Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: Efficiency, stability and entropy assessment of the mental health ecosystem of Gipuzkoa (Basque Country, Spain).

Decision support systems are appropriate tools for guiding policymaking processes, especially in mental health (MH), where care provision should be delivered in a balanced and integrated way. This study aims to develop an analytical process for (i) assessing the performance of an MH ecosystem and (ii) identifying benchmark and target-for-improvement catchment areas. MH provision (inpatient, day and outpatient types of care) was analysed in the Mental Health Network of Gipuzkoa (Osakidetza, Basque Country, Spain) using a decision support system that integrated data envelopment analysis, Monte Carlo simulation and artificial intelligence. The unit of analysis was the 13 catchment areas defined by a reference MH centre. MH ecosystem performance was assessed by the following indicators: relative technical efficiency, stability and entropy to guide organizational interventions. Globally, the MH system of Gipuzkoa showed high efficiency scores in each main type of care (inpatient, day and outpatient), but it can be considered unstable (small changes can have relevant impacts on MH provision and performance). Both benchmark and target-for-improvement areas were identified and described. This article provides a guide for evidence-informed decision-making and policy design to improve the continuity of MH care after inpatient discharges. The findings show that it is crucial to design interventions and strategies (i) considering the characteristics of the area to be improved and (ii) assessing the potential impact on the performance of the global MH care ecosystem. For performance improvement, it is recommended to reduce admissions and readmissions for inpatient care, increase workforce capacity and utilization of day care services and increase the availability of outpatient care services.

Modelling the balance of care: Impact of an evidence-informed policy on a mental health ecosystem.

Major efforts worldwide have been made to provide balanced Mental Health (MH) care. Any integrated MH ecosystem includes hospital and community-based care, highlighting the role of outpatient care in reducing relapses and readmissions. This study aimed (i) to identify potential expert-based causal relationships between inpatient and outpatient care variables, (ii) to assess them by using statistical procedures, and finally (iii) to assess the potential impact of a specific policy enhancing the MH care balance on real ecosystem performance. Causal relationships (Bayesian network) between inpatient and outpatient care variables were defined by expert knowledge and confirmed by using multivariate linear regression (generalized least squares). Based on the Bayesian network and regression results, a decision support system that combines data envelopment analysis, Monte Carlo simulation and fuzzy inference was used to assess the potential impact of the designed policy. As expected, there were strong statistical relationships between outpatient and inpatient care variables, which preliminarily confirmed their potential and a priori causal nature. The global impact of the proposed policy on the ecosystem was positive in terms of efficiency assessment, stability and entropy. To the best of our knowledge, this is the first study that formalized expert-based causal relationships between inpatient and outpatient care variables. These relationships, structured by a Bayesian network, can be used for designing evidence-informed policies trying to balance MH care provision. By integrating causal models and statistical analysis, decision support systems are useful tools to support evidence-informed planning and decision making, as they allow us to predict the potential impact of specific policies on the ecosystem prior to its real application, reducing the risk and considering the population's needs and scientific findings.

Efectividad de una intervención psicoeducativa en la reducción de la sobrecarga del cuidador informal del paciente con esquizofrenia (EDUCA-III-OSA) / Effectiveness of a psychoeducational intervention in reducing burden in informal caregivers of schizophrenic patients (EDUCA-III-OSA)

Los familiares de pacientes con esquizofrenia o trastorno esquizoafectivo frecuentemente padecen consecuencias negativas derivadas de su labor como cuidadores. El objetivo del estudio EDUCA-III-OSA es evaluar la efectividad de un programa de intervención psicoeducativa (PIP) en la reducción de la sobrecarga del cuidador informal tras la intervención a los 4 meses y 16 meses después. Se llevó a cabo un estudio multicéntrico con diseño cuasi-experimental de grupo único. La variable dependiente principal fue la sobrecarga, medida a través del Inventario de Sobrecarga de Zarit (ZBI) y el Cuestionario de Evaluación de Repercusión Familiar (IEQ). Las variables secundarias fueron la ansiedad (STAI-X), la salud mental del cuidador (GHQ-28) y la depresión (CES-D). 39 cuidadores de 5 centros diferentes participaron en el estudio. Tras la intervención (4 meses), las variables de sobrecarga (d de Cohen = 0.26), depresión (d = 0.42), salud mental (d = 0.76) y ansiedad-estado (d = 0.59) experimentaron una mejora moderada. Esta mejora se vio incrementada a los 16 meses en las variables de sobrecarga (d = 0.56) y ansiedad-estado (d = 0.89), mientras que la variable de salud mental experimentó un descenso (d = 0.39). Tras la aplicación de la intervención psicoeducativa manualizada se produjo una mejoría en el estado psicológico de los cuidadores informales. Estos cambios se mantuvieron un año después

Families of patients with schizophrenia usually experience negative consequences. The aim of the EDUCA-III-OSA study is to test the effectiveness of a psychoeducational intervention program (PIP) to reduce the caregiver burden at post-intervention (4 months) and at follow-up (16 months). A multicentre quasi-experimental study design with a unique group of informal caregivers who received intervention was used. The intervention consisted of 12 weekly group sessions. The primary outcome variable was burden, measured through the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ). Secondary outcome variables were anxiety (STAI-X), mental health (GHQ-28), and depression (CES-D). 39 caregivers from 5 research sites participated in the study. After the intervention (4 months), the variables of burden (Cohen's d = 0.26), depression (d = 0.42), mental health (d = 0.76), and anxiety-state (d = 0.59) showed a moderate decrease. These improvements increased 16 months later in the variables of burden (d = 0.56) and anxiety-state (d = 0.89), while the mental health variable decreased (d = 0.39). After the application of the intervention program a marked improvement in the psychological status of informal caregivers was produced. These changes held one year later

Use of the self-organising map network (SOMNet) as a decision support system for regional mental health planning.

BACKGROUND: Decision-making in mental health systems should be supported by the evidence-informed knowledge transfer of data. Since mental health systems are inherently complex, involving interactions between its structures, processes and outcomes, decision support systems (DSS) need to be developed using advanced computational methods and visual tools to allow full system analysis, whilst incorporating domain experts in the analysis process. In this study, we use a DSS model developed for interactive data mining and domain expert collaboration in the analysis of complex mental health systems to improve system knowledge and evidence-informed policy planning. METHODS: We combine an interactive visual data mining approach, the self-organising map network (SOMNet), with an operational expert knowledge approach, expert-based collaborative analysis (EbCA), to develop a DSS model. The SOMNet was applied to the analysis of healthcare patterns and indicators of three different regional mental health systems in Spain, comprising 106 small catchment areas and providing healthcare for over 9 million inhabitants. Based on the EbCA, the domain experts in the development team guided and evaluated the analytical processes and results. Another group of 13 domain experts in mental health systems planning and research evaluated the model based on the analytical information of the SOMNet approach for processing information and discovering knowledge in a real-world context. Through the evaluation, the domain experts assessed the feasibility and technology readiness level (TRL) of the DSS model. RESULTS: The SOMNet, combined with the EbCA, effectively processed evidence-based information when analysing system outliers, explaining global and local patterns, and refining key performance indicators with their analytical interpretations. The evaluation results showed that the DSS model was feasible by the domain experts and reached level 7 of the TRL (system prototype demonstration in operational environment). CONCLUSIONS: This study supports the benefits of combining health systems engineering (SOMNet) and expert knowledge (EbCA) to analyse the complexity of health systems research. The use of the SOMNet approach contributes to the demonstration of DSS for mental health planning in practice.

[Models for primary care and mental health collaboration in the care of people with depression: main results and methodological challenges of a systematic overview]. / Modelos de colaboración entre atención primaria y salud mental en la asistencia sanitaria a las personas con depresión: resultados principales y retos metodológicos de una meta-revisión sistemática.

BACKGROUND: Weaknesses in the collaboration between Primary Care (PC) and Mental Health (MH) are a relevant problem in the care of depressed patients. It is necessary to analyse and appraise the existing models of collaboration to assess their applicability to the Spanish Health System. The aim of this study is to know the main characteristics of the different models of collaboration between PC and MH in the care of patients with depression and the quality of their effectiveness evidence. METHODS: Systematic overview of secondary studies published from 2001 to 2010 in MEDLINE, PsycINFO, Embase, LILACS, IBECS, IME and The Cochrane Library. Assessment of reviews applying the AMSTAR tool. Approximative synthesis of the quality of evidences. RESULTS: A total of 69 studies were assessed. Quality of evidences is generally low or inconclusive due to the great variability among contexts and the methodological weaknesses. The most effective strategies integrate interventions for assigning responsibility for patient follow-up, redesigning management and communication/information sharing. Overviews of secondary studies on collaborative models facilitate access to published evidence, but entail important methodological challenges. CONCLUSION: The quality of evidences on effectiveness of PC-MH collaboration models in depression care is mainly low or inconclusive, and the more simplified are the analysis of components, processes and implementation conditions, the less meaningful and applicable they are.

Modelos de colaboración entre atención primaria y salud mental en la asistencia sanitaria a las personas con depresión: resultados principales y retos metodológicos de una meta-revisión sistemática / Models for primary care and mental health collaboration in the care of people with depression: main results and methodological challenges of a systematic overview

Fundamentos: Las carencias en la colaboración entre Atención Primaria (AP) y Salud Mental (SM) constituyen un problema relevante en la atención a los pacientes con depresión. Resulta necesario analizar y evaluar los modelos de colaboración existentes para valorar su aplicabilidad en el sistema de salud español. El objetivo del presente estudio es conocer las principales características de los distintos modelos de colaboración AP-SM en la atención a los pacientes diagnosticados de depresión y la calidad de la evidencia científica acerca de su efectividad. Métodos: Meta-revisión sistemática de los estudios secundarios publicados entre 2001 y 2010 en MEDLINE, PsycINFO, Embase, LILACS, IBECS, IME y la Biblioteca Cochrane. Las revisiones se evaluaron mediante la herramienta AMSTAR. Se realizó una síntesis aproximativa de la calidad de las evidencias encontradas. Resultados: Se evaluaron 69 estudios. La variabilidad según contextos y las carencias metodológicas condicionan que la calidad de las evidencias sea en general baja o dudosa. Las estrategias más efectivas integran intervenciones de responsabilización en el seguimiento de los pacientes, rediseños en la gestión, e información y comunicación compartidas. Las meta-revisiones de estudios secundarios sobre modelos colaborativos favorecen la accesibilidad a las evidencias publicadas, pero conllevan importantes retos metodológicos. Conclusiones: La calidad de la evidencia sobre la efectividad de los modelos de colaboración AP-SM durante la atención sanitaria a las personas con depresión es predominantemente baja o dudosa y su significado y aplicabilidad son menores cuanto más se simplifica el análisis de sus componentes, procesos y circunstancias de implementación (AU)

Background: Weaknesses in the collaboration between Primary Care (PC) and Mental Health (MH) are a relevant problem in the care of depressed patients. It is necessary to analyse and appraise the existing models of collaboration to assess their applicability to the Spanish Health System. The aim of this study is to know the main characteristics of the different models of collaboration between PC and MH in the care of patients with depression and the quality of their effectiveness evidence. Methods: Systematic overview of secondary studies published from 2001 to 2010 in MEDLINE, PsycINFO, Embase, LILACS, IBECS, IME and The Cochrane Library. Assessment of reviews applying the AMSTAR tool. Approximative synthesis of the quality of evidences. Results: A total of 69 studies were assessed. Quality of evidences is generally low or inconclusive due to the great variability among contexts and the methodological weaknesses. The most effective strategies integrate interventions for assigning responsibility for patient follow-up, redesigning management and communication/information sharing. Overviews of secondary studies on collaborative models facilitate access to published evidence, but entail important methodological challenges. Conclusion: The quality of evidences on effectiveness of PC-MH collaboration models in depression care is mainly low or inconclusive, and the more simplified are the analysis of components, processes and implementation conditions, the less meaningful and applicable they are (AU)