Optimizing eating disorder treatment: The case for measurement-based care

Presented by Caitlin Shepherd, PhD

Within Health is committed to using data to inform treatment and clinical outcomes. Therefore, they have initiated a measurement-based care initiative to ensure they are keeping up to date with the best practices in the field.

This article will look at measurement-based care (MBC) in more detail and how it can be implemented in a treatment setting.

Overview of measurement-based care (MBC) and rationale

A common misconception about measurement-based care (MBC) is that it is a “cookbook medicine” approach that reduces patients to “just a number.”

What is MBC?

Contrary to the common misconception, MBC promotes a data-driven and patient-centered approach to healthcare. MBC is defined as the use of systematic and routine patient-reported outcome measures throughout care as a core element of evidence-based practice.1

The primary purpose of the data collected in an MBC model is to track patient progress to inform treatment decisions and engage patients in their own care. However, the data can also be aggregated and used for quality improvement and program evaluation efforts.

What is EBP?

Evidence-based practice (EBP) is the integration of three key components:2

  1. Best available research, which may include but is not limited to empirical evidence from random controlled trials and evidence from qualitative research from case reports and expert opinion.
  2. Patient’s characteristics, values, circumstances, and preferences.
  3. Clinical expertise, which is required in order to determine how to integrate the other two elements of EBP to make informed and individualized treatment.

The three components of EBP are considered essential for providing optimal care for eating disorders and other mental health disorders.3 Ongoing monitoring of patient progress, adjustment of treatment, and consideration of individual differences are all crucial parts of EBP that are facilitated by MBC.

Components of MBC

There are several frameworks of the MBC model. Here at Within Health, we have adopted the three-part “Collect, Share, Act” model of MBC, developed by the Veteran’s Health Administration, the MBC and Mental Health Initiative, and the Yale Measurement Based Care Collaborative. The MBC approach fosters a collaborative relationship between the clinical team and the client. 


Clients are more likely to engage and follow through on a treatment plan they help create. The “Collect” phase of MBC involves:4

  • Explaining to the client the rationale being MBC and explain how you’ll be using the measures together in treatment together. This helps engage the client in the MBC process early on.
  • Selecting relevant measures together for treatment in addition to the measures required by the eating disorder program. It helps enhance care by linking the measure to the client’s goals.
  • Regularly administering patient-reported measures at specified time points throughout treatment as a standard part of care. Repeating the measure frequently provides scores that can guide the treatment plan over time.

While the process may differ by program, the primary goal of the “Collect” phase is to engage clients in collaboration within the MBC model, with a focus on transparency. To achieve this, a clinician will:4

  • Describe the process, including how often the measures will be repeated and who can access the information.
  • Discuss the impact on care, including creating individualized goals, assessing progress over time, and modifying treatment plans as needed.
  • Explain why each measure was selected and how it relates to the client’s treatment.


Once data is collected, there needs to be a clear process for sharing this information with clients so they can see how the data is being used to benefit them. The “Share” phase of MBC involves:4

  • Reporting the measure data to the client and explaining what the data means. 
  • Discussing the data with the client and asking if they feel they match their subjective experience, then explore discrepancies, if any. 
  • Providing education on the measures or individual responses and clarifying any confusion. 
  • Linking scores to the client’s goals and treatment plan. 

Client-clinician collaboration results in clients being more satisfied with treatment and with their care team, as well as supports a shared language between client and clinician, enhancing communication. 


After reviewing and discussing the data, the final phase is to “act” on the information gathered via a collaboration between clinician and client. This shows that MBC isn’t the collection of data for data’s sake; it’s data used to optimize collaboration and tailor treatment to meet an individual client’s goals.  The “Act” phase of MBC involves:4

  • Appraising the scores on the patient-reported outcome measure to inform your evaluation of how the treatment is going, e.g., improvement, lack of change, etc. Then, discuss what these results mean for the client.
  • Brainstorming with the client to determine possible adjustments in treatment based on the appraisal. Utilize all the clinical data, client input, and clinical impressions to generate ideas.
  • Choose a plan of action from the available possibilities in collaboration with the client. Discuss what option best meets your shared goals of treatment.

Why MBC?

Research shows that MBC is associated with several benefits. When it comes to the clients, the benefits of MBC include:5,6

  • Improving client outcomes with respect to psychological disturbances, symptoms, interpersonal problems, social functioning, and quality of life. 
  • Reduced rate of nonresponse and lower dropout rates, potentially due to the closer monitoring of outcomes, timely treatment modifications, and greater client engagement that MBC allows.
  • Increased client satisfaction potentially thanks to the active involvement of clients in the treatment process. 
  • Ensuring respect for treatment rights by actively engaging clients in treatment decisions.
  • Individualized, tailored care.
  • Encouraging engagement and empowerment by giving clients a voice in treatment, which can be particularly important when working with eating disorder populations.

There are benefits to providers and organizations that go beyond more satisfied and empowered clients, including:5,6

  • Alerting clinicians to lack of progress so that they can adjust treatment accordingly in collaboration with the client
  • Clarifying diagnoses by streamlining the assessment process, as well as enhancing the accuracy of clinician conclusions
  • Facilitating case conceptualization and treatment planning
  • Support quality improvement efforts by using the data available
  • Identifying programming needs and shaping services accordingly
  • Utilizing data to inform funding decisions, provide additional quality-of-care management, and improve client care through the addition of new programs

Barriers to MBC implementation

Despite the research showing the benefits of MBC to clients and practitioners, it is underused, with less than 20% of behavioral health practitioners using it in their practice.7 This underuse could be due to client, practitioner, and organizational barriers.7


  • Time for completing measures
  • Concerns about privacy
  • Reported outcomes (e.g., satisfaction survey) may impact client and practitioner relationship
  • Patient symptoms (e.g., cognitive impairment, personality disorders) interfering with measures


  • Negative attitudes about MBC, e.g., it is no better than clinical judgment
  • Administrative burden, e.g., time, human resources, and financial
  • Lack of clarity, e.g., concerns that measures don’t fit clients
  • Concerns about how the data will be used, e.g., performance evaluation, judge bonuses, etc.


  • Lack of resources for training
  • Staff issues, e.g., turnover, lack of leadership support
  • Guidance required for selecting measures
  • Organizational norms, culture, and climate

Facilitators of MBC implementation

Some things can be done to address the barriers above. The literature suggests that challenges to MBC implementation can be overcome by:7

  • Providing training, experience, and support
  • Using graphs to visualize the data
  • Maintaining fidelity to the model
  • Utilizing “local champions” that actively embrace and promote MBC and can encourage other practitioners to do the same
  • Using HIPAA and HL7-compliant technologies to reassure privacy concerns
  • Incentivize MBC at both the provider and the organizational level

Measures for eating disorder settings

Another challenge for practitioners in implementing MBC is deciding on what measures to use when there is an overwhelming variety of options. The recommended measures for eating disorders fall into three categories: 

Core features of illness

Below are some of the measures that could be useful in an MBC model for eating disorders, but there are other measures available:

  • Eating Disorder Examination-Questionaire (EDE-Q): This is the measure we use at Within Health as it is relatively short and has a broad scope, covering restriction, body and weight concerns, and frequency of eating disorder behaviors, amongst others.
  • Eating Pathology Symptoms Inventory (EPSI) 
  • Eating Attitudes Test-26 (EAT-26)
  • Eating Disorder Inventory 3 (EDI-3)

Depending on the client population, more focused measures could be used, such as the Nine-Item ARFID Screen or the Binge Eating Scale, to address more specific eating disorder symptoms. 

Functional assessment/quality of life (QOI)

Functional and QOI measures assess the impact of eating disorders across different domains, such as relationships, school/work, etc., and include:

  • Eating Disorders Quality of Life (EDQOL): This is the measure we use at Within Health, as it covers a wide range of domains, including psychological, physical, financial, cognitive, school/work, and more.
  • Clinical Impairment Assessment (CIA)
  • Eating Disorder Quality of Life Scale (EDQLS)

Other measures of functionality may be more suitable for certain populations or therapeutic approaches, e.g., measures more targeted toward assessing emotional regulation difficulties. 

Co-occurring symptoms

The measures for co-occurring symptoms assess comorbid psychiatric conditions and symptoms, with mood disorders, depression, and anxiety given the highest priority. Measures include:

  • State-Trait Anxiety Inventory (STAI): The measure we use at Within Health as we find it very helpful for our client population, who regularly experience fluctuating anxiety levels.
  • Generalized Anxiety Disorder-7 (GAD-7)
  • Patient Health Questionnaire-9 (PHQ-9)
  • Beck Depression Inventory-II (BDI-II)

Additional measures include those that assess trauma, obsessive compulsive disorder (OCD), and substance use, to name a few. 

Considerations for diverse populations

It’s important to recognize the limitations of measures, particularly where marginalized populations are concerned. 

Measurement tools are biased as they are based on specific samples (typically white, female, and cis-gendered) used in the development, standardization, and validation process. Therefore, incorporating MBC into broader EBP models means using clinical judgment and available client information when interpreting data.

Some research has been conducted to determine the appropriateness of using patient-reported outcome measures with different populations and establish group-specific cutoffs, norms, and levels. Depending on the client, group-specific measures and values may be more useful than general ones. 

Further reading

For more information on how to learn more about MBC implementation, The Yale Measurement Based Care Collaborative and Cohens Veterans Network are great sources of information. 


  1. Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA Psychiatry, 76(3), 324–335. 
  2. Titler, M. G. (2008). The evidence for evidence-based practice implementation. Patient safety and quality: An evidence-based handbook for nurses.
  3. Peterson, C. B., Becker, C. B., Treasure, J., et al. (2016). The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC Medicine, 14, 69.
  4. Yale Measurement Based Care Collaborative. (n.d.). Psychiatry. Accessed Nov 2023.
  5. Waldrop, J., & McGuinness, T. M. (2017). Measurement-based care in psychiatry. Journal of Psychosocial Nursing and Mental Health Services, 55(11), 30-35.
  6. Scott, K., & Lewis, C. C. (2015). Using measurement-based care to enhance any treatment. Cognitive and Behavioral Practice, 22(1), 49-59.
  7. Lewis, C. C., Boyd, M., Puspitasari, A., et al. (2019). Implementing Measurement-Based Care in Behavioral Health: A Review. JAMA Psychiatry, 76(3), 324–335.