Reports From the Field

Quality of Life and Population Health in Behavioral Health Care: A Retrospective, Cross-Sectional Study



The Triple Aim for health care—improving the individual experience of care, increasing the health of populations, and reducing the costs of care—was first proposed in 2008.1 More recently, some have advocated for an expanded focus to include a fourth aim: the quality of staff work life.2 Since this seminal paper was published, many health care systems have endeavored to adopt and implement the Quadruple Aim3,4; however, the concepts representing each of the aims are not universally defined,3 nor are the measures needed to populate the Quadruple Aim always available within the health system in question.5

Although several assessment models and frameworks that provide guidance to stakeholders have been developed,6,7 it is ultimately up to organizations themselves to determine which measures they should deploy to best represent the different quadrants of the Quadruple Aim.6 Evidence suggests, however, that quality measurement, and the administrative time required to conduct it, can be both financially and emotionally burdensome to providers and health systems.8-10 Thus, it is incumbent on organizations to select a set of measures that are not only meaningful but as parsimonious as possible.6,11,12

Quality of life (QOL) is a potential candidate to assess the aim of population health. Brief health-related QOL questions have long been used in epidemiological surveys, such as the Behavioral Risk Factor Surveillance System survey.13 Such questions are also a key component of community health frameworks, such as the County Health Rankings developed by the University of Wisconsin Population Health Institute.14 Furthermore, Humana recently revealed that increasing the number of physical and mental health “Healthy Days” (which are among the Centers for Disease Control and Prevention’s Health-Related Quality of Life questions15) among the members enrolled in their insurance plan would become a major goal for the organization.16,17 Many of these measures, while brief, focus on QOL as a function of health, often as a self-rated construct (from “Poor” to “Excellent”) or in the form of days of poor physical or mental health in the past 30 days,15 rather than evaluating QOL itself; however, several authors have pointed out that health status and QOL are related but distinct concepts.18,19

Brief single-item assessments focused specifically on QOL have been developed and implemented within nonclinical20 and clinical populations, including individuals with cancer,21 adults with disabilities,22 individuals with cystic fibrosis,23 and children with epilepsy.24 Despite the long history of QOL assessment in behavioral health treatment,25 single-item measures have not been widely implemented in this population.

Milwaukee County Behavioral Health Services (BHS), a publicly funded, county-based behavioral health care system in Milwaukee, Wisconsin, provides inpatient and ambulatory treatment, psychiatric emergency care, withdrawal management, care management, crisis services, and other support services to individuals in Milwaukee County. In 2018 the community services arm of BHS began implementing a single QOL question from the World Health Organization’s WHOQOL-BREF26: On a 5-point rating scale of “Very Poor” to “Very Good,” “How would you rate your overall quality of life right now?” Previous research by Atroszko and colleagues,20 which used a similar approach with the same item from the WHOQOL-BREF, reported correlations in the expected direction of the single-item QOL measure with perceived stress, depression, anxiety, loneliness, and daily hours of sleep. This study’s sample, however, comprised opportunistically recruited college students, not a clinical population. Further, the researchers did not examine the relationship of QOL with acute service utilization or other measures of the social determinants of health, such as housing, employment, or social connectedness.

The following study was designed to extend these results by focusing on a clinical population—individuals with mental health or substance use issues—being served in a large, publicly funded behavioral health system in Milwaukee, Wisconsin. The objective of this study was to determine whether a single-item QOL measure could be used as a brief, parsimonious measure of overall population health by examining its relationship with other key outcome measures for patients receiving services from BHS. This study was reviewed and approved by BHS’s Institutional Review Board.


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