Search

Objective: To investigate the variability and stability of psychotherapists' effectiveness and the implications of this differential effectiveness for quality improvement in a managed care environment., Study Design: Subset archival outcome data for patients receiving behavioral health treatment were divided into 2 time periods to cross-validate the treating therapists' effectiveness. After categorizing the therapists as "highly effective" and "others" during the baseline period, the stability of their individual effectiveness was cross-validated in the remaining time period., Methods: Outcomes for 10 812 patients (76.0% adults, 24.0% children and adolescents) treated by 281 therapists were included. Patients initiated treatment between January 1999 and June 2004. Mean residual change scores obtained by multiple regression were used to adjust for differences in case mix among therapists. Raw change scores as well as mean residualized change scores were compared between the 71 psychotherapists identified as highly effective (25%) and those identified as other (remaining 75%)., Results: During the cross-validation period, mean differences in residualized change score between highly effective therapists and others were statistically significant (difference = 2.8; P < .001), which corresponded to an average of 53.3% more change in raw change scores with the highly effective therapists. Results could not be explained by case mix differences in diagnosis, age, sex, intake scores, prior outpatient treatment history, length of treatment, or therapist training/experience., Conclusion: Behavioral health outcomes for a large system of care could be significantly improved by measuring clinical outcomes and referring patients to therapists with superior outcomes.

Evidence is presented demonstrating that placebo control groups benefit more from psychotherapy than no-treatment control groups but less than patients who receive theory-driven treatments. Through a brief review of the results of comparative outcome studies, studies which compare patient outcomes for those seen by trainees or paraprofessionals versus professional therapists and those which show an early response of a sizable portion of patients, a case is made for the powerful effects of common factors in psychotherapy. The early response phenomenon has proposed another challenge to the unique effects of specific psychotherapies and to the wisdom of emphasizing the causative effects of specific techniques in the treatment of specific disorders.

Many branches of medicine rely heavily on lab tests to monitor client treatment response and use this information to modify their treatment. By contrast, those who offer psychological interventions seldom rely on formal assessments (lab tests) to monitor their clients' response to treatment. Data are presented that demonstrate that clinicians rarely accurately predict who will not benefit from psychotherapy. This finding is contrasted with the use of a questionnaire (lab test data) and decision rules on the basis of a client's expected progress. Results have indicated that formal methods of monitoring were able to identify 100% of the patients whose condition had deteriorated at termination, and 85% by the time they had attended three treatment sessions. Practitioners are encouraged to consider formal methods of identifying the deteriorating client.

We describe and illustrate our system to measure, monitor, and feed back information about patient treatment. This clinical innovation relies on research-based clinical decision tools that provide psychotherapists with timely warnings when a patient's deviation from an expected treatment response foretells possible treatment failure. We summarize the results of four controlled studies using this methodology; the collective results suggest that measuring, monitoring, and predicting treatment failure (feedback) enhance treatment outcomes for patients who have a negative response. Clinicians are encouraged to employ these methods in routine practice despite their confidence in their own ability to predict patient outcome.

The true value of ultrasound in acute abdominal pain lies in its ability to detect gynecologic disorders and effectively rule out other causes of acute abdominal pain that require surgical repair. Although the emergent gynecologic indications discussed in this article are few in number, this does not suggest that the nonpregnant patient presenting to the ED with abdominal pain should not receive an ultrasound examination. On the contrary, the author believes that in a "perfect world," ultrasound should be the initial imaging study in most of these patients. The reality is that it is difficult to convince radiology colleagues to call in a sonologist in the middle of the night for any indication other than ovarian torsion when CT scans can diagnose ovarian cysts and tubo-ovarian abscess. As was pointed out in the section on ovarian torsion, even adequate ovarian blood flow does not rule out this diagnosis.Ideally, an ultrasound of the pelvis could be undertaken at the time of the pelvic examination, adding as little as 5 to 10 minutes. If a gynecologic disorder could be confirmed, other imaging studies might be unnecessary,thereby reducing cost (potential savings on laboratory tests, cervical cultures, or CT scans), length of stay, and adverse complications of CT(contrast material reactions, and radiation exposure).Emergency medicine ultrasound continues to grow at a rapid pace. We are working toward a time when most EPs will be competent and comfortable performing bedside ultrasound examinations in a limited number of applications. The gynecologic application of ultrasound,however, requires skill beyond the level of the primary applications of emergency medicine ultrasound-specifically, mastering Doppler ultra-sound. Although ultrasound has proved to be a valuable imaging modality in the nonpregnant patient with acute abdominal pain when performed by a seasoned sonographer, the role of ED ultrasound has been limited to those EPs with significantly more training. The author believes that even limited expertise in gynecologic ultrasound is valuable in helping direct the management of these patients. Further research by skilled EP sonographers eventually will help define the role of EPs in this particular application of ultrasound. EPs should not be discouraged from developing expertise in this examination when a confirmatory study in radiology will be performed. Miles on the "ultrasound odometer" will not only sharpen sonographic skills but also will help the EP to better communicate with nonpregnant patients presenting with abdominal pain. There is a fairly specific barometer already in place to gauge one's gynecologic ultrasound skills: a seasoned EP sonographer never skips over the chart of a young woman with right lower quadrant pain.

The use of information technology (IT) for the purpose of improving psychotherapy outcomes in the context of routine clinical practice is described. IT efforts from two research programs, one in Germany and the other in the United States, are based on evidence that not all patients who enter treatment have a positive outcome and that continuous monitoring of patient treatment response with immediate feedback to therapists can be used to increase the likelihood of success for the poorly responding client. Such monitoring and feedback can best be accomplished by IT methodologies. Suitable IT systems are described, and their strengths and limitations are highlighted. Evidence is presented that supports the positive value of such efforts for improving patient treatment response., (Copyright 2004 Wiley Periodicals, Inc. J Clin Psychol 60: 285-299, 2004.)

Clinically significant change refers to meaningful change in individual patient functioning during psychotherapy. Following the operational definition of clinically significant change offered by Jacobson, Follette, and Revenstorf (1984), several alternatives have been proposed because they were thought to be either more accurate or more sensitive to detecting meaningful change. In this study, we compared five methods using a sample of 386 outpatients who underwent treatment in routine clinical practice. Differences were found between methods, suggesting that the statistical method used to calculate clinical significance has an effect on estimates of meaningful change. The Jacobson method (Jacobson & Truax, 1991) provided a moderate estimate of treatment effects and was recommended for use in outcome studies and research on clinically significant change, but future research is needed to validate this statistical method.