Once we have established the framework for Mental HSR, and have discussed the two dimensions that must be taken into account when dealing with com- plex questions, we will briefly review some of the key concepts in Mental HSR.
9.4.1 Need
Need is one of the main drivers of health service use.
In layman’s terms it may mean the existence of a health problem [15], but a definition must be more complex than this. According to The Dictionary of Epidemiology [16] the term ‘need’ has both ‘a precise and all-but-undefinable meaning in the public health context’. The fact is that when using the word
‘need’, there are implied value judgements that define what, and when, a health status can be defined as a health problem. For instance, in the case of mental health, before psychiatric deinstitutionalisation, the needs of outpatient treatment for people affected by schizophrenia were not considered, whereas since deinstitutionalisation, and in the context of the subsequent progressive sensitisation of citizens, their needs for communitarian treatment have been taken into account.
From an economist’s point of view, ‘need’ can be defined as ‘the minimum amount of resources needed to exhaust an individual’s capacity to benefit’. A relatively simple definition from a health economics point of view, provided by Davis, states that ‘need is a subjective feeling state that initiates the process of choosing among medical resources’ [15].
Other authors, from a sociological standpoint, have distinguished four approaches to define need [15, 17, 18]:
• Normative need: those needs ‘objectively’ defined by professionals.
• Felt need: those needs ‘subjectively’ defined by individuals.
• Expressed need: defined by the actions carried out by individuals. That is, for instance, seeking care for a health problem.
• Comparative need: derived from examining the services provided in one area to one population
and using this information as the basis to determine the sort of services required in another area with a similar population.
From a Mental HSR approach, a mental health need is defined as:
‘the requirement of individuals to enable them to achieve, maintain, or restore an acceptable level of social independence or quality of life, as defined by particular care agency or authority’ [17].
9.4.2 Want, demand and supply
Need is related to other key concepts:want,demand andsupply. The four terms are in some sense over- lapped, and sometimes they are used loosely. Simply put, want is understood to mean what the indi- viduals would like but may not act upon,demand refers to the expressed want (some authors will say to the expressed need) andsupplyrefers to the ser- vices/treatment/kinds of care that are available [15, 18]. As a goal, mental health systems try to increase the overlap between need, demand and supply.
Additionally, some authors have argued for the importance of differentiating betweenunmetandmet needs [15], according to whether people are receiving effective services or care, or not. Moreover, others have pointed out the importance of the existence of treatment to determine whether something is a need.
That is, to say, if no treatment exists for an illness, one could argue that, rather than a need for this treatment, there is awant.
9.4.3 Efficacy, effectiveness and efficiency
The study of the efficacy, effectiveness and efficiency of mental health services is among the key issues in Mental HSR. The concepts refer to the effects of an intervention.Efficacy is assessed by answer- ing the question ‘Can it work?’ That is, does a given intervention causes more good than harm to specifically diagnosed patients who are adequately treated and who totally comply with the full treat- ment? In other words, efficacy tries to assess whether an intervention (be it a drug, a surgical procedure or an organisational arrangement) works in ideal
conditions. Typically, randomised clinical trials are designed to evaluate the efficacy of interventions.
On the other hand, effectiveness is measured by answering the question ‘does it work?’ That is, in everyday conditions, will the treatment work?
Everyday conditions can depart from the ideal for a number of reasons, such as incomplete diagnostic efforts, comorbidity and insufficient compliance by the provider and/or the patient. Assessing effective- ness is important for more accurate planning and evaluation of services provision.
Lastly, efficiencytakes into account the relation- ship between costs and effects. Two different types of efficiency are defined: (i)Productionefficiency refers to achieving a given level of output at minimum cost, that is if two interventions obtain the same results, the intervention with lower costs will be more effi- cient. (ii)Allocative efficiency refers to maximising the results, in this case on population health, with a given amount of resources. With a health bud- get, maximum allocative efficiency will be achieved if resources are devoted to the interventions that produce the maximum improvement in health [19].
There are three ways of estimating efficiency depending on the way outcome is measured: cost- effectiveness, cost-utility and cost-benefit. All three take into account costs in monetary units (which could be direct, such as the costs of treatments, or indirect, for example productivity losses associated with illness) but differ in the unit of outcomes: in cost-effectiveness analysis the consequences of the intervention (outcomes) are measured in the most appropriate natural effects or physical units, such as
‘reduction in psychotic symptomatology’ or ‘cases adequately detected’. In cost-utility analyses, the outcomes are measured in health state preference scores or utilities. The most common measure used in cost-utility analysis is the quality-adjusted life-year (QALY). Finally, cost-benefit analysis measures the consequences, the outputs, in monetary terms, for instance, applying a monetary value to the illness status or life [20].
9.4.4 Appropriateness of care
Most of the concepts discussed above deal with the results, outputs or outcomes of health services. When
interested in evaluating the process of providing services, adequacy or appropriateness of care is important. Appropriateness tries to assess whether the particular patient receives adequate treatment, in a timely manner, from the appropriate profes- sional, in the right setting. According to Shape and Faden [21], the concept of appropriateness has to be considered from at least three different perspectives:
(i) the clinical point of view, that is is there enough evidence about a procedure in terms of potential ben- efits and harm?; (ii) the perspective of the individual patient; that is when studying appropriateness, the values and ‘nonclinical’ benefits and harm to the patients and their interests have to be incorporated.
In other words, from a patient’s point of view, an intervention will be considered as adequate when the patient has participated in the decision-making pro- cess and has freely accepted it once informed and, finally, (iii) from the societal point of view, that is in an era of escalating healthcare costs and contained financing, procedures should also be cost-effective.
The relationship of needs with effectiveness and adequacy can be understood through the following example. Imagine an epidemiological research study designed to assess whether the citizens of a region with mental health needs are receiving appropriate interventions. Following the steps suggested by Spasoff [15] and Muir Gray [22], we should proceed as follows:
1 We should estimate the number of people in need (as a proxy we can use the prevalence of people with mental disorders).
2 We should measure the actual level of health ser- vice utilisation by people with the problem (that is how many people with mental disorders are using health services for their emotional problems?).
3 We should determine, from evidence-based liter- ature, which interventions are beneficial (effective and/or cost-effective) for their problems.
4 We should try to assess whether recommendations from literature are consistent with the kind of care that they are receiving.
This type of approach is illustrated in Table 9.2.
In cell (a) there is the number of cases for which the intervention is indicated and who is actually receiving
Table 9.2 The relationship between needs for treatment and appropriateness of care.
Receiving Not receiving Not receiving any Total
recommended recommended intervention
intervention intervention Intervention is
indicated
(a) Met
need/adequately treated
(b) Inappropriate treatment
(c) Unmet need Total need for intervention
Intervention is not indicated
(d) Inappropriate treatment
(e) Inappropriate treated
(f) Appropriate non-treatment
No need for intervention
Total Total treated Not treated Total cases of problem
Adapted and modified from: Spasoff RA (1999)Epidemiologic Methods for Health Policy, Oxford University Press, New York, p. 111 [15].
it. These could be considered as patients whose needs have been met. Cell (b) represents the number of people for whom the intervention is needed but they are receiving an intervention which does not meet minimum quality standards. In cell (c) are those patients who are not receiving any treatment, despite their need for it. These are the cases with unmet need. Cells (d and e) indicate misuse of resources such as cases where people are receiving treatment for which the intervention is not indicated. In other words, there are cases of inappropriate treatments.
Lastly, cell (f) shows those cases without a need for intervention who are, appropriately, not treated.
Nevertheless, this approach has some limitations which should be acknowledged. If we use ‘norma- tive’ needs, assuming that anyone with a psychiatric diagnosis is in need, we could be overestimating the number of people with unmet needs. Moreover, it is important to bear Tansella’s and Thornicroft’s matrix in mind, and try to describe the various factors that would explain why people are not expressing their needs or receiving the required treatment. Of course, unmet need could also simply be due to the fact that effective treatments are not being supplied in a particular country/area, are not considered to be cost-effective, or a lack of conclusive evidence exists regarding effective treatments for a problem.
Another limitation of this approach is that it does not consider the patient’s perspective. A person could be diagnosed but does not feel disabled enough to seek care or, conversely, a person could be in need of some kind of mental health care that does not meet diagnostic criteria.
9.4.5 Small area variations (SAV)
Related to the study of appropriateness, another important issue for Mental HSR is the study of small area variations (SAVs). This concept refers to the large differences in the rates of use of medical services between geographical regions. Such varia- tions can be detected between countries, provinces or regions [23]. The study of SAVs is important because it could indicate poor access to health ser- vices or underuse of resources in some areas. It could also show iatrogenic consequences of overuse.
Briefly, the steps in analysing SAVs are:
1 Determination of numerator. For instance, num- ber of emergency psychiatric consultations during a month.
2 Determination of denominators. For instance, health regions.
3 Adjustment for age and gender.
4 Use of statistical test to control random fluctuations.
Different hypotheses have been put forward to explain what causes SAVs. Among the most com- monly cited are the following:
1 The uncertainty hypothesis: according to this hypothesis, formulated by the first time by Wennberg [24], variability is low when there is clinical consensus (and/or scientific evidence) about which is the best procedure. When there is uncertainty about the best therapeutic option, health professionals act for the best according
to their own criteria. In these cases of high uncertainty, factors related to health-system pro- visions play an important role in explaining SAV.
2 Enthusiasm hypothesis: this hypothesis suggests that the inappropriate use of a procedure is equal in areas with high and low use of services. Never- theless, in areas with high use of services, there are few clinicians who are enthusiastic about a pro- cedure being responsible for the variability [25].
3 Patient practice variations hypothesis: states that differences in morbidity explain SAV.
Variables related to demand (i.e. the patient) such as socioeconomic level, studies, ethnicity, health status and beliefs are the main source of variability [26].
9.4.6 Factors associated with access to health care
Different models have been proposed to understand why people access health care. One of the most used is the Behavioral Model and Access to Medical Care by Ronald M. Andersen [27]. Figure 9.1 depicts the components and their interrelation.
This model suggests that people’s use of health ser- vices is a result of a combination of factors related to the environment, their predisposition to use these ser- vices, along with factors that may enable or impede use, and their need for health. It also includes feed- back loops. For instance, outcomes may, in turn, affect perception of need and health behaviour.
The first component of the model, the environ- ment, refers explicitly to the national health policy, the resources devoted to health and their organi- sation. For instance, in a country with a national health system with universal coverage, higher access to healthcare than in a country with a private health system would be expected. With respect to external environment, the influences of political and econom- ical components are also taken into account.
The second component, population characteris- tics, covers three distinct factors:
• Predisposing characteristics include: demographic characteristics such as age and gender; social structure (education, occupation and ethnicity);
social networks, interactions and networks and
the health beliefs that comprise the attitudes, values and knowledge that people have about both health and health services. In the case of Mental HSR, the stigma associated with mental disorders is also one of the key elements that could explain lower use.
• Enabling resources refer to the community and personal facilities that people have. For instance, income, health insurance, a regular source of care and perceived social support, are just some of the enabling factors.
• The perceived need for care, as discussed above.
The third component of the model is the use of health servicesper se, traditionally the main outcome.
Additionally, other personal health practices, such as diet, exercise or self-care are recognised as interacting with the formal use of services.
The inclusion of other outcomes (fourth com- ponent) such as: perceived health status, evaluated health status and consumer/user/patient satisfaction allows research to include other outcomes that could be important to health policy. Thus, Andersen sug- gests some additional measures such as ‘effective access’, which is achieved when utilisation studies show that use improves health status or consumer satisfaction with services, and ‘efficient access’ which is established when the level of health status or sat- isfaction increases relative to the amount of health care services consumed.
9.4.7 Equity
The International Society for Equity in Health (ISEqH) defines equity in health as:
‘the absence of potentially remediable, systematic differences on one or more aspects of health across socially, economically, demographically or geographically defined population groups or subgroups’ [28].
Investigations related to mental HSR and equity will explore, for instance, whether people with equivalent needs receive equal treatment (horizontal equity) or whether those with greater mental health needs receive preferential treatment (vertical equity).
ENVIRONMENT
Health care system External environment
POPULATION CHARACTERISTICS Predisposing
characteristics
Enabling resources
Need
OUTCOMES
(satisfaction with treatment, perceived or/and evaluated health status, quality of life…)
HEALTH BEHAVIOUR
Personal health practices Use of Health Services
Fig 9.1 Behavioral Model and Access to Medical Care by Ronald M. Andersen. Adapted from: Andersen RM (1995) Revisiting the behavioral model and access to medical care: does it matter?Journal of Health and Social Behavior,36, 1–10 [27].
Using his model of access to care, Andersen defines equitable access as occurring when demographic and need variables account for most of the variance in utilisation, whereas inequitable access occurs when social structure (for instance ethnicity), health beliefs or enabling resources (income) determine who gets medical care [27].