Questions to consider when deciding which measurement instrument to use

Lynn F. Bufka and Nicholas Camp

Before choosing a screening instrument for the primary care setting or an outcomes measurement tool to assess care, a variety of factors must be taken into account.

Careful selection of screening tools or measurement approaches appropriate to the setting is essential. The regular use of some type of screening instrument is encouraged, because use of such a tool ensures systematic evaluation of all patients and lessens the problem of undetected symptoms due to reliance on interviews by untrained staff.

The regular use of some type of outcomes measurement tool is also encouraged to provide systematic information about treatment progress at the level of the individual, as well as the level of the practice. A wide variety of screening and measurement approaches exist, each with different attributes that make it appealing in different settings. Approaches include paper-and-pencil self-report surveys, computer questionnaires, and very brief interview screens administered by the provider or other trained staff members.

Whichever approach is adopted, implementation of a standard, structured approach ensures that all patients are systematically assessed. Earlier assessment helps to identify those individuals who would benefit from more thorough psychological and psychiatric assessment, and measurement of outcomes benefits those in treatment by helping to advance treatment and document effectiveness.

Existing screening tools range from established self-report measures to brief, clinician-administered interviews. Existing outcomes measures range from tools that track symptom change and diagnostic status to those that evaluate functioning and quality of life.. Some of the instruments are long, some are short, and most do a reasonably good job of recognizing psychological problems and measuring general psychotherapy outcomes.

However, they are not all equally user-friendly across treatment settings, and the utility of the information given varies across instruments. Clearly, no single tool is best for all applications. The given approach must be functionally useful to the particular setting, and the benefits of implementing the approach must outweigh the burdens. The practitioner in each setting needs to determine what is needed in a measurement tool to make it useful to that setting.

What Information Is Needed From the Assessment?

If the purpose is to assist primary care staff in making a decision as to whether to refer the patient to a mental health practitioner, then a brief screening tool may be sufficient. However, if primary care staff are going to provide the mental health treatment, more detailed information may be needed from the assessment tool.

Different assessment tools are designed to provide varying amounts of detail, ranging from
simple information about the presence or absence of symptoms to complex diagnostic impressions. Before choosing an assessment tool, it is important to have a clear understanding of the needs of the particular care setting, and how much diagnostic information is necessary.

When choosing a tool for both initial assessment and ongoing outcomes tracking, it is important to determine which outcomes are important to assess and the level of detail needed for effective decision making.

Who Will Administer the Tool?

Assessment tools can be administered by clinicians or support personnel, or self-administered by the client. There are advantages and disadvantages to all of these options. In a medical setting, the patient may be uncomfortable talking about mental health issues, and may be more comfortable responding to a questionnaire than directly to a medical professional.

As outcomes measures, these self-report tools provide easy options for the clinician to collect information systematically, with little personal time invested. However, some instruments can be difficult to interpret when completed by patients who tend to minimize psychological factors and instead focus on somatic factors, and this can be compounded when completed in a primary care setting by individuals not prepared to focus on mental health problems.

Also, self-report measures cannot be used with clients who are unable to read, and they are difficult to use with severely disturbed patients. On the other hand, clinician-administered screening systems give the clinician the opportunity to interact with the patient but take much time to administer regularly. Another option is for support personnel to administer or assist in administration of the assessment. This option is contingent on personnel time, training, and sensitivity to patient issues.

In addition, if patients are not initiating care for mental health problems, then they can occasionally be uncomfortable with the idea of talking directly to staff about concerns, particularly to non-health care staff.

How Long Does It Take?

There are three aspects of timing to consider. The first important issue pertains to the length of time it takes to administer the assessment tool. The second pertains to the time it takes to score the tool, and the third pertains to the amount of time it takes to review the information and interpret the results.

Time of administration varies based on mode of administration and the length of the tool. With experience, many self-report tools take only 2–3 minutes to review. Most tools must be scored; thus, ease of scoring is an important factor. Without some form of cutoff or clear diagnostic threshold, screening information may be useless. The effort it takes to score the assessment tool must be factored into the cost and benefit of administrating the tool. Some tools with software programs for scoring make it possible to obtain rapid results. Other assessment tools are easily scored by the practitioner.

Another scoring approach is a fax-back system, wherein the completed assessment tool is faxed to a central scoring destination, and within a brief amount of time a report is returned. Still others can be administered and scored online and, increasingly, this option will be integrated into electronic health records systems for some subsets of tools. With the use of instruments that have quick administration and scoring, the clinician can potentially review the results of the assessment before the patient has left the office.

How Will the Data Be Used?

In many settings, a screening tool is used only for assessment; that is, it indicates the likely presence of psychopathology and is used only for clinical purposes. In this instance, relatively immediate results that are available soon after the tool is completed are ideal. However, in other settings, the data are used to profile practice demographics and to track treatment outcomes.

Tools that track factors specific to treatment focus may be more desirable for measuring outcomes. In these instances, simple screens of pathology are not sufficient, and tools measuring symptoms and diagnoses may be needed. Or tools that provide an overall picture of mental health functioning, general life functioning, or quality of life may be better keyed to the treatment focus and may therefore be more suitable as outcome measures.

Tools that can be administered and scored by computer may be capable of exporting data into a spreadsheet for further analysis. Publishers of some tools provide monthly aggregate reports that detail over all patient demographics and symptom profiles.

Will Data Be Shared with Patients?

In a primary care setting, mental health findings may have to be demystified. Frequently, patients who present with somatic complaints, and often their physicians, do not recognize possible connections between physical and mental health problems.

However, technology-supported tools with automated scoring may also generate reports that can help demystify for the patient (and the physician) the exact nature of the mental health problems. The self-reported information is analyzed within a mental health framework, and the physician and patient are assisted in understanding the relationship between somatic concerns and mental health problems.

It can also be very beneficial to share outcomes data with patients. Systematic collection of information and mapping that information over time can illustrate to patients continued problems, as well as areas of improvement. The data can be used as a motivator for continued treatment or a starting point for discussion about why treatment may not be progressing. These data can also identify when to end treatment or when to consider other treatment options.

Finally, both assessment and outcomes information can be very useful when aggregated to develop an understanding of the types of patients presenting for treatment within a particular practice setting and to examine clinical strengths and relative weaknesses in the provision of care.

Does the Tool Make Sense to the Client?

In order for an instrument to be useful in most settings, it must make sense to the patient. The purpose of the tool and directions for completion must be clear. Self-report tools should be worded in everyday language and written at the appropriate reading level of most patients. In addition, the instrument should be straightforward in nature and easy to fill out.

For example, older patients may require a tool in larger print than younger patients, and patients taking certain psychotropic medicines may have difficulty filling in small circles. Finally, the results should be integrated into patients’ overall health care.

References

Martin m. Antony & David H. Barlow, 2010, Handbook of assessment and treatment planning for Psychological disorders, Second edition, structured and semi-structured diagnostic interviews, The Guilford Press

Read Also

Evaluating the Psychometric Properties of Psychological measures (Introductory)

Potential considerations in Selection of a diagnostic interview

Structured and Semi-Structured Diagnostic Interviews

Brief measures for screening and measuring mental Health outcomes

Psychometrics and tool development considerations
Barriers to the implementation of Standardized Screening and outcomes measurement
Principles and Practice of assessment in primary care settings
Factors Influencing Assessment
The Current Status of Health Measurement
Evaluating a Health Measurement: The User’s Perspective
Types of Health Measurements
Identifying and Controlling Biases in Subjective Judgments in health measurement