Isn't It About Time to Employ Measurement-Based Care in Practice?

Abstract

Measurement-based care is by no means novel. In fact, for decades the regularmeasurement of both symptoms and side effects has been an integral component of all randomized controlled trials that establish the efficacy of antidepressant medications. Research clinicians, blind to treatment type, use both symptom and side effect measures to adjust and tailor thedosage toeachpatient, attempting tomaximize thedosage and therapeutic effects, side effects permitting. In the early 1990s, the Agency for Healthcare Policy and Research commissioned the development of clinical practice guidelines for the diagnosis and treatment of depression in primary care. These guidelines recommended the regular measurement of symptoms and side effects to manage depression because the evidence that supported the efficacy of bothmedications andpsychotherapywasbasedoncontrolled trials that used these processes. These procedures, the authors reasoned, would serve to tailor the dosage to each patient, avoiding underdosing and severe side effectswhilemaximizing individual benefit (1). Both the Texas Medication Algorithm Project (TMAP) (psychiatric outpatients) (2, 3) and the German Algorithm Project (GAP) (psychiatric inpatients) (4, 5) required clinicians to regularly assess symptoms and side effects and to consider dosage and medication changes at specified times during treatmentbasedon thesemeasurements.Both studies, however, combined these measurement-based care procedures with medication algorithms that included a varying range of medication options. These two-part interventions (measurement-based care procedures and the algorithms) weremore effective than treatment as usual in both studies (6, 7). Whether the benefit was due to the measurementbased care procedures per se, to medication differences, or to both was unknown. The cleverly designed, blind-rater, 24-week, randomized, controlled, single-site trial thatDr. Guo and colleagues report in this issue (8)was able to isolate the effect ofmeasurementbased care processes alone by requiring clinicians in both the measurement-based care and standard treatment groups to use the same twomedicationswithin the samedosage ranges. This design allowed between-group differences to be attributed to the use (or not) of measurement-based care. The results reveal a wide range of clinically meaningful benefits that seem largely attributable to more aggressive— albeit patient-tailored—dosing without increasing side effects, number of clinic visits, or attrition compared with usual care procedures. Patients in the measurement-based care group responded or remitted about twice as fast as those in the standard treatment group. Furthermore, the response and remission rate differences between the groups were substantial, equaling or exceeding differences between medication and placebo, based on the numbers needed to treat. Thus, how a medication is delivered may be as important as which medication is chosen. Importantly, measurement-based care did not increase the number of visits, but medication adjustments were twice as frequent in the measurement-based care visits compared with standard treatment visits. Tailored but higher medication dosages in measurement-based care likely led to a greater proportion of responders actually achieving remission in the measurement-based care group. Suboptimal dosing seems amajor cause of response that falls short of remission, which in turn is associated with a greater risk of relapse (9). The study’s research staff provided immediate feedback to measurement-based care clinicians on their adherence to the recommended dosing schedule. Such staffing is not sustainable in real-world practice.However, computerized reminder systemshavebeen developed and can become part of the electronic medical record as a sustainable alternative (10, 11). Such prompts are likely very helpful and contribute to the greater dosing observed in measurement-based care. What are the implications of this study for patients, practitioners, and payers? By providing patients with the tools and experience of monitoring their symptoms and side effects, measurement-based care seemingly better prepares them to participate in shared decision making and their own longer-term care. Despite the absence of controlled-trial evidence, one might speculate that regularmeasurements provide a level of precision that facilitates cross-coverage between physicians, the acquisition of reliable second opinions, and enhanced efficiency of telemedicine visits by using patient-based metrics to assess outcome even at a distance. If measurement-based care procedures offer at least some of these benefits, why are they not more widely used in practice?