A proposed value matrix for the evaluation of psychiatric consultations in the general hospital

A Proposed Value Matrix for the Evaluation of Psychiatric Consultations in the General Hospital* John S. Lyons, Ph.D. and David B. Larson, M.D., M.S.P.H.

Abstract: strategy of determining the value of psychiatric consultation services in the general hospital is presented. Value analysis, a theoretically driven model for establishing the worth of mental health services from multiple perspectives, is used to propose a value matrix for consultation psychiatry. Based on an integration of decision theory and evaluation science, the goal of value analysis is to establish a range of outcomes that might be viewed as important from various perspectives. This hypothesizedmatrix of economic and clinical values for patients, families, medical staff, providers, payors, and society provides a framework for evaluating outcomes of psychiatric

consultation services.

Recently, an incrementally developed methodology called value analysis has been proposed to address problems inherent to cost-effectiveness analysis and allow for the integration of economic and clinical outcomes from multiple perspectives in mental health services research [l]. Costeffectiveness analysis suffers from three substantive problems that can be classified as semantic, practical, and conceptual.

Cost-Effectiveness Analysis Semantically, the term cost-effectiveness overemphasizes “costs” and leads to semantic confusion *The views expressed in the present paper do not necessarily reflect those of the National Institute of Mental Health. This paper was presented in part to the 17th Annual European Conference on Psychosomatic Research, Marburg, West Germany, 1988. From Northwestern University Medical School (J.S.L.) and the National Institute of Mental Health. Address reprint requests to: John S. Lyons, Ph.D., Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, 303 East Chicago Avenue, Chicago, IL 60611. General Hospital Psychiatry11, 345-351, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

with cost efficiency [2,3]. Frequently, cost-effective is used to describe the least expensive alternative independent of clinical outcome. This semantic confusion exists not only in conversations with decision makers but also in the scientific literature [2]. The intent of cost-effectiveness analysis has been to balance the costs of an intervention with its outcome. Unfortunately, the term itself works at crosspurpose with this objective. Practically, the combination of costs and clinical outcomes into a single mathematical model is thwarted by the use of dramatically different methods of measurement. Cost-effectiveness has been described by some as an effort to put the measurement of economic and clinical outcomes of an intervention into a single number [4]. However, acceptable statistical means are not currently available to accurately combine costs and effects [3]. Other cost-effectiveness methods that require the determination of cost per patient by change in level of functioning after treatment are difficult to apply to comparisons across services [5]. Finally, cost-effectiveness suffers conceptually in that this method provides no clear way to determine whether one service is, in fact, more cost-effective than another. Cost-effectiveness evaluation does work well when one service is both the least expensive and most effective or when multiple services are equal in either effectiveness or cost. Unfortunately, this strategy is of little use in situations when an alternative is both more effective and more expensive [3]. As Sofer [6] points out, the implicit contract between the patient and the physician does not permit unilateral decisions by that provider to choose a particular intervention because it is “almost as good, but cheaper.” 345 ISSN 0163~8343/89/$3.50

J. S. Lyons and D. B. Larson

Value Analysis To address the shortcoming of cost-effective analysis we have proposed a strategy termed value anaZyssis. This strategy does not represent a radically different approach to the empirical study of psychiatric consultation services. Rather, the attempt is made to combine current thinking in the philosophy of science, decision theory, evaluation sciand health services research into an ence, integrated model for studying mental health services. By definition, mental health services research does not operate as a closed system; therefore, philosophies of science that assume perfect experimental control cannot hope to be applicable to these research questions. Derived from a realist philosophy of science [7], value analysis combines both aspects of logical positivism, which has been the dominant philosophy in psychiatric research and has been termed the received review [8], and social constructionism [9], which emphasizes the nonobjective or perceptual aspects of the scientific process and could be called the perceived view. In value analysis, the importance of experimental verification (logical positivism) is maintained while the subjective nature of interpretation based on perspective (social constructionism) is explicitly included in the technique. This hybrid philosophy has been termed realist [7]. The choice of the term value is taken from Kahneman and Tversky’s [lo] term decision value, “the contribution of an anticipated outcome to the overall attractiveness or aversiveness of an option or choice” [p. 3491. However, other connotations of value increase the semantic propriety. The use of the word “value” connotes a perspective or implicit priorities [11,12]. Thus, both the worth and the perspective implied by value is appropriate to the understanding of mental health services. The central task in value analysis is to formulate and test a set of values that vary by type of outcome (economic versus clinical) and by different perspectives. As McGlynn and colleagues [13] indicate, outcomes valued by patients, providers, support systems, and society are usually different and may be noncomplementary. The perspectives of interest may vary depending upon the type of service; however, examples of perspectives include patient, provider, and payor. Generally, a perspective should be included if there is a reason to believe that perspective is at risk, has a vested in346

terest in the outcome of a service, or is involved in decision making regarding that service. The theory of value analysis proposes that, because the importance of outcomes vary by perspective, it is critical to consider any perspectives with the potential for gain or loss from the service when setting out to evaluate the worth of a service or system of care. Evaluation research is legion with examples of well-intentioned and well-designed research efforts that lead to little or no policy shifts. We believe that a major reason for this failure is an implicit overemphasis of certain perspectives without recognizing the importance of the perspectives of various decision makers.

Psychiatric Consultation The psychiatric consultation itself is an intervention that has the potential for both clinical and economic impact [14-201. Wise [21] has proposed that regardless of positive findings in outcome research, consultation-liaison (C-L) psychiatry has been unable to firmly establish permanent financial underpinnings. He attributes this failure, in part, to an absent recognition of the needs of an important perspective-the consumer of consultation services, the nonpsychiatrist physician. However, there are other identifiable consumers of these services including patients, their families, administrators, and payors. Thus, research in this area is facilitated by a careful consideration of the worth of consultations from the different perspectives at risk. To date, consultation outcome research has emphasized either the patients’ clinical perspective (symptom relief) or the payors’ economic perspective (length of stay) [22,23]. What has been absent is a means for bringing together and integrating these results in a fashion that contributes to our knowledge about the process and outcome of this intervention. One means of organizing these outcomes is through the development of a hypothetical value analysis matrix. There are multiple ways to establish a proposed value matrix for any given mental health service. Because multiple perspectives must be considered (what outcome is important to whom?), either a survey of these perspectives or a consensus group approach may prove useful to establish each representative’s view of the important dimensions of worth for the service under study. An alternative strategy is to use a

A Proposed Value Matrix

review of the literature to develop hypothesized values and insert these a priori into a value matrix. It is this second approach that will be used _ in the present article. Table 1 provides a proposed value matrix for psychiatric consultation in the general hospital. Seven perspectives are included: the patient, the the consultant, the medical patient’s family, staff, the hospital, the third party payor, and society at-large. For each relevant perspective, hypothetical positive and negative economic and clinical values are taken from the research literature. The following is a detailed review of each cell within this proposed value matrix. Obviously, not all the potential values can be operative for every consultation case. The full value matrix represents aspects of the consultation process that, based on the literature, demand study if one is to understand the full complexity of the service.

Table 1. Proposed

value matrix for psychiatric

Patient Perspective From the perspective of the patient, consultation psychiatry potentially has both positive and negative clinical and economic values. The positive values include both symptom relief, decreased disability, enhanced well-being clinically, and a faster return to work economically [14-201. The potential negative values include the stigma associated with receiving psychiatric care [24] and the potential negative effects of the consultation, including such things as psychopharmacologic side effects [25] or an inappropriate tampering with “healthy denial” through a clinical push for insight [26]. The potential for negative effects may also exist in situations involving refusal of treatment [27]. The negative economic value to the patient is the charge for the consultation for which the patient might be fully responsible. In the case of psychiatric services, third-party

consultation

in the general hospital Clinical

Economic Perspective Patient

Positive Return to work

Negative Charge

Positive

Negative

Symptom relief Enhanced well-being

Stigma Distress Side effects

Family

Return to work

Charge

Reduced burden

Stigma Distress

Consultant

Income Increased

Time

Enhanced

Job stress

well-being

referrals

Medical staff

Reduced work load

Time

Reduced burden Quality care Reduced stress

Increased

complexity

Hospital

Cost offset Profit Reduced liability

cost Liability Loss

Improved quality assurance Improved consumer satisfaction

Complaints Negative outcome

Payor

Cost offset

cost

Improved consumer satisfaction Meet consumer demand

Complaints Unmet demand

Society

Return to work Cost offset

cost

Enhanced

quality of life

347

J. S. Lyons and D. B. Larson

payors often services.

do

not

fully

reimburse

these

including research, preparing seeing other patients.

for meetings,

and

Family Perspective

Medical Staff

The perspective of the family is quite similar to that of the patient in terms of the potential positive value of return to work and the negative values of the charge for services, the stigma of psychiatric care, and distress created by the consultation [28]. However, an additional potentially positive value is the reduction in burden of care [26,30] that might be associated with a positive clinical outcome beginning in the hospital with fewer visits and continuing after discharge. Interestingly, given that one proposed positive patient outcome for psychiatric consultation services is discharge to home [16,31], there is then a possibility that the intervention can increase family burden, particularly when the patient is elderly or cognitively impaired

Psychiatric consultations can reduce the workload of medical staff [33] and thereby result in a positive economic value. However, there is the negative economic value of time spent requesting the consultant and then discussing the case. On the positive clinical side, consultations have the potential to reduce burden and job stress (unpublished results), increase staff mental health and knowledge, and enhance the quality of patient care. On the negative clinical side, consultations can increase the complexity of a case. This increased complexity can be particularly difficult or threatening if the medical staff member has moderate to severe deficits in mental health clinical skills. Consultants may be negatively perceived if they are viewed as coercive, addressing difficult psychiatric-related patient issues that this staff would prefer to ignore [34].

~321.

Consultant Perspective From the viewpoint of the consultant, psychiatric consultations to medical patients have potentially both positive and negative values. On the positive side economically, consultations may mean a direct source of income and a potential for expanding a referral base for the consultant’s clinical practice. The income from consultations is generally much less of an important positive value if the consultant is salaried; however, recent changes in the economics of hospital services often require consultation services to track their billings and, if they are not profitable, to at least minimize losses. Thus, the positive economic value of consultations to the consultant or service has increased in importance in this post-DRG era. On the negative side, consultations frequently need to be done within a short period of time and can take a great deal of professional time. That time is not always under the control of the consultant. In addition, consultations are not always paid for. If the consultant is responsible for billing, this overhead becomes an added expense. The positive clinical value of consultations to the consultant would come from enhanced self-esteem and wellbeing associated with good job performance and respect from colleagues. The negative clinical value would be the potential for job-related stress, time lost from relaxation or lost from other priorities 348

Hospital Perspective The positive economic values of psychiatric consultations from the perspective of the hospital include both the profit (charge-cost) from the provision of service and the potential for cost offset under conditions of cost containment and prospective payment. The profit value to the hospital for consultation services will in all likelihood be quite low. In fact, C-L services may not operate in the black. In addition, cost offset can be a negative economic value from the perspective of the hospital if the patient’s medical care is reimbursed on a feefor-service (cost-plus) basis. Perhaps the most important economic value to the hospital is reduced liability; however, this has received little research attention. Clinically, the positive value to the hospital is enhanced quality assurance and increased consumer satisfaction. Proportionate to the risk of negative clinical outcomes, there are also risks for negative values from the hospital perspective. However, in addition to the overall perspective of a hospital administration, there are likely to be differences in perspectives even within the hospital. For example, it is likely that the Quality Assurance Committee will stress patient outcome, whereas the Financial Planning group will emphasize billable income.

A Proposed Value Matrix

Payor Perspective The primary positive economic value to a thirdparty payor of psychiatric consultations is cost offset [35]. That is, by spending money on psychiatric services, the payor may spend less on other usually unnecessary medical services for that patient [36381. Evidence suggests that psychiatric comorbidities are associated with increased medical utilization; therefore, the potential for cost offset effects is high [3941]. On the negative economic side, if the payor reimburses consultation services, the amount reimbursed is a negative economic value. Clinical values are of relevance to payors to the extent that they are related to consumer satisfaction and consumer demand. Insurance companies need to provide the range of services that meet the demands of their consumers. Consumer satisfaction with psychiatric consultation has received little research attention, nor has the relationship between clinical outcome and consumer satisfaction been the focus of much research. The particular cells in the value matrix can thus emphasize the need for future research.

Societal Perspective There are potentially two positive economic values of consultations--cost offset and return to work. Society values an overall reduction in expenditures for medical care and a maximum work force. Clinically, enhanced quality of life and reduced disability represents valued positive outcomes from a societal perspective. Again, the potentially negative clinical values of psychiatric consultations from a societal perspective have received very little research attention; however, it is conceivable that if negative effects are found for consultations, these effects certainly could have important policy implications for our society at large.

Statistical Analysis The matrix approach proposed currently significantly complicates the analysis of outcome data. Multivariate techniques designed to handle multiple dependent measures would, in fact, defeat one of the primary goals of value analysis. multivariate analysis of variance For example, (MANOVA) works by finding the linear combination of multiple dependent measures (outcomes) that maximizes group differences. If this statistical approach is taken, a step-down analysis [42] would

be necessary to attempt to isolate which outcome measures independently contribute to treatment group differences. Perhaps more appropriate than multivariate analysis would be a Bayesian methodology [43] in which the probability is determined that individual cases would achieve specific cut points on outcome values. One could then take this matrix of probabilities and combine them through matrix algebra with weights based on the priorities decision makers place on each value in the fashion proposed by the multiple-attribute utilities technique [44].

Conclusions The proposed value matrix provides a cogent outline for outcome research on the impact of psychiatric consultation services in medical patients. Some of the values proposed have been documented empirically; others await scientific investigation now that the theoretical framework has been proposed. However, by understanding valued outcomes, both economic and clinical, from the perspectives of those with a vested interest in the potential outcomes, one is better able to understand what previously could be seen as a complex decision-making process involving the initiation of consultation services by hospitals, the referral to these services by medical staff, and the delivery of these services by the consultant. It might be tempting to initially peruse the values in Table 1 and label some as important and others as trivial based on what research has emphasized without the explicit consideration of perspective. “Importance” and “triviality,” of course, depend primarily on one’s perspective. Thus, such a priori labeling would be a mistake if one hoped to fully understand the complex nature of this mental health intervention. For example, one might say that reduction of symptomatology is paramount and, therefore, the well-being and job satisfaction of the consultant is nearly irrelevant. From the perspective of the patient and his or her family it is indeed obvious that symptom relief is a highly valued outcome and that the consultant’s well-being and job satisfaction is much less relevant. In contrast, one might consider it troublingly “diagnostic” if a patient were more concerned about the consultant’s well-being than his or her own. A well-trained psychiatrist might feel somewhat guilty about consciously placing his or her well-being on a level alongside the well-being of a patient. However, for those who have worked on 349

J. S. Lyons and D. B. Larson

a frequently harried consultation service, it is equally obvious that if the consultation staff is overworked, the delay in responding to call increases, the amount of time spent on consultations drops, and the quality of that effort suffers. Difficult cases are poorly managed, referred elsewhere, or “dumped” on junior, frequently less experienced staff. Thus, failure to consider this “trivial” value is in actuality a failure to consider the perspective of the consultant in studying the outcome of consultations. Similarly, several authors have emphasized the utility of considering economic aspects such as cost offset effects as side effects or incidental effects [35,45]. Although such a focus is completely legitimate when one is studying the consultation process from the patient’s perspective, it becomes self-defeating when considering the process from an alternative perspective, such as payors or hospital administration. We would be guilty of incredibly poor training if we were to admonish new psychiatric consultants to “go out there and save money” rather than to provide quality care for persons with mental illness, albeit physicians are increasingly recognizing their role as manager of health care dollars [46]. Nonetheless, general hospitals may not always see the treatment of psyto their mission. chopathology as central Administrators may see their goal as the maintenance of fiscal responsibility so that their hospital can continue to provide general medical or surgical care to those in need. Given the matrix of values proposed in Table 1, one might think that the ideal study of the outcome of psychiatric consultations would simultaneously assess all the values enumerated there. Such a task would be methodologically complex, in that the unit of analysis changes by outcome variable; therefore, a more practical approach to elucidating the actual values of psychiatric consultations would be a series of studies, replicated at multiple sites that address these posited values from different perspectives. The problem with many evaluations, particularly with efforts to determine the cost-effectiveness of an intervention, is the attempt to distill a very complex outcome into a single number [4]. We believe that exactly the opposite must occur. The single number must be broken into its component parts as seen from frequently competing perspectives. That is, we must embrace the complexity of the phenomenon that we study and allow for this complexity in the design and analysis of 350

our work. It is in this spirit that value analysis has been proposed.

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Value Matrix

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