We first examined whether the quality of care measures varied by mental health status and by the number of physical health comorbidities. We hypothesized that the complexity of the overall constellation of conditions would reduce individual quality measures. We next examined disease-specific quality measures for physical health conditions, including medication adherence, and specific recommended tests or procedures, such as hemoglobin A1c tests (HbA1c) for persons with diabetes, minimally adequate treatment for depression, defined as ≥8 psychotherapy visits,25,26 and the use of assertive community treatment (ACT) for persons with schizophrenia. Each measure reflects use over the 3-year study period. We examined the average differences in quality of care measures by mental health and physical health indicators and their interactions. Finally, we examined quality of care measures for depression and schizophrenia as a function of the number of physical health comorbidities.
We conducted 2 sets of sensitivity analyses; first, we excluded months during which an individual spent >15 days in an inpatient facility or was in a residential facility such as a skilled nursing home. These individuals might be expected to have a lower probability of receiving screening or other quality measures, but possibly a higher probability of autofilled prescriptions, and thus higher medication adherence. Because these restrictions excluded only 4.9% of persons in the sample and produced results very similar to those reported for the full sample, they were not separately reported. The second sensitivity analysis included only the 43% of the sample enrolled on Medicaid for at least 80% of the study period, sometimes referred to as the continuously enrolled. The results are reported as supplemental digital content (Tables, Supplemental Digital Content 2–6, http://links.lww.com/MLR/A603; http://links.lww.com/MLR/A604; http://links.lww.com/MLR/A605; http://links.lww.com/MLR/A606; http://links.lww.com/MLR/A607), which repeat all analyses in continuously enrolled subsamples) and described in brief below. Because of the reduced generalizability of the continuously enrolled sample, we retain the results from the full sample as our main sampling approach.
This study was approved by the University of North Carolina Institutional Review Board.
The final sample included 188,531 unique persons with ≥2 of the 8 target chronic conditions (Table, Supplemental Digital Content 7, http://links.lww.com/MLR/A608, which contains demographic information). Average age was 43, 34% of the sample was male, 40% African American, and 2.6% Latino. The average length of Medicaid enrollment during the 3-year study period was 23 months. Although 77% of the sample was enrolled in Medicaid for at least 1 year, only 43% of the sample was continuously enrolled for at least 80% of the 36-month study period.
Almost 25% of persons aged 50 and older with MCC received Medicaid-funded colorectal cancer screening during the 3-year period (Table 1). Captured colorectal cancer screening methods range from annual fecal occult blood testing to colonoscopy on a 10-year schedule. Thus, if the ACS guidelines27 had been followed, we would expect to see 30%–100% of the sample screened during the 3-year period, depending on proportion of the sample using each method. Among women aged 40 and above, 41% had evidence of breast cancer screening during the 3-year period, despite ACS guideline recommendations of annual screening for women aged 40 and older. Because US Preventive Services Task Force guidelines recommend screening mammography every 2 years between ages 50 and 74,28 we additionally examined breast cancer screening rates within this age group, and found that 42% had evidence of mammography during the 3-year window. Cervical cancer screening, as evidenced by Medicaid-paid Pap smear claim, occurred for 30% of women aged 21–65 during the 3 years.
For both colorectal and breast cancer, screening rates among individuals with MCC were higher for those with depression and lower for those with schizophrenia, compared with persons without either psychiatric condition (Table 1). Rate of screening was positively associated with a greater number of medical comorbidities. These patterns were similar for breast cancer screening among women aged 50–74 (data not shown). Cervical cancer screening rates were slightly higher among women with depression compared with those without either psychiatric illness, but we saw no difference between women with and without schizophrenia.
The mental and physical health interactions (Table 2) indicate that depression had a positive association with both colorectal and breast cancer screening among people with one of the measured physical health conditions; the marginal difference from depression diminished as the number of medical conditions increased. Cervical cancer screening showed no difference by depression status across any of the measured levels of physical health conditions. In contrast, reductions in colorectal and breast cancer screening associated with schizophrenia were most pronounced among persons with 2 medical conditions. Women with schizophrenia and ≥2 medical conditions had higher rates of cervical cancer screening than women without either schizophrenia or depression.
Persons whose MCCs include depression had lower rates of adherence to medications in all classes examined (Table 3). When compared with persons with MCC without depression, we also found lower rates of HbA1C testing and nephropathy screening among those with comorbid diabetes, lower use of lipid profiles among those with depression and either diabetes or hyperlipidemia, and lower use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among those with diabetes, hypertension, and depression. We found similar results for persons with schizophrenia and other target medical conditions, except for a higher rate of adherence for diabetes and hyperlipidemia among persons with comorbid schizophrenia. We found higher rates of liver function tests both for persons with depression and for those with schizophrenia, as compared with persons with MCC without either of these psychiatric impairments. Short-acting β-agonist overuse was lower among those with asthma and schizophrenia than among those with asthma and neither psychiatric impairment, but overuse increased with the number of medical comorbidities. Greater numbers of medical comorbidities were otherwise generally associated with higher scores on quality of care measures across target conditions.
We found variable differences by depression and schizophrenia status on disease-specific quality and adherence measures from models using mental and physical health interactions (Table 4). For some measures (eg, adherence to diabetes medications, short-acting β-agonist overuse) the differences between those depressed and those without either psychiatric condition increased with the number of medical comorbidities. For other measures (eg, lipid profiles), the association with depression decreased as the number of medical comorbidities increased. Differences between persons with schizophrenia and persons with MCC with other conditions were generally larger than the differences observed by depression status.
We estimate a proportion of days covered of 33% for persons with MCC with depression 46% among those with comorbid schizophrenia (Table 5). Adherence increased substantially in both classes as the number of medical conditions increased. Almost 40% of persons with depression received individual or group psychotherapy during the 3-year period, but this rate decreased with a greater number of physical comorbidities. The proportion receiving at least 8 psychotherapy visits among those with depression was low and constant across comorbidities, with a 1.6 percentage point decline among persons with ≥3 medical conditions. Twelve percent of persons with comorbid schizophrenia received ACT, and the receipt of ACT was unaffected by the number of medical comorbidities in this sample.
The results of the sensitivity analysis on the continuously enrolled subsample varied somewhat from those reported here (Tables, Supplemental Digital Content 2–6, http://links.lww.com/MLR/A603; http://links.lww.com/MLR/A604; http://links.lww.com/MLR/A605; http://links.lww.com/MLR/A606; http://links.lww.com/MLR/A607); which report results of all analyses from the continuously Medicaid-enrolled subsample). Depression generally had a similar or larger difference in cancer screening, quality, and adherence measures to those reported here, and schizophrenia generally had smaller effect, although both terms lost significance in several models. The effects of medical comorbidities on cancer screening were generally smaller and those on disease-specific measures were generally larger.
This work serves as a starting point in comparing cancer screening, single-disease quality of care measures, and medication adherence among persons with varying combinations of physical and psychiatric conditions. It contributes to the growing literature on the role of mental illness on the receipt of guideline-concordant care among persons with MCC.29,30 In summary, quality of care metrics were generally, but not always lower among those with depression or schizophrenia, and often higher among those with increasing levels of medical comorbidities. A number of exceptions to these trends were noted. From the complex interactions and patterns of care we observed, 4 key points emerge.
First, greater burden of disease is not always associated with lower levels of quality of care measures used in our study. This result is consistent with other works31 finding a positive association between the number of comorbidities and a composite quality measure. Although persons with MCC may have more complicated and sometimes conflicting medical regimes, they may also experience greater economies of scope or opportunities for care. We often found better medication adherence among those with more, not fewer, medical comorbidities (Tables 3 and 5). This pattern may reflect the existence of a subgroup of patients with MCC who are more experienced interacting with the healthcare system. For example, these patients may be better at establishing formal and informal caregiver networks or using aids such as weekly pillboxes to manage their care. These skills may make such patients more likely to receive care consistent with established guidelines.
Second, among persons with MCC, we generally, but not always, found detrimental quality associated with poorer mental health. It is by now well known that major depression is associated with decreased medication adherence,20 and these results also seem to apply among persons with MCC. Adherence rates to antidepressant and antipsychotic medications reported here were somewhat lower than adherence rates in other published studies.24,32,33 Somewhat paradoxically, in almost half of the quality and adherence measures, differences by depression status were greatest among persons with a single chronic condition and decreased as the number of conditions increased. We also found that persons with depression had generally greater rates of cancer screening, possibly reflecting greater opportunities for screening with a greater number of healthcare contacts. These results are somewhat at odds with prior studies of cancer screening by depression status,34 which found slightly lower rates of breast cancer screening and no difference in colorectal cancer screening. Their study used a survey measure of depression symptoms rather than administrative diagnoses, however.
Third, comparing people with comorbid schizophrenia to those with MCC without schizophrenia or depression also yielded several surprising findings. While persons with schizophrenia had generally poorer cancer screening rates, they often had better adherence to medications, such as diabetic agents and medications for hyperlipidemia. This finding may reflect a system that has converged around the most acutely ill to improve care and subsequent health outcomes. Alternatively, it may reflect the greater awareness of metabolic-related side effects associated with the use of many of the second-generation antipsychotic medications, although these rates are still noted to be suboptimal.35,36
Finally, we saw that number of medical conditions had mixed effects on evidenced-based services among those with a psychiatric impairment. Persons with a greater burden of chronic physical health conditions generally had higher medication adherence, but also had lower use of psychotherapy for those with depression. This likely reflects greater use of the medical system and reduced contact with the specialty mental health system among those with more physical health demands.37 In contrast, persons with schizophrenia are more likely to use the specialty mental health system than to use primary care,38 regardless of their burden of physical health conditions, and thus we did not see a similar reduction in the use of psychosocial therapies typically provided by specialty mental healthcare.
A number of limitations should be noted. Estimates were based on information in administrative data, and therefore do not capture all services that may have been received during times of Medicaid ineligibility or through other programs, such as free breast and cervical cancer screening programs. In addition, guideline-concordant screening rates may be underestimated due to clinical factors that would exclude individuals from screening recommendations but were unobservable in available data; such as prior hysterectomy or double mastectomy. For example, DuBard et al39 found that as much as 50% of a sample of Medicaid eligible women aged 50–64 had prior history of a hysterectomy from chart review, rendering them ineligible for cervical cancer screening. If unobservable differences are correlated with our key variables, this could partially explain these results (eg, if women with schizophrenia had disproportionately high rates of hysterectomy). Our comorbidity indicators may reflect residual differences between comorbidity groups that are not accounted for by included covariates. Consistent with this fact, our models are not intended to be causal; rather, they are intended to examine the relationships between comorbidity levels and service use and quality received by persons with varying combinations of the 8 target disorders. Finally, and perhaps most importantly, these data do not contain information on health outcomes and quality of life which may be most important to persons with MCC.
Although cancer screening and single-disease guideline measures are important indicators of quality of care received and laudable benchmarks for improving care for persons with MCCs, there are a number of complexities inherent in treating and measuring the quality of care for this complex population. Treating MCC represents both a challenge and an opportunity to achieve greater quality, possibly at lower cost. In the context of the MCC conversation, mental illness complicates the receipt of high-quality care in a way that requires increased attention. Further effort should be devoted to identifying the specific obstacles to high-quality care and simultaneously advancing the science of quality measurement in this growing and costly population.
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quality of care; multiple chronic conditions; mental illness; Medicaid
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© 2014 by Lippincott Williams & Wilkins.