How a Learning Health Network Could Transform Bipolar Disorder Treatment: A Conversation With Andrew Nierenberg, MD

“Psychopharm Today” is a video-podcast series, created collaboratively with the American Society of Clinical Psychopharmacology (ASCP), in which members converse about the latest hot topics in psychopharmacology.

Most clinicians cannot say how their patients are doing overall. The Bipolar Action Network aims to change that, according to Andrew A. Nierenberg, MD, the Thomas P. Hackett, MD, Endowed Chair in Psychiatry at Massachusetts General Hospital (MGH) and professor of psychiatry at Harvard Medical School. Nierenberg also directs the Dauten Family Center for Bipolar Treatment Innovation at MGH.

Nierenberg spoke with Jessica Gannon, MD, of the University of Pittsburgh, in this episode of “Psychopharm Today.” He described the network as a learning health network, a model developed at Cincinnati Children's Hospital that has been used successfully 15 times. In these networks, health care systems collaborate closely, share outcomes data, and apply improvement science to complex conditions.¹

He cited 2 examples. Solutions for Patient Safety brings together about 150 children's hospitals that share data on hospital-acquired harm. In ImproveCareNow, more than 100 clinics treating about 30,000 young people with inflammatory bowel disease work together to improve outcomes.²

Measuring Outcomes

According to Nierenberg, the first question for any health system is whether better patient outcomes are a priority. The second is whether the system knows its patients' outcomes, and none of the participating systems did. To keep the burden low for patients and clinicians, the network chose the Clinical Global Impression-Severity (CGI-S) scale as its core outcome measure.

The data gave Nierenberg his first view of his own clinic's outcomes. The clinic treats about 425 patients with bipolar disorder. About 30% are doing well and 70% are not. For patients who are not doing well, the network supports structured peer consultation, and the results of each consultation feed back into a shared database.

Network members are also adopting tactics that are common in other areas of medicine but rare in psychiatry, such as previsit planning. With this approach, labs and patient-reported data are collected before an appointment, so the clinician has actionable information during the visit.

Experts by Experience

Patients and family members, whom the network calls "experts by experience," help redesign care. The network is built as an actor-oriented organization, a model from Øystein Fjeldstad of BI Norwegian Business School, so any member can test an idea without asking permission. Projects led by experts by experience include a mood-tracking app and a tool that stores a patient's medication history, including response and tolerability.

"They solve the problems we wouldn't even know about," said Nierenberg.

Spreading Improvement

The network holds about 3 learning sessions a year, both virtual and in person. Members share network-wide and local projects at these sessions. Nierenberg drew a distinction between traditional quality improvement and improvement science. Improvement science relies on repeated plan-do-study-act cycles and a "science of spread." Experts in system change advise members to start small, show better outcomes, and let other sites adopt what works.

Health care systems interested in joining can contact the Bipolar Action Network to see whether it is a good fit.

Dr Gannon is an associate professor of Psychiatry at the University of Pittsburgh.

Dr Nierenberg is a professor of psychiatry at Harvard Medical School and a psychiatrist at Massachusetts General Hospital.

References

1. Britto MT, Fuller SC, Kaplan HC, et al. Using a network organisational architecture to support the development of learning healthcare systems. BMJ Qual Saf. 2018;27(11):937-946.

2. Crandall WV, Margolis PA, Kappelman MD, et al. Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease. Pediatrics. 2012;129(4):e1030-e1041.