Mental health quality improvement goes global
Authors: Benjamin G. Druss
Journal: World Psychiatry (2018)

The field of quality assessment in health care traces its origins back more than 50 years to A. Donabedian's seminal article outlining a framework for understanding quality of care from a health systems perspective1. Quality improvement in mental health is a younger enterprise. A 2006 report from the US Institute of Medicine outlined the challenges in assessing and improving quality of care for mental disorders, including lack of standardized approaches for diagnosing mental health and substance use disorders; limited evidence base supporting current quality measures, and fragmentation and lack of information technology infrastructure to measure quality. Nonetheless, the report argued that quality improvement principles could, and should, be applied to efforts to improve mental health care2. Since the publication of that report over a decade ago, innovations in health technology, the growth of large integrated health systems, and movement of mental health into the mainstream of health care have helped spur a rapid growth of mental health quality improvement in the US3. Kilbourne et al's important paper4 provides an update on the state of mental health care quality improvement worldwide. The authors describe initiatives to measure and improve care within the US and other developed countries, and make recommendations to better incorporate them into routine practice. The paper provides a valuable framework for understanding quality improvement from an international perspective. There are tensions inherent in mental health care quality improvement that become particularly evident in efforts to consider this process from a global perspective. Historically, performance measurement systems in the US and other developed countries have been built on existing administrative datasets5. The elements of these datasets vary across countries and health systems – for instance, fee-for-service systems typically aggregate billable claims, whereas countries whose systems focus on inpatient care primarily collect data from these settings. Differences in structure and financing of mental health systems may shape the availability of data and constrain the collection of uniform measures across countries. They may also change the relative priorities placed on measures across domains of care. For instance, inpatient readmission has become a focus of incentive payment systems in the US Medicare program, where cost reduction and shifting to outpatient care have been central policy goals6. Low- and middle-income countries may face particular challenges in measuring quality. These countries commonly lack an information technology infrastructure to measure and track quality. Quality assessment in these countries typically relies heavily on counts of facilities or providers per capita7. The World Health Organization uses the treatment gap – the proportion of those with a mental disorder diagnosis who do not receive any care – as a common metric of unmet need across countries8. This measure has been important from a policy and advocacy perspective. However, it also has limited ability to capture more nuanced views of quality of care among individuals once they have begun treatment. The field of mental health care quality assessment is currently moving from an emphasis on measuring delivery of care towards assessing clinical outcomes. This is an important development, since improving outcomes is a central goal of any health system. However, it is important to keep in mind that, more than with other health conditions, mental disorders can only be understood in their individual and social contexts. This is particularly the case for functional outcomes such as quality of life, employment and recovery. There is a need to further develop the science of mental health functioning, and to understand how to adapt and interpret these measures of function across countries and cultures. The most important function of quality assessment is in using these measures to improve care. Moving from quality assessment to care improvement requires attention to both desired goals and potential unintended consequences. D. Campbell famously noted that, once a quantitative indicator is used for decision making, there is the potential for the measure and the underlying processes to become corrupted9. Pay-for-performance and public reporting of outcome measures can create incentives to cherry-pick patients who are more likely to improve. They can also lead providers to "teach to the test" and neglect domains of care that are difficult to measure. These potential challenges are universal, but may take different forms across countries based on incentive structures and organization of health systems. We should approach quality improvement like we do with any other intervention in medicine – as a powerful tool that carries both potential benefits and risks. We need to develop and test the best practices for improving quality of care across different systems. A variety of social science disciplines can help inform these efforts. Behavioral economics can provide guidance on how to structure monetary and non-monetary incentives to change mental health provider and patient behaviors. Implementation science can provide insights into how to disseminate mental health interventions such as quality improvement within complex systems of care. Medical anthropology can provide a greater understanding of how to understand and improve mental health function across countries and cultures. These challenges and opportunities are not unique to mental health care quality improvement. In the final interview prior to his death, Donabedian highlighted the importance of focusing on patients' experiences rather than simply on the technical aspects of care in quality improvement efforts: "The view of quality that is taken in the hospital is really limited to technical competence and, more recently, to superficial attention to the interpersonal process. The role of the doctor is to actively make sure that the patient arrives at a decision that is a reasonable one for him or her… it is the ethical dimension of individuals that is essential to a system's success"10. This emphasis on the patient should be the central organizing principle in future efforts to measure and improve mental health care across the globe. Benjamin G. Druss Rollins School of Public Health, Atlanta, GA, USA