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Rational allocation of finite resources

Treatment resources are not infinite. Clinical and ethical considerations, therefore, demand that resources be allocated to patients with the highest need and greatest probability of benefit. The scores obtained from the outcome questionnaires provide a decision support tool for allocation of treatment resources to patients based on clinical need and probability of benefit.

The probability of additional improvement with further treatment is a direct function of the severity of distress. Resources allocated to the treatment with questionnaire scores well into the clinical range tend to result in large effect sizes and high value. See TrajectoryOfChange for more on this topic.

At the other end of the severity continuum, patients with scores closer to the mean of a community sample, tend to show little improvement on test scores regardless of the number of sessions. In fact, the scores for these patients tend to trend toward greater distress with treatment, so that with each additional session the average patient is reporting a gradual worsening on symptoms. Since the level of distress is low, the gradual increase in reported distress may not be of clinical significance. However, from the point of view of allocation of resources, many of these patients would be better served by brief therapy and/or intermittent contact. From the point of view of the ValueEquation, resources allocated to these patients have a negative value!

Approximately 25% of patients in a typical outpatient population will have test scores in this normal range of distress. A rational allocation of resources would result in these patients having on the average significantly lower cost per episode of care than patients with very high levels of distress.

In actual practice, the difference in the cost of an episode of care for patients at these two extremes is relatively modest, or the order of a 20% to 25% difference between patients in the normal range or the severe range. Furthermore, a significant percentage of patients in the normal range are placed on a medication, to no apparent benefit.

Patients with test scores in the normal range tend to report a high level of satisfaction with psychotherapy, and may continue in treatment for long periods of time, if so encouraged. It is likely that these patients are also gratifying to the clinician due to their high level of functioning and satisfaction with treatment.

The high usage of resources by patients in the normal range provides an opportunity to reduce cost and increase value. Even a modest reduction in the average length of treatment for these patients can result in significant savings to the health plan and employer, while having no measurable impact on the overall outcome of care.

At the same time, increasing the treatment resources for patients with high level of distress can result in a significant improvement in outcomes as well as the value of the services, despite the apparent higher costs.

Clinicians who use the outcome measures as a decision support tool when making decisions about the number and frequency of treatment encounters with any given patient will tend to show higher value than those that do not.

-- JebBrown - 19 Feb 2007

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