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Meta-Analysis
. 2016 Jul 13;7(7):CD011119.
doi: 10.1002/14651858.CD011119.pub2.

Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults

Tony Kendrick  1 , Magdy El-Gohary, Beth Stuart, Simon Gilbody, Rachel Churchill, Laura Aiken, Abhishek Bhattacharya, Amy Gimson, Anna L Brütt, Kim de Jong, Michael Moore
Affiliations
Meta-Analysis

Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults

Tony Kendrick et al. Cochrane Database Syst Rev. .

Abstract

Background: Routine outcome monitoring of common mental health disorders (CMHDs), using patient reported outcome measures (PROMs), has been promoted across primary care, psychological therapy and multidisciplinary mental health care settings, but is likely to be costly, given the high prevalence of CMHDs. There has been no systematic review of the use of PROMs in routine outcome monitoring of CMHDs across these three settings.

Objectives: To assess the effects of routine measurement and feedback of the results of PROMs during the management of CMHDs in 1) improving the outcome of CMHDs; and 2) in changing the management of CMHDs.

Search methods: We searched the Cochrane Depression Anxiety and Neurosis group specialised controlled trials register (CCDANCTR-Studies and CCDANCTR-References), the Oxford University PROMS Bibliography (2002-5), Ovid PsycINFO, Web of Science, The Cochrane Library, and International trial registries, initially to 30 May 2014, and updated to 18 May 2015.

Selection criteria: We selected cluster and individually randomised controlled trials (RCTs) including participants with CMHDs aged 18 years and over, in which the results of PROMs were fed back to treating clinicians, or both clinicians and patients. We excluded RCTs in child and adolescent treatment settings, and those in which more than 10% of participants had diagnoses of eating disorders, psychoses, substance use disorders, learning disorders or dementia.

Data collection and analysis: At least two authors independently identified eligible trials, assessed trial quality, and extracted data. We conducted meta-analysis across studies, pooling outcome measures which were sufficiently similar to each other to justify pooling.

Main results: We included 17 studies involving 8787 participants: nine in multidisciplinary mental health care, six in psychological therapy settings, and two in primary care. Pooling of outcome data to provide a summary estimate of effect across studies was possible only for those studies using the compound Outcome Questionnaire (OQ-45) or Outcome Rating System (ORS) PROMs, which were all conducted in multidisciplinary mental health care or psychological therapy settings, because both primary care studies identified used single symptom outcome measures, which were not directly comparable to the OQ-45 or ORS.Meta-analysis of 12 studies including 3696 participants using these PROMs found no evidence of a difference in outcome in terms of symptoms, between feedback and no-feedback groups (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.16 to 0.01; P value = 0.10). The evidence for this comparison was graded as low quality however, as all included studies were considered at high risk of bias, in most cases due to inadequate blinding of assessors and significant attrition at follow-up.Quality of life was reported in only two studies, social functioning in one, and costs in none. Information on adverse events (thoughts of self-harm or suicide) was collected in one study, but differences between arms were not reported.It was not possible to pool data on changes in drug treatment or referrals as only two studies reported these. Meta-analysis of seven studies including 2608 participants found no evidence of a difference in management of CMHDs between feedback and no-feedback groups, in terms of the number of treatment sessions received (mean difference (MD) -0.02 sessions, 95% CI -0.42 to 0.39; P value = 0.93). However, the evidence for this comparison was also graded as low quality.

Authors' conclusions: We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies, and should follow them up for longer than six months.

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Conflict of interest statement

The authors have declared the following relevant interests.

Tony Kendrick: lead researcher on a grant of £244,892 from the National Institue for Health Research (NIHR) Research for Patient Benefit programme, for the PROMDEP feasibility study of using PROMs to monitor patients with depression in primary care. Unpaid member of the NICE Indicator Advisory Committee for England, which considers evidence about the effectiveness of interventions such as the one subject to this Cochrane review, in recommending whether GPs and Clinical Commissioning Groups should be incentivised to implement them.

Magdy El‐Gohary: none known.

Beth Stuart: co‐applicant on the PROMDEP study.

Simon Gilbody: co‐applicant on the PROMDEP study.

Rachel Churchill: leads and takes responsibility for the Cochrane Common Mental Disorders Group, which has supported parts of the review process and is funded by a grant from the National Institute of Health and Research (NIHR) in the UK.

Laura Aiken: none known.

Abhishek Bhattacharya: none known.

Amy Gimson: none known.

Anna Brütt: none known.

Kim de Jong: Two studies on which she was lead author are included in this review (De Jong 2012 and De Jong 2014), but TK and MEG carried out the data extraction from those studies.

Michael Moore: Co‐applicant on the PROMDEP study.

Figures

1
1
PRISMA flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison: 1 Difference in outcome feeding back OQ‐45 or ORS scores versus no feedback, outcome: 1.1 Mean improvement in symptom scores: OQ‐45 PROMS.
5
5
Funnel plot of comparison: 1 Difference in outcome feeding back OQ‐45 or ORS scores versus no feedback, outcome: 1.2 Mean improvement in symptom scores: OQ‐45 or ORS PROMs.
1.1
1.1. Analysis
Comparison 1 Difference in outcome feeding back OQ‐45 or ORS scores versus no feedback, Outcome 1 Mean improvement in symptom scores: OQ‐45 PROMS.
1.2
1.2. Analysis
Comparison 1 Difference in outcome feeding back OQ‐45 or ORS scores versus no feedback, Outcome 2 Mean improvement in symptom scores: OQ‐45 or ORS PROMs.
1.3
1.3. Analysis
Comparison 1 Difference in outcome feeding back OQ‐45 or ORS scores versus no feedback, Outcome 3 Number of treatment sessions received: all participants.
2.1
2.1. Analysis
Comparison 2 Subgroup analysis: Setting, Outcome 1 Mean improvement in symptom scores by setting.
3.1
3.1. Analysis
Comparison 3 Subgroup analysis: Whether participants were given a formal diagnosis or not, Outcome 1 Mean improvement in symptom scores by whether participants were given a formal diagnosis or not.
4.1
4.1. Analysis
Comparison 4 Subgroup analysis: Feeback given to clinician, participant or both, Outcome 1 Mean improvement in symptom scores: feedback given to clinician, participant or both.
5.1
5.1. Analysis
Comparison 5 Subgroup analysis: Whether feedback included treatment instructions or an algorithm, Outcome 1 Mean improvement in symptom scores by whether feedback included treatment instructions or an algorithm.
6.1
6.1. Analysis
Comparison 6 Subgroup analysis: studies involving Michael Lambert versus studies not involving him, Outcome 1 Mean improvement in symptom scores by whether studies involved Michael Lambert.
7.1
7.1. Analysis
Comparison 7 Post hoc analyses ‐ 'on track' and 'not on track' participants, Outcome 1 Mean improvement in symptom scores: 'not on track' participants only.
7.2
7.2. Analysis
Comparison 7 Post hoc analyses ‐ 'on track' and 'not on track' participants, Outcome 2 Number of treatment sessions received by 'on track' and 'not on track' participants.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011119

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