Abstract
BackgroundSome outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. This review had three goals: (1) assess the effectiveness of quality improvement, implementation, and dissemination strategies intended to improve the mental health care of children and adolescents; (2) examine harms associated with these strategies; and (3) determine whether effectiveness or harms differ for subgroups based on system, organizational, practitioner, or patient characteristics.MethodsSources included MEDLINE®, the Cochrane Library, PsycINFO, and CINAHL, from database inception through February 17, 2017. Additional sources included gray literature, additional studies from reference lists, and technical experts. Two reviewers selected relevant randomized controlled trials (RCTs) and observational studies, extracted data, and assessed risk of bias. Dual analysis, synthesis, and grading of the strength of evidence for each outcome followed for studies meeting inclusion criteria. We also used qualitative comparative analysis to examine relationships between combinations of strategy components and improvements in outcomes.ResultsWe identified 18 strategies described in 19 studies. Eleven strategies significantly improved at least one measure of intermediate outcomes, final health outcomes, or resource use. Moderate strength of evidence (from one RCT) supported using provider financial incentives such as pay for performance to improve the competence with which practitioners can implement evidence-based practices (EBPs). We found inconsistent evidence involving strategies with educational meetings, materials, and outreach; programs appeared to be successful in combination with reminders or providing practitioners with newly collected clinical information. We also found low strength of evidence for no benefit for initiatives that included only educational materials or meetings (or both), or only educational materials and outreach components. Evidence was insufficient to draw conclusions on harms and moderators of interventions.ConclusionsSeveral strategies can improve both intermediate and final health outcomes and resource use. This complex and heterogeneous body of evidence does not permit us to have a high degree of confidence about the efficacy of any one strategy because we generally found only a single study testing each strategy.Trial registrationPROSPERO, CRD42015024759.
Highlights
Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness
We found no studies on regulatory components and just one study testing the effectiveness of a financial component, for pay for performance [56]
We had insufficient or low strength of evidence of no benefit for more than half of the outcomes that we evaluated, our findings suggest that several approaches can improve both intermediate and final health outcomes and resource use
Summary
Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. One in five children and adolescents living in the USA has one or more mental, emotional, or behavioral health disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria in any given year [1]. These disorders contribute to problems with family, peers, and academic functioning. They may exacerbate coexisting conditions and reduce quality of life. Mental health interventions that improve outcomes for children and adolescents with mood disorders, anxiety disorders, disruptive behavior disorders, psychotic disorders, eating disorders, and substance use disorders have been tested and shown to yield varying degrees of benefit [5, 6]
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