Background: The present study investigates the suitability of various treatment outcome indicators to evaluate performance of mental health institutions that provide care to patients with severe mental illness. Several categorical approaches are compared to a reference indicator (continuous outcome) using pretest-posttest data of the Health of Nation Outcome Scales (HoNOS). Methods: Data from 10 institutions and 3189 patients were used, comprising outcomes of the first year of treatment by teams providing long-term care. Results: Findings revealed differences between continuous indicators (standardized pre-post difference score ES and ΔT) and categorical indicators (SEM, JTRCI, JTCS, JTRCI&CS, JTrevised) on their ranking of institutions, as well as substantial differences among categorical indicators; the outcome according to the traditional JT approach was most concordant with the continuous outcome indicators. Conclusions: For research comparing group averages, a continuous outcome indicator such as ES or ΔT is preferred, as this best preserves information from the original variable. Categorical outcomes can be used to illustrate what is accomplished in clinical terms. For categorical outcome, the classical Jacobson-Truax approach is preferred over the more complex method of Parabiaghi et al. with eight outcome categories. The latter may be valuable in clinical practice as it allows for a more detailed characterization of individual patients.
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Across all health care settings, certain patients are perceived as ‘difficult’ by clinicians. This paper’s aim is to understand how certain patients come to be perceived and labelled as ‘difficult’ patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among ‘difficult’ patients, and three case studies of ‘difficult’ patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The ‘difficult’ patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient’s behaviours is made. The status of ‘difficult’ patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into ‘difficult’ or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients’ contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.
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BACKGROUND & AIMS: Dietetic interventions contribute to certain health objectives and other outcomes, but are mostly part of a multimodal and multidisciplinary approach what makes evaluating the actual effects of dietitians' involvement rather complex. Although monitoring and outcome evaluation (M&OE) can provide routine data to prove the effectiveness of dietetic interventions, this has not been established yet in different dietetic settings.METHODS: A comprehensive framework for M&OE in dietetics was developed by dietetic experts from five European higher education institutes for dietetics in the course of the EU sponsored project "Improvement of Education and Competences in Dietetics (IMPECD)".RESULTS: Firstly, clear definitions on M&OE are proposed to facilitate the use of consistent terminology, with a specific emphasis on the term "impact" covering macro-level outcomes such as cost-effectiveness. Secondly, the Dietetic Care Process (DCP) was merged into a logic model to demonstrate the position of M&OE in relation to intervention planning and implementation, in both group and individual settings. Thirdly, selecting the appropriate indicators is indispensable to monitor and evaluate outcomes, and requires a high level of dietitians' critical reasoning. A categorized overview of indicators is provided to support this process. Lastly, the consortium developed a checklist to give dietitians a handle on what elements could be included in their M&OE plan and trigger them to perform M&OE in practice.CONCLUSIONS: Innovative M&OE models may help dietitians to demonstrate their effectiveness in improving clinical outcomes and justify their role in health care.
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