Continuous Improvement for Veterans In Care-Mood Disorders
Amy M. Kilbourne PhD MPH
VA Ann Arbor Healthcare System
Ann Arbor, MI
Funding Period: April 2004 - September 2007

BACKGROUND/RATIONALE:
Bipolar disorder is one of the leading causes of morbidity worldwide, and is associated with significant personal and societal costs. However, there is a dearth of information on the quality, cost and outcomes of care for veterans with bipolar disorder.

OBJECTIVE(S):
The goal of this study was to refine process and outcome measures for bipolar disorder and determine how patient factors (e.g. substance use, adherence, medical comorbidity) are associated with gaps in quality of care for bipolar disorder in the VA. This research was accomplished using data from a cohort study of patients receiving care for bipolar disorder at a large VA healthcare system. By identifying vulnerable populations at increased risk of poor processes and outcomes of care for bipolar disorder, the long-term goal of this research was to inform future patient, provider, and system-level interventions to improve quality of care for this group.

METHODS:
Eligible patients with an active diagnosis and treatment plan for bipolar disorder completed a brief survey at the time of enrollment and one year later on socio-economic characteristics, substance use, adherence, and outcomes (e.g., symptoms, functioning). A chart review was conducted to assess patient's co-occurring psychiatric and substance use diagnoses, quality of care, and treatment preferences. We assessed the processes of care based on claims and chart review data using quality indicators previously derived from the American Psychiatric Association and VA clinical practice guidelines for bipolar disorder and co-occurring conditions (e.g., metabolic syndrome, substance use disorders). Data on adequate pharmacotherapy, drug level and safety monitoring, and outpatient continuity of care was collected from the VA National Patient Care (NPCD) and Pharmacy Benefits Management databases. Additional data on medical comorbidity and inpatient use was ascertained from the NPCD. Confirmatory data on quality of care for bipolar disorder, medical comorbidity, and patient factors (e.g., preferences; visit adherence) was collected via CPRS chart review.

FINDINGS/RESULTS:
Between July 2004 and July 2006, 435 veterans were eligible and completed surveys (mean age=49, 14.3% female, 23% non-white). Of the 435, 22% were currently employed, 55% were homeless at some point, and 28% used illicit drugs within the past year. Most (68%) were currently experiencing a manic, hypomanic, or mixed episode (55%). Mean SF-12 scores were 37.9 (physical health) and 31.8 (mental health). Compared to psychiatric care, patients reported greater difficulty accessing medical services, including specialist visits (19% versus 9%) and overall care when needed (17% versus 11%). In additional 60.3% were currently prescribed mood stabilizers and 65.5% were prescribed atypical antipsychotics. Overall, based on quality indicators we derived for this study, 39.7% received adequate serum drug level for mood stabilizers; 38.8% received a thyroid function test for lithium; and the majority (71.4% -75.9%) received complete blood counts and hepatic function tests for valproate or carbamazepine. Based on quality indicators representing current practice guidelines, about half of patient prescribed atypical antipsychotics received cholesterol counts (49.6%) and 68.7% received serum glucose levels. Nearly half of the respondents reported adherence difficulty. Patients experienced an average of 2.8 barriers, with 41 percent perceiving at least three. Minority veterans reported poorer adherence than white patients (56 percent versus 40 percent, p=.01), while claiming more overall barriers, particularly financial burden, binge drinking, and difficulty obtaining psychiatric care when needed. Multivariable models revealed that the total number of barriers was significantly associated with poor adherence (OR=1.24 per barrier). The most significant were low medication insight, binge drinking, and difficulty accessing psychiatric care (ORs of 2.41, 1.95 and 1.73, respectively). Multivariate results indicated that positive therapeutic alliance was associated with better adherence (Health Care Climate Questionnaire effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress".

IMPACT:
Understanding variations in quality of care as well as risk of co-occurring conditions can inform intervention strategies for patients with bipolar disorder. Based on our findings from CIVIC-MD, we conducted an intervention designed to improve medical care access and outcomes among veterans with bipolar disorder. Findings from this research will also benefit VA mental health providers, program leaders, and policy makers, by implementing a feasible methodology for collecting and combining patient and administrative data to monitor the processes and outcomes of care for bipolar disorder.

PUBLICATIONS:

Journal Articles

1. Kilbourne AM, Lasky E, Pincus HA, Good CB, Cooley S, Basavaraju A, Greenwald D, Fine MJ, Bauer MS. The continuous improvement for veterans in care: Mood Disorders (civic-md) Study, a VA-academic partnership. Psychiatric Services. 2008; 59(5): 483-5.
2. Gildengers AG, Whyte EM, Drayer RA, Soreca I, Fagiolini A, Kilbourne AM, Houck PR, Reynolds CF, Frank E, Kupfer DJ, Mulsant BH. Medical burden in late-life bipolar and major depressive disorders. American Journal of Geriatric Psychiatry. 2008; 16(3): 194-200.
3. Kilbourne AM, Brar JS, Drayer RA, Xu X, Post EP. Cardiovascular disease and metabolic risk factors in male patients with schizophrenia, schizoaffective disorder, and bipolar disorder. Psychosomatics. 2007; 48(5): 412-7.
4. Kilbourne AM, McCarthy JF, Post EP, Welsh D, Pincus HA, Bauer MS, Blow FC. Access to and satisfaction with care comparing patients with and without serious mental illness. International Journal of Psychiatry in Medicine. 2006; 36(4): 383-99.
5. Kilbourne AM, McCarthy JF, Welsh D, Blow F. Recognition of co-occurring medical conditions among patients with serious mental illness. Journal of Nervous and Mental Disease. 2006; 194(8): 598-602.
6. Kilbourne AM, Pincus HA, Schutte K, Kirchner JE, Haas GL, Yano EM. Management of mental disorders in VA primary care practices. Administration and Policy in Mental Health. 2006; 33(2): 208-14.
7. Kilbourne AM, Pincus HA. Patterns of psychotropic medication use by race among veterans with bipolar disorder. Psychiatric Services. 2006; 57(1): 123-6.
8. Kilbourne AM, Salloum I, Dausey D, Cornelius JR, Conigliaro J, Xu X, Pincus HA. Quality of care for substance use disorders in patients with serious mental illness. Journal of Substance Abuse Treatment. 2006; 30(1): 73-7.
9. Kilbourne AM. The burden of general medical conditions in patients with bipolar disorder. Current Psychiatry Reports. 2005; 7(6): 471-477.
10. Kilbourne AM, Bauer MS, Han X, Haas GL, Elder P, Good CB, Shad M, Conigliaro J, Pincus H. Racial differences in the treatment of veterans with bipolar disorder. Psychiatric Services. 2005; 56(12): 1549-55.
11. Kilbourne AM, Haas GL, Mulsant BH, Bauer MS, Pincus HA. Concurrent psychiatric diagnoses by age and race among persons with bipolar disorder. Psychiatric Services. 2004; 55(8): 931-3.

DRA: Mental Illness
DRE: Resource Use and Cost
Keywords: Depression, Bipolar disorder
MeSH Terms: none