Benefits and challenges in practice-oriented psychotherapy research in Germany: The TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy

Abstract

Objective: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. Method: Both projects and their results indicating high effect sizes are briefly described. Results: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. Conclusions: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system.

Ziel: In diesem Artikel werden zwei im deutschen ambulanten Psychotherapiesystem durchgeführte patientenorientierte Langzeitforschungsprojekte fokussiert. Das TK-Projekt (Techniker Krankenkasse) ist die erste Studie, welche ein Qualitätssicherungs- und Feedbacksystem in Hinblick auf deren praktische Durchführbarkeit in der deutschen Routineversorgung evaluiert. Die andere Studie („Qualitätssicherung in der ambulanten Psychotherapie in Bayern“; QS-PSY-BAY) wurde entwickelt um einen neuen Ansatz der Qualitätssicherung in der ambulanten Psychotherapie zu testen, indem man elektronische Dokumentation von Patientencharakteristika und Ergebnisparameter verwendete. Außerdem bietet dieses Projekt die Gelegenheit Daten über die gesundheitsbezogene Kosten ambulanter Psychotherapie zu analysieren. Methode: Beide Projekte und ihre Ergebnisse, die hohe Effektgrößen zeigen, werden kurz beschrieben. Ergebnisse: Aus der Perspektive der Forschungsteams, der Beiräten und anderen Interessensgruppen werden die Erfahrungen mit diesen Projekten diskutiert. Dabei liegt der Fokus auf den Hindernissen, Herausforderungen, Schwierigkeiten und dem Nutzen der Entwicklung und Durchführung dieser Studien. Die Dreieckszusammenarbeit von Therapeuten, Forschern und den Krankenkassen/Gesundheitsdiensten stellte sich in beiden Studien als ergiebig heraus. Schlussfolgerungen: Trotz mancher Kontroversen zwischen den Partnern, zeigen die Erfahrungen die Relevanz von Praxis-Forschungs Kollaborationen, da diese wichtige Informationen über ambulante Psychotherapien im Gesundheitssystem liefern.

Obiettivo: in questo articolo verranno illustrati due progetti di ricerca a lungo termine focalizzati sul paziente, effettuati all’interno dell’assistenza psicoterapeutica ambulatoriale tedesca. Il progetto TK (Techniker Krankenkasse) è stato il primo studio che aveva lo scopo di valutare la garanzia di qualità e il sistema di verifica per quanto riguarda gli aspetti pratici nel trattamento di routine tedesco. L'altro studio (“Quality Assurance in Outpatient Psychotherapy in Bavaria ”; QS-PSY-BAY) è stato progettato per testare un nuovo approccio alla garanzia della qualità della psicoterapia ambulatoriale attraverso l’uso della documentazione elettronica delle caratteristiche del paziente e dei parametri di esito. Questo progetto ha offerto, poi, la possibilità di analizzare i dati sui costi legati alla salute dei pazienti in trattamento psicoterapeutico ambulatoriale. Metodo: Sono descritti brevemente i progetti ed i loro risultati con maggior effect size. Risultati: Vengono analizzate le esperienze di questi progetti a partire dal punto di vista dei gruppi di ricerca, dei comitati consultivi e di altri operatori interessati, focalizzando l’attenzione sugli ostacoli, le sfide, le difficoltà e i benefici nello sviluppo e nell'attuazione di questi studi. La collaborazione a tre che coinvolge terapeuti, ricercatori e compagnie di assicurazione sanitaria / istituti del servizio sanitario si èrivelata fruttuosa in entrambi gli studi. Conclusioni: Nonostante alcune polemiche osservate tra i partner, queste esperienze segnalano l'importanza di una collaborazione nella ricerca pratica per fornire informazioni importanti alla consegna in psicoterapia ambulatoriale nel sistema sanitario.

Objetivo: Neste artigo são analisados dois projetos de investigação a longo-prazo focados no paciente desenvolvidos no sistema Alemão de psicoterapia em ambulatório. O projeto TK (Techniker Krankenkasse) é o primeiro estudo para avaliar um sistema de garantia de qualidade e de feedback com vista à sua viabilidade prática nos cuidados de de rotina Alemães. O outro estudo (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) foi desenhado para testar uma nova abordagem para a garantia de qualidade na psicoterapia em ambulatório utilizando documentação electrónica acerca das características do paciente e das medidas de resultado. Além disso, este projeto fornece a oportunidade para analisar dados dos custos relacionados com a saúde dos pacientes em psicoterapia em ambulatório. Método: São descritos de forma breve ambos os projetos e os seus resultados indicando tamanhos de efeito elevados. Resultados: A partir das perspetivas das equipas de investigação, conselhos consultivos e outras partes interessadas, as experiências destes projetos são discutidas com foco nos obstáculos, desafios, dificuldades e benefícios associados ao desenvolvimento e implementação dos estudos. O triângulo de colaboração entre terapeutas, investigadores e companhias de seguros de saúde/instituições de serviços de saúde veio a ser frutífero em ambos os estudos. Conclusões: Apesar de algumas controvérsias entre os parceiros, as experiências indicam a importância das colaborações investigação-prática para fornecer informação relevante acerca disponibilização de psicoterapia em ambulatório no sistema de saúde.

本文針對在德國心理治療門診系統中，二個以病人為主的長期研究計劃進行探討。TK(技術人員醫療保險，TechnikerKrankenkasse)計劃是德國第一個考慮到日常照護系統之實際可行性，所進行之品質保障及回饋系統的評估研究。另一研究（巴伐利亞心理治療門診之品質保證，“Quality Assurance inOutpatient Psychotherapy in Bavaria”; QS-PSY-BAY）則是運用病人特性及治療結果參數之電子文件的新方法，來檢驗門診病人的品質保障。此外，本計劃也有機會分析病人接受心理治療門診服務的健康相關支出資料。方法：簡述二個計劃之內容及具高效果值的結果。結果：從研究團隊、諮詢委員會及利益相關團體的觀點，探討發展及應用這二個計劃的阻礙、挑戰、困境及獲益經驗。二個研究中，治療師、研究者及健康保險公司／健康照護組織的三方合作，都帶來很好的成效。結論：儘管合作伙伴間仍存在一些爭議，這些經驗指出實務－研究合作的重要性，它可以為健康照護系統中心理治療門診服務提供重要參考資訊。

Keywords:

• outcome research
• process research
• mental health services research

Acknowledgments

Members of the Scientific Advisory Board were J. Brockmann, F. Caspar, G. Rudolf, C. E. Scheidt (coordinator), U. Stangier, and H. Vogel.

The TK research team (Werner W. Wittmann, Wolfgang Lutz, Andrés Steffanowski, Jan R. Böhnke, David Kriz, Julian Rubel, Manuel Völkle) would like to thank Katharina Köck, André Bittermann, Niklaus Stulz, Armita Tschitsaz-Stucki, Eva Schürch, and Sven Tholen for their collaboration on prior reports of the project and on training courses for therapists in the introductory phase of the study. Furthermore we would like to thank all participating patients, therapists and reviewers, the Techniker Krankenkasse (Dr. Ruprecht, project management TK), the participating regional associations of statutory health insurance (Hessen, Südbaden und westfalen-Lippe), the Hogrefe test system (e.g., Prof. Hänsgen and Karl-Heinz Schlawis), the scientific advisory board (especially Prof. Scheidt and Prof. Caspar), as well as Prof. Fydrich, Dr. Nagel, Prof. Schulte and Prof. Grawe^† for their support in different forms and phases of the project.

We would like to thank the entire project team of the KVB and the “Verband der Ersatzkassen e.V. Berlin” (vdek), the initiating group of therapists (Emma Auch-Dorsch, Ellen Bruckmayer, Dr. Friedrich von Heymann, Dr. Irmgard Pfaffinger), other supporters (Prof. H. Letzel, Klemens Funk) as well as the scientific advisory board of the QS-PSY-BAY project (Prof. P. Henningsen, Prof. H. Jungnitsch, Prof. Th. Loew), the Institute for Quality Assurance in Psychosomatics (IQP) München, the Cibait-AG Saarbrücken as well as the Otto-Selz-Institute of the University of Mannheim for their cooperation and support. We also would like to thank all therapists and patients for their engagement and trust.

Notes

¹ Schizophrenia, schizotypal and delusional disorders, mood (affective) disorders, neurotic, stress-related and somatoform disorders, behavioral syndromes associated with physiological disturbances and physical factors, and disorders of adult personality and behavior.

1. Schizophrenia, schizotypal and delusional disorders, mood (affective) disorders, neurotic, stress-related and somatoform disorders, behavioral syndromes associated with physiological disturbances and physical factors, and disorders of adult personality and behavior.