Benchmarking Patterns in the Pharmacologic Treatment of Major Depressive Disorder (MDD)
Amy K. Rosen PhD
VA New England Health Care System
Bedford, MA
Funding Period: April 2000 - March 2002

BACKGROUND/RATIONALE:
Improving depression care quality is a national priority. Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement.

OBJECTIVE(S):
The objectives are to assess the adequacy of depression care in Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records; to identify patient, provider, and facility-level characteristics predicting adequate depression care; and to link depression care process measures to an important patient-centered health outcome, health-related quality of life (HRQL).

METHODS:
This is a cohort study of patients from 14 VHA hospitals in the Northeastern US relying on existing databases. Subject eligibility criteria: at least one depression diagnosis in 1999, neither schizophrenia nor bipolar disease, and at least one VHA prescribed antidepressant in the period of depression care profiling (6/1999 - 8/1999). Depression care was evaluated with process measures from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used logistic regression to identify patient and provider-level characteristics predicting depression care adequacy. We employed analysis of variance to identify crude and risk-adjusted differences in depression care among the facilities; we calculated expected adequacy of care with probabilities identified in above regression models. Facility-level quality improvement implementation (QI) was determined from the 1998 National Quality Improvement Survey. Pearson's correlation was used to establish the relationship of facility-level QI to depression care adequacy. HRQL was identified using the 1999 Large Survey of the Health of Veterans (LSHV); physical component summary (PCS) and mental component summary (MCS) scores. We utilized logistic regression to evaluate the association of depression care adequacy with HRQL, adjusting for patient age, sex, race, and comorbid illness burden.

FINDINGS/RESULTS:
12,678 patients were eligible for depression care profiling. Adequate dosage was identified in 90%; 45% had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), Black race, and treatment exclusively in primary care. Mean depression care adequacy (dosage/duration) differed among the 14 facilities (p<.0001); these variations persisted even after risk adjustment. Depression care adequacy was not correlated with QI: (r=.004, p=.98) between QI and risk-adjusted dosage adequacy; and (r=.17, p=.55) between QI and risk-adjusted duration adequacy. Our sample included 3,312 LSHV respondents (58% response rate; 63% in the full LSHV). Their mean Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were 33.5 and 31.7 (versus 38.8 and 46.7 in the full LSHV); higher scores indicate better health status. There was no significant association between depression care adequacy and HRQL: (beta coefficient (B)=.14, p+.82) and (B=.81, p=.27) between dosage adequacy and PCS and MCS, respectively, adjusting for patient age, sex, race, and comorbid illness burden; (B=.19, p=.19) and 9B=.35, p=.39) between duration adequacy and PCS and MCS, respectively, adjusting for patient age, sex, race, and comorbid illness burden.

IMPACT:
Under-treatment of depression is a problem despite the considerable mental health access and pharmacy benefits in VHA. Certain patient populations may be at higher risk for inadequate care, including younger and Black patients, and those treated exclusively in primary care settings. More work is needed to align current practice with best-practice guidelines. While QI is critical to ongoing improvement, it is not always associated with higher quality care. Practical application of a depression guideline-based process measure in VHA was not associated with HRQL; further work is needed to define depression quality indicators that can predict health care outcomes.

PUBLICATIONS:

Journal Articles

1. Charbonneau A, Parker V, Meterko M, Rosen AK, Kader B, Owen RR, Ash AS, Whittle J, Berlowitz DR. The relationship of system-level quality improvement with quality of depression care. American Journal of Managed Care. 2004; 10(11 Pt 2): 846-51.
2. Charbonneau A, Rosen AK, Owen RR, Spiro A, Ash AS, Miller DR, Kazis L, Kader B, Cunningham F, Berlowitz DR. Monitoring depression care: in search of an accurate quality indicator. Medical Care. 2004; 42(6): 522-31.
3. Charbonneau A, Rosen AK, Ash AS, Owen RR, Kader B, Spiro A, Hankin C, Herz LR, Jo V Pugh M, Kazis L, Miller DR, Berlowitz DR. Measuring the quality of depression care in a large integrated health system. Medical Care. 2003; 41(5): 669-80.

DRA: Health Services and Systems, Mental Illness
DRE: Communication and Decision Making, Quality of Care
Keywords: Clinical practice guidelines, Depression, Quality of life
MeSH Terms: none