Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• Compare the effectiveness of strategies to increase adherence to evidence-based guidelines and treatment regimens. One nominator recommended rewording this item as below, stating that it would be more informative to split this into distinct bullets. The aspect of increasing adherence to evidence based guidelines relates primarily to clinicians whereas adherence to treatment regimens is more dependent upon patients, although there is some overlap of involvement with each of these questions.
• Compare the effectiveness of strategies to increase the provision of evidence-based, guideline concordant treatment approaches to patients.
• Compare the effectiveness of strategies to increase patients’ adherence to treatment.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of strategies such as using multidisciplinary treatment, electronic health records, decision support capabilities, and personal health records- for increasing health professionals’ use of guideline-concordant treatments, increasing patients’ adherence to guideline-based regimens, and improving continuity of care and communication. (One nominator recommended deleting this item.)
• Compare the effectiveness of technological interventions (such as pill bottles with automated reminders, therapeutic interactive voice response systems, and phone- and web-based programs to enhance adherence) with standard care. (One nominator recommended deleting this item.)
• Compare the effectiveness of strategies for enhancing adherence to medication regimens for people with SMI. (One nominator commented that it is important to note that adherence data can sometimes be difficult to interpret. Although it would seem that it is straightforward to tell if a person is or is not taking a medication, there can be many reasons for “non-adherence” ranging from patient preference to adverse effects that outweigh the treatment
• Compare the effects of preference sensitive care with usual care on patient adherence with treatment and other outcomes of importance.
• Compare the effectiveness of strategies to disseminate and implement research findings and new discoveries into community practice to foster evidence-based, state-of-the-art treatment.
• Compare the effectiveness of strategies to implement evidence-based practices using dissemination and demonstration projects.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with Serious Mental Illness (SMI) and specific mental illnesses

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Improvement in patients’ adherence to guideline-based regimens, including medication regimens
• Improvement in patients’ continuity of care and communication
• Improvement in the initiation of guideline-based treatments by clinicians.
• Reduced symptoms
• Reduced morbidity and mortality
• Reduced risk to self and others
• Reductions in frequency and duration of hospitalizations or emergency visits
• Enhanced functioning and quality of life

Describe any health-related risks, side effects, or harms that you are concerned about.

• An important risk to consider relates to the unintended consequences of emphasizing guideline based regimens when they may not be appropriate for a given individual. Patients may have personal preferences that differ from the guideline recommended approach or they may have complex comorbidities for which no evidence is available or for which standard guideline-based regimens may be inappropriate.
• If patients are adherent to recommended treatment, it is conceivable that they may experience more harms from that adherence that from nonadherence. For example, if a patient regularly adheres with antipsychotic treatment despite experiencing only a minor degree of symptom relief, yet develops weight gain, diabetes and metabolic syndrome, adherence would actually be a harm

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

More than 30 percent of the US population suffers from a mental illness each year.1 Recent studies have shown that many patients with SMI do not receive treatments that are consistent with evidence-based guidelines. The Schizophrenia Patient Outcomes Research Team (PORT) client survey reported that the rates at which patients’ treatment conformed to the recommendations were modest at best, generally below 50%. There is considerable variation in treatment for serious mental illness (SMI). Recent studies have shown that many patients with SMI do not receive treatments that are consistent with evidence-based guidelines. (See See also Mojtabai R et al. Schizophr Bull. 2009 Jul;35(4):679-95; West et al. Psychiatr Serv. 2005 Mar;56(3):283-91.) Nonadherence with treatment is a frequent occurrence in the course of treatment for any disorder (e.g., acute infection, hypertension, diabetes). Thus, it is not surprising that adherence can also be a challenge for individuals with serious mental illness. There are many contributors to this, some of which are general factors and some which are more specific to living with a psychiatric disorder (http://www.arcmesa.org/7142/monograph.htm). Whatever the contributors, treatment non-adherence is important to address as it is associated with symptom recurrence and related complications (e.g., need for acute emergency or inpatient care, increased distress from symptoms, increased risk to self or to others, disruptions in functioning and effects on quality of life).

1. National Comorbidity Survey Replication. 12-month prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Boston, MA: Harvard School of Medicine; 2007. Accessed July 8, 2010, from http://www.hcp.med.harvard.edu/ncs/ftpdir/table_ncsr_12monthprevgenderxage.pdf

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Better ways to increase adoption of guideline-based treatments by clinicians will increase the likelihood of improved clinical outcomes for patients. Answers to these research questions will also be able to inform the development of practice guideline recommendations for psychiatrists relating to enhancing patient adherence. In terms of day-to-day clinical practice, I have observed the negative impact that poor treatment adherence can have on patient’s lives and those of their families. This makes it important to develop treatments that are tolerable and effective for patients and also deliver them in a fashion that will support ongoing adherence. I have also been a co-investigator in a longitudinal study of individuals who experienced a first hospitalization for a psychotic episode. Naturalistic followup of these individuals over 10 years showed substantial discrepancies between actual care and guideline-recommended treatment (Mojtabai R et al. Schizophr Bull. 2009 Jul;35(4):679-95). Gaps in care and unmet treatment needs were particularly pronounced for provision of recommended psychosocial treatments and at least half of these individuals continued to experience significant symptoms. Given the public health impact of undertreated and untreated mental illness and the burdens and distress (for patients and for families) associated with persistent symptoms, approaches to increase the provision of guideline-concordant treatment are essential.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Differences in clinicians’ adherence to practice guidelines obviously reflect variations in clinical care. If evidence clearly supports particular interventions to enhance guideline adherence by clinicians or treatment adherence by patients, then this could inform changes in policy that would improve patient outcomes (e.g., enhanced reimbursement to support greater time spent with patients in preference sensitive care, directly observed therapy, assertive community treatment, assisted outpatient treatment, long acting injectable medication use)

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to treatment adherence. Evidence on approaches to increasing clinician use of guidelines could be applied to the development and dissemination of the American Psychiatric Association’s Practice Guidelines.

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

One common issue that contributes to patient difficulties with adherence relates to difficulties in obtaining needed treatments, either due to financial hardship, lack of adequate transportation to reach treatment sites, lack of insurance or lack of coverage of specific treatments. Inequities in the availability of treatments across communities and geographic areas can also make it difficult for patients to adhere to treatment and for clinicians to recommend guideline-based treatment.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to treatment adherence. Evidence on approaches to increasing clinician use of guidelines could be applied to the development and dissemination of the American Psychiatric Association’s Practice Guidelines.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

1- The Practice Guidelines project of the American Psychiatric Association was asked for the name of someone to participate; my name was submitted; 2- Through AHRQ and CTSA activities