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Using Mixed Methods to Examine the Role of Veterans Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance

Elwy, A. Rani PhD; Glickman, Mark E. PhD; Bokhour, Barbara G. PhD; Dell, Natalie S. MPH; Mueller, Nora M. MAA; Zhao, Shibei MPH; Osei-Bonsu, Princess E. PhD, MSPH; Rodrigues, Stephanie PhD; Coldwell, Craig M. MD, MPH; Ngo, Tu A. PhD, MPH; Schlosser, James MD, MBA; Vielhauer, Melanie J. PhD; Pirraglia, Paul A. MD, MPH; Eisen, Susan V. PhD

doi: 10.1097/MLR.0000000000000056
Applied Methods

Background: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment.

Objectives: To determine whether veterans’ illness perceptions of depression may be serving as barriers to guideline-concordant treatment.

Research Design: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study.

Subjects: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast.

Measures: The Illness Perceptions Questionnaire-Revised, measuring patients’ perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans’ illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study.

Results: A total of 839 veterans screened positive for a new episode of depression from May 2009–June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans’ illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment.

Conclusions: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans’ illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

*Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford

Department of Health Policy and Management, Boston University School of Public Health, Boston

Department of Psychiatry, UMass Memorial Medical Center, University Campus, Worcester

§Department of Psychiatry, Boston University School of Medicine, VA New England Healthcare System, Bedford, MA

Psychology Service, Edith Nourse Rogers Memorial VA Hospital, Bedford

General Mental Health Service, VA Boston Healthcare System

#Department of Psychiatry, Boston University School of Medicine

**Primary Care Service, Providence VA Medical Center, Providence, RI, Boston, MA

This study was funded by the Department of Veterans Affairs, Health Services Research and Development Service (Grant IAC 07-087 to A.R.E.).

A.R.E. is an investigator with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research and Development Service, Quality Enhancement Research Initiative. The remaining authors declare no conflict of interest.

Reprints: A. Rani Elwy, PhD, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Road (152), Bedford, MA 01730. E-mail: rani.elwy@va.gov.

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