Penelope
YES the message did get through, to some people and YES ....we agree..
Chris
Chris
Chris Brown- Program Manager
WHO European Office for Investment for Health and Development, Venice. Italy
+390412793865
+390412793847
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----- Original Message -----
From: The Health Equity Network (HEN) <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Wed Aug 03 16:53:54 2011
Subject: Re: "Reducing spending on low clinical value treatments"
I am not sure if the message below got through, but I am very concerned about the use of PROMs to determine which treatments should be provided.
"I hesitate to join in this discussion where there are so many well-known experts. However, among other things the arguments appear to be exposing the limitations and potential misuse of PROMs (Patient Reported Outcome Measures ). As I understand it, these measure/compare paitents' health status etc before and after treatment. However, the benefit of any treatment/intervention is surely the difference between health status etc after treatment and health status etc (in the future) had there been no treatment. Whilst this cannot be known precisely for any individual, it will be known for a population of patients. Thus with any condition which (on average) is likely to deteriorate over time (and where there is no detriment from early treatment) the 'benefit' is likely to be far higher than the simple before/after difference. Further, it would appear that the logic of arguing that a condition must be allowed to deteriorate before treatment so that the before/after difference is sufficiently high could also logically lead to arguing against any preventative measures/therapy for currently well people."
Penelope Mullen
----- Original Message -----
From: Ash Paul <mailto:[log in to unmask]>
To: [log in to unmask]
Sent: Tuesday, August 02, 2011 9:36 PM
Subject: Re: "Reducing spending on low clinical value treatments"
Dear Martin,
Yeah you are right there, the research area of Patient Reported Outcomes (PRO) in mental disorders and conditions is not advanced as medicine and society might expect from a medical specialty that does not rely on unequivocal biological indexes.
This delay may have been due to the difficulty to adequately define and distinguish the domains of (i) the patients’ reports of symptoms and associated impairments observed and described by the patient himself or herself from (ii) the patients’ behaviors and observed associated impairments described by the clinician/interviewer. PRO assessment in mental disorders and conditions is to be disentangled from the assessment of the domain of the patients’ behaviors, performances and conduct observed by the clinician or somebody else: this domain should focus only on “report that comes directly from the patient”, in line with the assessment of PRO in medical disorders.
However, this neglected domain of mental health care is now being looked at urgently on both sides of the pond.
This specific domain of psychopathology, originally named by Jaspers “phenomenology” and defined in terms of “Subjective Phenomena of Morbid Psychic Life” - recently hypothesized extinct : Andreasen NC. DSM and the death of phenomenology in America: An example of unintended consequences. Schizophr Bull 2007;33(1):108-112. http://schizophreniabulletin.oxfordjournals.org/content/33/1/108.long <http://schizophreniabulletin.oxfordjournals.org/content/33/1/108.long> - is reformulated and advanced by contemporary psychiatric phenomenology as (i) a component of the assessment of the symptoms (indicators) of the disorder and of the diagnostic formulation (in combination with other components like patient’s judgment and behaviour), and as (ii) the core of disorder-specific “patient reported outcomes”, comparable to PROs of medical illnesses. This reformulation enables the appropriate assessment of PROs in severe mental disorders and schizophrenia in line with medical illnesses. For example, the operational definition of the “passively received experiences” (the simplest, most immediate PROs) of schizophrenia enables this domain to share the characteristics of the “passively received experiences” of pain regarding intensity, relief and frequency - Moscarelli M. Passive and Active Schizophrenia: Toward a New Descriptive Micropsychopathology. Schizophr Bull 2009; 35(6):1183-96. http://schizophreniabulletin.oxfordjournals.org/content/35/6/1183.long <http://schizophreniabulletin.oxfordjournals.org/content/35/6/1183.long> . - Pain has been recognized as a symptom that merits clinical attention in all patients receiving care for any disorder by the NIH Clinical Center, Legal, Ethics, and Safey Issues (http://www.cc.nih.gov/participate/patientinfo/legal.shtml <http://www.cc.nih.gov/participate/patientinfo/legal.shtml> ): “Every patient has the right to appropriate assessment and relief of pain”. Similarly, the subjectively disturbing “passively received experiences” of schizophrenia may share the right to be appropriately assessed and targeted by treatment for relief.
These are not my words, they are words of advice given to me by eminent conultants in mental health psychiatry.
As a NHS Commissioner, I strongly feel that the first step in getting these mental health PROMs is to map out standards for mental health services and insert them into our contracts with the mental health service providers, just as they have done in Scotland:
http://www.icptoolkit.org/home.aspx
* CAMHs standards (PDF, 1138K) <http://uk.mg1.mail.yahoo.com/his/idoc.ashx?docid=1ff79055-a85f-456a-aea0-ee47ab963fc0&version=-1>
* CAMHs toolkit Background Reading (PDF, 35K) <http://uk.mg1.mail.yahoo.com/his/idoc.ashx?docid=e1e43f4b-9bb1-430d-b20f-cac519cd3ee8&version=-1>
* Integrated Care Pathways for Mental Health Standards Dec 2007 (PDF, 1512K <http://uk.mg1.mail.yahoo.com/his/idoc.ashx?docid=072bb37c-ea1c-4578-86fe-eaa4f9b84d90&version=-1>
Regards,
Ash
From: Martin Rathfelder <[log in to unmask]>
To: [log in to unmask]
Sent: Tuesday, 2 August 2011, 20:13
Subject: Re: "Reducing spending on low clinical value treatments"
If we only reward patient outcomes we won't be spending much on mental
health will we?
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