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MAKING BETTER USE OF EPIDEMIOLOGICAL, CLINICAL AND ECONOMIC RESEARCH FINDINGS IN MENTAL HEALTH FIELD

Silvia Gabriela SCINTEE**, Adriana GALAN**

The increasing burden of disease under the financial constraints calls for more rational funding and provision of health care services. The increasing costs of psychiatric care and unsatisfactory mental health indicators require a more informed, research evidence based decision-making. Under the general health care reform changes that consisted mainly from replacing a centrally planned health system with a market oriented system, managers and health care professionals need a more explicit use of epidemiological, clinical and economic studies in order to set priorities for services provided. The purpose of this paper is to provide a framework for utilisation of epidemiological, clinical and economic data in decision making process.

WHY ECONOMICAL AND EPIDEMIOLOGICAL RESEARCH ARE IMPORTANT

Economical evaluation provides a framework for choices, and choices are imposed by the fact that the need is almost infinite, while resources are scarce. Economic evaluation answers questions like:

- what services to provide, when and at what level of provision; - how and where to provide these services;

- who should get the services. Epidemiological research has a paramount importance for mental health bringing evidence in regards with:

- the aetiology and history of the diseases;

- distribution and prediction of diseases and risk factors in a population;

- the effectiveness of intervention programmes.

Epidemiological principles and methods could also be applied in clinical practice. The main concerns of clinical epidemiology are:

- to define the normality and abnormality;

- to validate the diagnostic tests; - to study the evolution and the prognostic of the diseases;

- to study the treatment effectiveness

Many research studies are conducted without a clear purpose and their findings are not properly used, as in most of the cases we try to find solutions without knowing what are the problems. Economic evaluation studies are rare, not encouraged and not funded, not only in mental health field, but also in all health care sector in Romania.

When a decision for conducting a research is made, the researcher should ask himself two big questions:

- what is the purpose of my research?-meaning what would be the use of the findings;

- what method (technique) is the most appropriate to my purpose? - assuring in this way that the results are valid.

MAIN AREAS OF APPLICATION

(i) mental health policy making process

Definition of the problem

- situation analysis

- problems identification

- priority setting

Policy formulation

- alternatives design

-involving stakeholders in choosing among alternatives Policy implementation

- dissemination of chosen policy

- implementation - monitoring and revising

Situation analysis should be focused on four main areas:

1. Other policies: national health policies and international mental health policies Any mental health policy should be consonant with the national health policy objectives, that usually refer to: reducing inequities, free access to efficient and effective services, assuring universal coverage, promotion of the patients’ rights.

Among policies promoted by WHO (for example) in the last 5 years there are: increasing role of primary care in the diagnosis and treatment of mental disorders, promoting human rights for persons with mental disorders, patients’ care in the community, better mental health of the refugees.

2. Mental health status of the population and mental health determinants The measurement of mental health status leads to the identification of the problems that mental health policies will address. This is the main area in which epi- demiological research could help. The methods used in problem identification could be classified in:

- indicators based methods;

- surveys based methods;

- consensus techniques based methods.

Indicators are usually obtained from routine data. They could provide information in regards with: the demographic characteristics of the population (factors such as population ageing and urbanisation are among the multiple factors that influence mental health), negative aspects of the population health (incidence and prevalence rates of diseases, the frequency of disability and handicap, mortality rates - that are of limited use in psychiatry), positive aspects of the population health (life expectancy without disability, neuropsychical growth), mental health determinants (the frequency of unhealthy lifestyles, the frequency of other risk factors), trends.

In order to cover the limits of traditional indicator based methods, has been developed a new approach of health status evaluation, namely the Global Burden of Disease. This new approach incorporates the non-fatal conditions into assessment of general health status, and measures disease burden in a currency that can also be used to assess the cost-effectiveness of intervention (cost per unit of disease burden averted). The indicator that measures the burden of disease is DALY (disability adjusted life years) and expresses years of life lost to premature death and years lived with a disability of specified severity and duration.

So, one DALY means one lost year of healthy life. A WHO study on the burden of disease for the world (1999) showed that unipolar major depression is the 5th cause of disability adjusted life years although causes very few deaths and is responsible for 4.1% of total DALY. Projections of future burden of disease are also useful for policy making. Studies of secular trends could allow DALY projections at any time in the future. A study conducted at Harvard School of Public Health (Murray and Lopez) showed that in 2020 the DALY hierarchy for US would change.In Romania such a study was conducted by the Institute of Public Health in 2000, for assessing the burden of diseases by calculating DALY for 1998. Mental and behavioural conditions are situated on the 3rd place.

Some specific information can not be obtained from the current statistical records and targeted designed studies are necessary (see table no. 1). For example, if the purpose of the study is to find the frequency of a disease, risk factors or other characteristics in a defined population at one particular time, a cross sectional study would be appropriate. Examining prognosis could be done by means of a cohort study. Case-control studies could be useful for proving the relationship between an epidemio- logical event (death or disease) and a risk factor, for example that alcohol consumption and suicide rate are related. Social survey techniques could be used for assessing the people opinions, attitudes and behaviour.

Leading causes of DALY for the world in 1999* (Michaud, Murray, Bloom - 2001) (click pentru imagine)

Projected change in rank order of DALY for the 15 leading causes in 2020 compared with 1990* (Michaud, Murray, Bloom - 2001) (click pentru imagine)

3. Mental health services organisation and functioning To evaluate mental health services it is necessary to have an overview of the production process. Evaluations could be carried out at each level of this process: structure (input), process (output), results (outcome). The input evaluation comprises the number and size of facilities, their geographical distribution, the number, distribution and qualifications of personnel, available equipment, etc.

The process aspects regard how health units perform their functions (such as patient admission, patient care, organisational management). Besides utilisation indicators, there are evaluated aspects of quality of care, accessibility, adequacy of services provided, effectiveness, efficiency, interpersonal relationship. Outcome is concerned with the impact of health services on individuals and community health. Here could be studied aspects such as number of treated cases, number of re-admissions, number of days without disability gained.

4. The availability of political, technical, managerial and financial resources

(ii) funding and planning of mental health services Funding mental health sector Provider payment system What needs should be covered How to organise services Mental health services funding has impact on the quantity and quality of services provided.

Leading causes of DALY for Romania in 1998 (click pentru imagine)

Table no. 1. Epidemiological studies and their application (click pentru imagine)

The research findings could be used by top level decision-makers in choosing the way of funding mental health services and also the method of provider payment. The recent changes in financing of Romanian health system would be a very opportunistic intervention study. The effects of introducing a social health insurance system could be assessed in regards with both service utilisation (length of stay, admission and re-admission rate), and mental health status of the population. Economical research findings could be used at deciding what psychiatric services to be included in the benefit package, and also who should pay for services not covered by the insurance system. Provider payment systems are also influencing the quantity and quality of services provided. The qualities of a good payment system should be: - to allow providers to reach a reasonable income as an incentive to provide good quality services; - to prevent waste and the provision of not necessary services; - to be easy to administrate.

Economical and epidemiological research could help to find how to pay providers of services in order to stimulate the provision of some services and to discourage the provision of others. A study conducted in 1999, in three districts (Salaj, Sibiu, Valcea), by the Romanian Association of Public Health and Health Services Management that took the changing in payment method for ambulatory care as an opportunistic experiment, showed how the level of services provided in most of specialities (including psychiatry) has decreased as doctors payment changed from fee for service to salary. The planning process starts with need assessment. Usually need assessment is confounded with assessment of the services utilisation. Still need should be differentiated by demand and use. Many times need is higher than use. It should be evaluated by studying the prevalence of the diseases within a cross-sectional study. In planning, future need is maybe more important than current need. In this case findings of cohort studies that are appropriate for studying prognosis are more useful. Findings of economical research have a great importance for planning process. Each type of economic analysis answers specific questions that the decisionmakers have to ask (see table no. 2):

(iii) mental health programmes development and implementation

Problem identification
Programme initiation
Programme planification
Programme implementation

Monitoring and evaluation Programme development starts also with problems identification and priority setting. The measurement of mental health status leads to the identification of the problems that intervention programmes will address. This is the main area in which epidemiological research could help and the same methods and techniques are used as in the case of policy making (see table no. 1). Economic evaluation studies are used for ensuring the allocative and operational efficiency of the intervention. The economic evaluation techniques answer questions like: what programme is worthwhile to be financed, what is the cheapest way of obtaining benefits. There are four types of economic evaluation, differentiated mainly by the way of measuring consequences and having different use (see table no. 2). Cost-minimisation analysis - apparently only the total cost of the programmes should be compared, as they are used for choosing between similar programmes with identical consequences (for example a programme of recovering for patients with schizophrenia in a specialised recovering institution with a programme of recovering for patients with schizophrenia in the community). Cost-effectiveness analysis - compare the cost per unit of effect (cost per day without disability, cost per life saved) of alternative programmes with common effects (for example a programme of reducing suicide rate by postgraduate training of GPs’ about diagnosis and treatment of patients with affective disorders with a programme of reducing suicide by introducing a nonstop hot line).

Table no. 2. Economic evaluation techniques (click pentru imagine)

Cost-benefit analysis - compare the cost/benefit ratio for programmes with different consequences (a programme of reducing suicide rate by improving community care for patients at risk after discharge and a programme for preventing behavioural disorders in institutionalised children). Cost-utility analysis - can be used when quality of life is taken into account for programmes with common effects. The consequences of these programmes could be measured in QALY or DALY. (iv) psychiatric practice Decision making in clinical practice could be supported by clinical epidemiology. This is an application of the epidemiology in clinical settings. The main areas of application of clinical epidemiology are: defining normality and abnormality status, validating diagnostic methods, choosing between treatment alternatives, evolution and prognosis of a disease. Besides the epidemiological methods applied at population level in clinical research case reports and case series could be used (see table no. 1). A case report is a description of one interesting and unusual case. They are useful for generating hypothesis. A case series is a description of several cases in which no attempt is made to answer specific hypothesis or to compare the results with another group of cases. They can be used as postmarketing studies for calculating the incidence of an adverse reaction. The recommended method when studying a treatment is randomised controlled trial. Research investigating the cause of disease might adopt any study design. Potential incentives that might encourage the application of research findings in mental health services management and clinical practice More research oriented donors. In the last decade we have received a lot of financial and technical support from international agencies. The major part of this external aid consisted only in helping our hospitals with drugs and equipment and funding intervention programmes without any previous research. Lobby to health authorities for taking into account the research funding when formulating policies. This could be the role of non-governmental organisation, professional bodies and associations. Flexibility in funding health units. A flexible budget for the hospital, for example, that would allow re-allocation of savings for the same unit, would determine managers to apply research findings for providing services in the most efficient way. Competition in receiving funds. Hospitals are financed by global budgets calculated on historical basis and adjusted by some utilisation indicators. If budgets would be negotiated on the basis of a business plan, managers would have an incentive to apply research findings for providing the cheapest services at an optimum quality. Postgraduate training of clinicians and decisionmakers in public health and health services management. Medical education is more individual than population oriented and doctors do not have a public health perspective and a health economic way of thinking. Possibility of co-operation with researchers from abroad. Common or comparative research could be an incentive in both developing research methods and applying finding in the field.

References

1. Beaglehole, R., Bonita, R., Kjellstrom, T. (1997) Bazele epidemiologiei, Ed. ALL, Bucuresti.

2. Enachescu, D., Marcu, M.G. (1995) Sanatate publica si management sanitar, Ed. ALL, Bucuresti.

3. Michaud, C.M., Murray, C.J.L., Bloom, B.R. (February 7, 2001) Burden of Disease - Implications for Further Research, in JAMA, Vol. 285(5), 535-539.

4. Mooney, G.H., Russell, E.M., Weir, R.D. (1992) Choices for Health Care - A Practical Introduction to the Economics of Health Provision, 2nd Ed., Studies in Social Policy Series, Macmillan Press Ltd.

* Paper presented at the Third WPA Regional Meeting on FINANCING MENTAL AND ADDICTIVE DISORDERS IN CENTRAL AND EASTERN EUROPE, Bucharest, Academy of Economic Studies, November 23-25, 2001 ** Institute of Public Health