Greenberg Greg A, Rosenheck Robert A
Northeast Program Evaluation Center, VAMC West Haven, CT 06516, USA.
Psychiatr Q. 2006 Summer;77(2):151-72. doi: 10.1007/s11126-006-9004-0.
There has been a growing interest in the implementation of evidence-based specialized mental health programs. However, there has been little study of the effectiveness of these programs in comparison with standard mental health care in real world mental health systems. This study used a national sample of patients from the Veterans Health Administration to compare changes in mental health status in various specialized mental health outpatient programs and in general psychiatric clinics. Hierarchical linear models were used to compare the association of both regularity and intensity of care in six specialized mental health programs with GAF change scores in patients treated in general psychiatric clinics. While improvements were observed in all programs, two specialized programs performed better overall than general psychiatric care, one was not significantly different, and three had poorer outcomes than general psychiatric clinics. Programmatic differences in target populations accompanied by imperfect risk adjustment for population differences most likely explain why these results differ from those observed in clinical trials. While the analytic strategies demonstrated here may have wider applicability to comparative performance assessment, this study provides a cautionary tale concerning the limits of conclusions that can be drawn from large scale outcomes monitoring efforts.
人们对实施循证专业心理健康项目的兴趣与日俱增。然而，与现实世界心理健康系统中的标准心理健康护理相比，这些项目的有效性却鲜有研究。本研究使用了退伍军人健康管理局的全国患者样本，以比较各种专业心理健康门诊项目和普通精神科诊所中患者心理健康状况的变化。采用分层线性模型比较了六个专业心理健康项目中护理的规律性和强度与普通精神科诊所治疗患者的总体功能评估（GAF）变化评分之间的关联。虽然所有项目都观察到了改善，但两个专业项目总体表现优于普通精神科护理，一个没有显著差异，三个项目的结果比普通精神科诊所更差。目标人群的项目差异以及对人群差异的不完全风险调整很可能解释了为什么这些结果与临床试验中观察到的结果不同。虽然这里展示的分析策略可能在比较绩效评估中有更广泛的适用性，但本研究为从大规模结果监测努力中得出的结论的局限性提供了一个警示故事。
