this a few years
ago noting that naturalistic data and RTC are, contrary to conventional
assumptions, remarkably similar (using the LSQ), even though the RTC data
controlled for co-morbidity etc.

Geof Gray

On Wed, Sep 2, 2009 at 1:31 PM, David Kraus <dkraus at bhealthlabs.com> wrote:

>  Geoffrey,
>
> Before you continue to disparage my life’s work, I believe you have an
> ethical responsibility to announce that you own/run a competitive system. If
> you have already done this and I’ve missed it, I apologize.
>
>
>
> That said, I welcome a good, scientific debate about the issues. I have
> slowly developed TOP over the past 20 years, refining items from an original
> 250 item pool down to the 58 current items based on sample sizes that now
> exceed a million cases—a dataset that allows for excellent benchmarking of
> results from primary care, specialty care, and integrated approaches. The
> tool has been independently validated by collaborators and competitors at
> Harvard, Penn State, Case Western, and Georgetown Universities, and we are
> in active collaboration with Departments of Family Medicine to create an
> Outcome-Based Referral system that will provide PCPs with excellent referral
> options if they decide not to treat BH issues in-house and don’t have access
> to the excellent pc/bh integration models discussed here.
>
>
>
> I would welcome reviewing LSQ references with published Jacobson & Truax
> (1991) *Reliable Improvement* statistics that are different than those
> reported from large, real-world datasets like those listed on our website
> (cf. Doucette, 2006; and Wampold & Brown, 2005’s JCCP paper on nearly
> 100,000 cases from PacifiCare datasets). In documenting reliable
> improvement, I believe TOP has clear and distinct advantage over other
> widely used tools and I believe the field is served by it being highlighted
> as an important consideration. I also freely admit that there is a downside
> to our approach—scale length. Roger Kessler, Alexander and others have
> clearly articulated this problem.
>
>
>
> Scale length is an important debate and I took what many may think is an
> odd approach twenty years ago in going for complexity rather than ease and
> simplicity. The reality is that patients rarely complain about scale length
> if the provider feels the questions are important and it can be integrated
> easily into standard workflows. Obviously these are two big Ifs, and we’ve
> worked hard to build processing infrastructures that offload these
> challenges for busy practitioners. Our 58 questions take about 15 minutes to
> complete (an amount of time that is shorter than most patients spend in the
> waiting room) and can be administered electronically (in the office or at
> home) or through print-on-demand paper/fax-based systems that our team
> processes for practitioners 24/7. If the scale is introduced as a normal
> course of business, patients do not worry that they are being stigmatized,
> but can overwhelm their PCP by talking about their stress rather than the
> “medical issues” that brought them into the office, and it is here where I
> think an integrate BH specialist can be invaluable.
>
>
>
> Frankly, as a clinician, I want the best chance of demonstrating the
> quality of my work, and believe that a relatively brief questionnaire that
> spans 13 domains and follows the APA/SPR Core Battery Conference
> recommendations (Horowitz, Lambert, & Strupp, 1997) can be very useful to
> therapists as well as PCPs that are often struggling to integrate multiple
> screenings for depression, anxiety, substance abuse, suicide etc. TOP covers
> these domains:
>
> 1) quality of life,
>
> 2) clinical domains (depression, panic/anxiety, mania, psychosis, substance
> abuse, sleep, suicidality, and homicidality), and
>
> 3) functional domains (work, social and sexual).
>
>
>
> Roger Kessler has advocated an excellent alternative approach that allows
> for 7 initial screening questions from a number of impressive tools that are
> obviously better known than TOP. I believe both approaches have merit.
>
> Our system provides a free, basic package that includes licensing rights to
> the tools, data processing engines and real-time/STAT lab reports that has
> worked well in primary care settings.
>
>
>
> Most importantly, I appreciate that this list serve is working on very
> important real-world challenges and I do have a “conflict of interest”. As
> such, I will return to my silent, learning mode unless someone makes
> statements about my life’s work that appear false and degrading.
>
>
>
>
>
> Sincerely,
>
> David
>
>
>
>
>
> David R. Kraus, PhD
>
> President, Founder, Chairman
>
> Behavioral Health Labs
>
>
>
> www.bhealthlabs.com
>
>
>
>
>
>
>
>
>
> *geoffrey gray* ggray at carepaths.com
> <pc-bh-integration%40lists101.his.com?Subject=Re%3A%20%5BPC-BH-Integration%5D%20Outcomes%20%26%20Evaluation&In-Reply-To=%3Cb2c0a15c0908310846u147aacb1i2b735503e7673dda%40mail.gmail.com%3E>
> *Mon Aug 31 11:46:14 EDT 2009*
>
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>
>  ------------------------------
>
> alexander,
>
> I agree that the TOPS is not appropriate for primary care. But i am also
>
> saying that it is psychometrically suspect and perhaps inappropriate with
>
> any population.  The TOPS shows rates of improvement that are not evidenced
>
> anywhere in the psychological literature. This raises a red flag. It is also
>
> unseemly for a company purporting to be "scientific" to make claims that are
>
> erroneous (see claim about LSQ--it is demonstrably false). Further, on
>
> reviewing the TOPS I see it has been subject to exactly one psychometric
>
> study; the LSQ has been subject to about 10 and has been used in rigorous
>
> outcomes research.
>
>
>
> On Sun, Aug 30, 2009 at 8:04 PM, Blount, Alexander <
>
> Alexander.Blount at umassmemorial.org <http://lists101.his.com/mailman/listinfo/pc-bh-integration>> wrote:
>
>
>
> >* Mass medicaid has required the TOPS for all cases with a few exceptions. A*
>
> >* very small number of early responders we're able to use other instruments.*
>
> >* It is long, fairly complex and very focused on psychiatric symptoms. It is a*
>
> >* very poor tool for primary care where many patients are particularly*
>
> >* sensitive to the stigma of a "mental" dx when the come presenting "medical"*
>
> >* problems.*
>
> >* *
>
> >* Alexander Blount*
>
> >* *
>
> >* ------------------------------*
>
> >*  *From*: pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >* *To*: pc-bh-integration at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >* *Sent*: Fri Aug 28 15:41:39 2009*
>
> >* *
>
> >* *Subject*: Re: [PC-BH-Integration] Outcomes & Evaluation*
>
> >* A post earlier today identified the TOPS package from Behavioral Health*
>
> >* Labs (www.bhealth.com) as an exemplary assessment system.*
>
> >* I went to their website and found this statement:*
>
> >* *
>
> >* Controlled studies consistently show behavioral health has excellent*
>
> >* outcomes with 80–90% of clients documenting reliable change.1 Outcome*
>
> >* tools should approximate these benchmarks, yet uni–dimensional*
>
> >* questionnaires will always fall short with heterogeneous, real–world patient*
>
> >* samples. Here are some examples:*
>
> >* *
>
> >* LSQ2TOP–DEPRS3TOP–FULL3   Improvement 20% 54% 91%  No change 72% 32% 5%*
>
> >* Deterioration 8% 14% 4%*
>
> >* *
>
> >* When nearly 90% of patients can show reliable improvement, why use a tool*
>
> >* that shows only 20-30%?*
>
> >* *
>
> >* *
>
> >* The TOPS people extol their measure because it shows 91% improvement while*
>
> >* other measures show less improvement. Some comments:*
>
> >* *
>
> >* 1) RTCs rarely show improvement over about 66% and naturalistic studies*
>
> >* rarely show that much; thus the TOPS shows an improvement rate unheard of in*
>
> >* behavioral health*
>
> >* *
>
> >* 2) They state that the LSQ shows a 20% improvement rate; this is untrue;*
>
> >* LSQ measures both improvement and recovery rates--together they average in*
>
> >* naturalistic settings (depending on the site, etc) of about 60%*
>
> >* *
>
> >* 3) If the TOPS measure shows 91% improvement of what use is it?*
>
> >* *
>
> >* It would appear that Behavioral Health Labs is engaged in marketing hype,*
>
> >* not science.*
>
> >* *
>
> >* *
>
> >* *
>
> >* *
>
> >* *
>
> >* *
>
> >* *
>
> >* On Fri, Aug 28, 2009 at 12:12 PM, Kessler, Rodger S. <*
>
> >* Rodger.Kessler at vtmednet.org <http://lists101.his.com/mailman/listinfo/pc-bh-integration>> wrote:*
>
> >* *
>
> >>*  Eric You are of course accurate. However the measurement problems are*
>
> >>* significant. Primary care settings are not research settings and there is*
>
> >>* literature that suggests that length of information collection is associated*
>
> >>* with lower response. So I am stuck. Part of the reason I use PHQ GAD and*
>
> >>* Audit, is that psychometrically  there are score ceilings that if not met*
>
> >>* after the first items, one can reasonably discontinue the measure. So… If*
>
> >>* someone is not in significant range then one can ask as few as 7 questions*
>
> >>* as a screen and followup. False positive and negative issues? Tons. But.. it*
>
> >>* still doesn’t deal wi prescription drugs smoking etc.*
>
> >>* *
>
> >>* One thing I meant to do and didn’t….*
>
> >>* *
>
> >>* Was to capture all of the different outcomes people have been suggesting*
>
> >>* in the last week and then feedback the group to the list. Has anyone else??*
>
> >>* If so please share. If not… I have nothing else to do, everyone who has*
>
> >>* suggested… Please resend the areas or measures to me at*
>
> >>* Rodger.Kessler at UVM.edu <http://lists101.his.com/mailman/listinfo/pc-bh-integration> and I will*
>
> >>* *
>
> >>*    1. Compile them and send them back to the list and*
>
> >>*    2.  Use them in the research workshop at CFHA  and discuss their*
>
> >>*    strengths and limits as part or a core focus for measurement dimensions.*
>
> >>*    Orif you have the energy (and memory) send me the list, dimensions and*
>
> >>*    measures, please…R*
>
> >>* *
>
> >>*  Rodger Kessler Ph.D. ABPP*
>
> >>* Research Director*
>
> >>* Collaborative Care Research Network*
>
> >>* Senior Scientist*
>
> >>* National Research Network*
>
> >>* American Academy of Family  Physicians*
>
> >>* Research Assistant Professor*
>
> >>* Department of Family Medicine*
>
> >>* Faculty Scholar*
>
> >>* Center for Clinical and Translational Science*
>
> >>* University of Vermont College of Medicine*
>
> >>* Berlin Family Health*
>
> >>* Fletcher Allen Healthcare*
>
> >>*   ------------------------------*
>
> >>* *
>
> >>* *From:* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration> [mailto:*
>
> >>* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>] *On Behalf Of *Eric Goplerud*
>
> >>* *Sent:* Thursday, August 27, 2009 3:39 PM*
>
> >>* *
>
> >>* *To:* pc-bh-integration at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *Subject:* Re: [PC-BH-Integration] Outcomes & Evaluation*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* It is important that we also include alcohol, substance abuse including*
>
> >>* pain medication misuse, and tobacco among the conditions that we measure and*
>
> >>* monitor in primary care/behavioral health integration projects.*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* Eric Goplerud, Ph.D.*
>
> >>* *
>
> >>* Center for Integrated Behavioral Health Policy*
>
> >>* *
>
> >>* Department of Health Policy*
>
> >>* *
>
> >>* George Washington University Medical Center*
>
> >>* *
>
> >>* 2021 K St., N.W., Suite 800 (mail address)*
>
> >>* *
>
> >>* 2121 K St., NW, Suite 210 (office address)*
>
> >>* *
>
> >>* Washington, DC 20006*
>
> >>* *
>
> >>* 202-994-4303*
>
> >>* *
>
> >>* 202-994-3472 (fax)*
>
> >>* *
>
> >>* www.ensuringsolutions.org*
>
> >>* *
>
> >>* *
>
> >>*   ------------------------------*
>
> >>* *
>
> >>* *From:* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration> [mailto:*
>
> >>* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>] *On Behalf Of **
>
> >>* ben007m at aol.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *Sent:* Thursday, August 27, 2009 10:21 AM*
>
> >>* *To:* pc-bh-integration at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *Subject:* Re: [PC-BH-Integration] Outcomes & Evaluation*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* All,*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* Great conversation!*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* Regarding both process and  outcome measurement, it is clear that we need*
>
> >>* to have a forum to discuss measurement of mental health in primary care, and*
>
> >>* a network to carry out such re search when the specific research questions*
>
> >>* are identified. We can do this – now - with all of your participation. Many*
>
> >>* of you are aware of the Collaborative Care Research  Network (CCRN). The*
>
> >>* CCRN was created to enhance the evidentiary support for mental health in*
>
> >>* primary care. By combining efforts from the field, we can use a national*
>
> >>* network to share data, resources, etc. all in the name of advancing*
>
> >>* collaborative care. For more information on the CCRN visit:*
>
> >>* http://bit.ly/xgkjB or for enrollment materials visit:*
>
> >>* www.aafp.org/nrn/ccrn Or, contact either of us back channel.*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* We would also encourage members of this list to come to the 2009 CFHA*
>
> >>* conference (www.cfha.net <http://www.cfha.net%3chttp:/www.cfha.net>)*
>
> >>* where questions like this get asked all the time. we will be doing a*
>
> >>* workshop during the meeting on exactly this topic. There will also be a*
>
> >>* dinner the Friday night of CFHA (October 23rd) to gather interested*
>
> >>* individuals in the CCRN and the larger research agenda for mental health and*
>
> >>* primary care. If you plan to attend CFHA, you should make plans for this*
>
> >>* dinner too!*
>
> >>* *
>
> >>* *
>
> >>* Ben and Rodger*
>
> >>* *
>
> >>*   Ben*
>
> >>* *
>
> >>* Benjamin F. Miller, PsyD*
>
> >>* *
>
> >>* Assistant Professor*
>
> >>* *
>
> >>* Department of Family Medicine*
>
> >>* *
>
> >>* University of Colorado Denver School of Medicine*
>
> >>* *
>
> >>* Email: benjamin.miller at ucdenver.edu <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *
>
> >>* Office: (303) 724-9706*
>
> >>* *
>
> >>* Cell: (857) 334-7833*
>
> >>* *
>
> >>* Administrative Director - Collaborative Care Research Network (CCRN<http://www.aafp.org/nrn/ccrn>)*
>
> >>* *
>
> >>* *
>
> >>* Senior Scientist - AAFP National Research Network*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* -----Original Message-----*
>
> >>* From: Jeanie Tse <jtse at iclinc.net <http://lists101.his.com/mailman/listinfo/pc-bh-integration>>*
>
> >>* To: pc-bh-integration at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>; pc-bh-integration at nccbh.net <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* Sent: Tue, Aug 25, 2009 7:36 am*
>
> >>* Subject: Re: [PC-BH-Integration] Outcomes & Evaluation*
>
> >>* *
>
> >>* We would also be interested in finding out how others are resolving this*
>
> >>* issue—agree that better evaluation procedures, tailored to community*
>
> >>* settings, are needed.  At ICL, we have been developing a short Healthy*
>
> >>* Living Questionnaire to look at self-reported health improvements.  We also*
>
> >>* look at the proportion of consumers who are accessing health interventions.*
>
> >>*  We have considered using the SF-8 health outcomes questionnaire as*
>
> >>* well—does anyone else have experience with this?*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *Jeanie Tse MD**
>
> >>* *
>
> >>* *Director of Integrated Health**
>
> >>* *
>
> >>* *Institute for Community Living**
>
> >>* *
>
> >>* *40 Rector Street**, 8th floor**
>
> >>* *
>
> >>* *New York**, New York 10006**
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *Tel: (212) 385-3030 ext 3113**
>
> >>* *
>
> >>* *Cell: (646) 761-7436**
>
> >>* *
>
> >>* *Fax: (212) 385-2380**
>
> >>*   ------------------------------*
>
> >>* *
>
> >>* *From:* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration> [mailto:*
>
> >>* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>] *On Behalf Of *Kessler,*
>
> >>* Rodger S.*
>
> >>* *Sent:* Monday, August 24, 2009 8:09 AM*
>
> >>* *To:* pc-bh-integration at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>; pc-bh-integration at nccbh.net <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *Subject:* Re: [PC-BH-Integratio n] Outcomes & Evaluation*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* Kendall, You are pointing to a crucial and perhaps the crucial flaw in*
>
> >>* the collaborative care enterprise. If Primary Care Behavioral Health is to*
>
> >>* gain traction within health care reform policy, rigorous process and outcome*
>
> >>* evaluation must be developed tons further. There used to be a show on public*
>
> >>* radio where the host would ask the audience” What do you know/” and the*
>
> >>* audience would yell out- “Not much!!”*
>
> >>* *
>
> >>* At this point that is a fairly accurate description of the state of the*
>
> >>* knowledge base about PCBH.  Despite the excellent outcomes of the IMPACT*
>
> >>* trials, if you look at the the recent AHRQ systematic review concluded that*
>
> >>* while collaborative care is effective we don’t know that it is much more*
>
> >>* effective than focused attention. We gotta do better.*
>
> >>* *
>
> >>* Ben Miller, Tai Mendenhall and I are doing a workshop at CFHA focusing on*
>
> >>* this question and suggesting domains and metrics for both process and*
>
> >>* outcome evaluation. In the mean time, locally, we are tracking PHQ, GAD and*
>
> >>* AUDIT scores, treatment initiation rates after referral, no show rates,*
>
> >>* volume contrasted to projections, co morbidity rates, range of physician*
>
> >>* referrers and a range of cost data. We will share our local data about PCBH*
>
> >>* in the Patient Centered Medical Home at yet another CFHA workshop this*
>
> >>* fall.  Happy to discuss this further back channel if helpful. Rodger*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* Rodger Kessler Ph.D. ABPP*
>
> >>* Research Director*
>
> >>* Collaborative Care Research Network*
>
> >>* Senior Scientist*
>
> >>* National Research Network*
>
> >>* American Academy of Family  Physicians*
>
> >>* Research Assistant Professor*
>
> >>* Department of Family Medicine*
>
> >>* Center for Translational Science*
>
> >>* University of Vermont College of Medicine*
>
> >>* Berlin Family Health*
>
> >>* Fletcher Allen Healthcare*
>
> >>*   ------------------------------*
>
> >>* *
>
> >>* *From:* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration> [mailto:*
>
> >>* pc-bh-integration-bounces at lists101.his.com <http://lists101.his.com/mailman/listinfo/pc-bh-integration>] *On Behalf Of *KENDALL*
>
> >>* ALEXANDER*
>
> >>* *Sent:* Friday, August 21, 2009 3:57 PM*
>
> >>* *To:* pc-bh-integration at nccbh.net <http://lists101.his.com/mailman/listinfo/pc-bh-integration>*
>
> >>* *Subject:* [PC-BH-Integration] Outcomes & Evaluation*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* We are really interested in what other Primary Care/Behavioral Health*
>
> >>* integrated projects are doing in terms of program evaluation as well as*
>
> >>* patient outcomes.  We want to get past satisfaction surveys and demographics*
>
> >>* to demonstrating program/service effectiveness and cost-savings.< /font>*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* What outcomes (both program and patient) are you measuring?  How are you*
>
> >>* demonstrating better patient outcomes and/or program outcomes?*
>
> >>* *
>
> >>* *
>
> >>* *
>
> >>* *Kendall P. Alexander, LCSW**
>
> >>* *
>
> >>* *Director of Integrated Services**
>
> >>* *
>
> >>* *North** Range** Behavioral Health**
>
> >>* *
>
> >>* *1300 North 17th Avenue**
>
> >>* *
>
> >>* *Greeley**, CO 80631**
>
> >>* *
>
> >>* * **
>
> >>* *
>
> >>* *(O) 970-347-2378**
>
> >>* *
>
> >>* *(Cell) 970-412-2051**
>
> >>* *
>
> >>* * **
>
> >>* *
>
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