Systematic review of evaluations of child and adolescent psychiatry

Research areas: Psychological & psychiatric interventions, Health economics

Duration: October 2008 - November 2009

Project co-operation: Philipp Radlberger and Ingrid Zechmeister (Project part: „Economic evaluations“, LBI-HTA-Project report 28)
Literature search and - documentation: Tarquin Mittermayr
Suggested by: SALK, BMG, TILAK, KAGES
Publications: 
HTA-Project report 27: Evaluations of child and adolescent psychiatry. Theory and practice about measurement dimensions, indicators and instruments (Roman Winkler) - https://eprints.aihta.at/846 
HTA-Project report 28: Child and adolescent psychiatry part 2: A systematic review of health economic evaluations (Philipp Radlberger) - https://eprints.aihta.at/862 
Duration: 10/2008 – 11/2009

Background:
The The treatment of mentally disordered children and adolescents largely uses extensive therapy concepts including medical, psychotherapeutic and socio-pedagogical interventions, which are adjusted to patients’ individual needs. However, in the context of therapeutic evaluations and quality assurance, there is a lack of evidence regarding therapeutic outcomes (such as clinical improvements, quality of life) and satisfaction rates of patients and their relatives concerning therapy care. Additionally, there is a need for socio-economic long-term outcomes assessing parameters such as school success or working ability of mentally disordered children and adolescents. Research also needs to focus on economic evaluations, which relate therapy outcomes to resource management.

Aims and research questions:
This research project pursued the goal to provide a systematic literature review regarding evaluation methods, to identify applied evaluation instruments and to analyse systematically therapy outcomes such as clinical symptoms, health-related life quality, patients’ satisfaction rates, socio-economic long-term outcomes and the cost effectiveness of treatments.
Against this backdrop, the following questions guided the systematic review:

Which evaluation indicators and which methods and instruments have been used to evaluate treatment programmes for mentally disordered children and adolescents within the international context? (LBI-HTA-Project report 27)Which therapy outcomes have been identified so far and which ones can be identified as benchmarks for the Austrian context? Which socio-economic long-term outcomes have been empirically analysed? (LBI-HTA-Project report number 27).Which costs, cost-effectiveness ratios and cost-benefit analyses have been documented in economic evaluations? (LBI-HTA project report 28).

Methods:
Systematic literature search of studies/reports in medical portals (Ovid Medline, Embase, CRD databases, PsycINFO, EconLit, ISI Web of Science), period 1985-2009; hand search; analysis; systematic literature review.

Results – “Evaluations in the context of therapy range and course of therapy”:
The therapeutic outcome, treatment satisfaction and the health-related quality of life of the patients turned out to be the primary evaluation dimensions in the course of the systematic review (14 studies included). Evaluation indicators provide a more precise understanding of these dimensions. In this context, clinical symptoms are core indicators for medical, psychotherapeutic and psycho-social treatment programmes. The quality of the treatment process as well as the “communication culture” among the involved actors, represent adequate evaluation aspects. This also links to health-related quality of life issues focusing even more strongly on the assessment of patient’s own human resources. In most cases, standardised empirical instruments are used to measure the evaluation indicators. The “MARSYS system“ (an “evaluation set” developed by a scientific board at the University of Marburg, Germany) was of particular interest because of its comprehensive view of aspects relevant to be considered when treating mentally disordered children and adolescents. Regarding the study results, study authors of the selected publications widely report about significant improvements in terms of the clinical symptoms. Concerning the “success factors” related to the improved clinical appearance, the building of “sustainable relationships” during the course of treatment plays a pivotal role for the initiation of “successful” treatments.

Results – “Economic evaluations”:
Over a period of 25 years, one systematic review and 25 single evaluations could be identified. Some indications, e.g. ADHD, are better examined than others. Regarding different interventions, there is disequilibrium in favour of family therapy interventions. Most of the evaluations are cost-effectiveness studies. Cost-effectiveness results of the interventions assessed are low, compared to interventions evaluated in somatic medicine. Most of the studies identified are inadequately transparent, especially with regards to information on cost data collection and modelling. The transferability of the evidence is limited because of context-specific interventions. As to the collection of cost-data, most studies are taking a public payers or insurances perspective. Besides, there are instruments, such as the ‘Client Service Receipt Inventory’ which is not only covering expenses occurring inside the public health system, but also other public or private costs

Ongoing research:
Based on these two systematic reviews, the LBI-HTA and the University Department of Child and Adolescent Psychiatry at the Christian-Doppler-Clinic (Salzburg) initiated an evaluation project. The data-collection started in April 2011 and it is mainly based on the outcome parameters identified in the systematic review. Moreover, this “field research” is accompanied by an economic evaluation. For further details concerning this ongoing project (duration 01/2010 until 12/2012).