Background. Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement.
Objectives. To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care.
Research Design. This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care.
Subjects. There were 12,678 patients eligible for depression care profiling.
Results. Adequate dosage was identified in 90%; 45% of patients 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.
Conclusions. Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.
Depression is a common illness with well-known risks for worse outcomes if left untreated, including increased morbidity, mortality, costs, and worsening health status. 1 Inadequacies in the diagnosis and treatment of depression have led to substantial quality improvement research during the last decade. 2-7 Depression clinical guidelines developed by the Agency for Health Care Research and Quality (AHRQ, formerly AHCPR), the American Psychiatric Association (APA), and the Veterans Health Administration (VHA) provide quality improvement milestones for depression care. 8-11 Synthesized from clinical research and expert panel consensus, these guidelines suggest optimal methods for diagnosing and treating depression in both psychiatric and primary care settings; recommendations for antidepressant minimum daily dosing, stage-specific treatment duration, follow-up clinical encounters, and brief problem-solving psychotherapy are found there. 8-11 Nonetheless, dissemination and implementation of depression guidelines into clinical practice have been slow, 12,13 and methods for monitoring the quality of depression care are still limited. 14
Although process measures are widely believed to be a powerful method of evaluating quality of care, 15-18 few health systems use guideline-based process measures to monitor the quality of depression care. 19,20 Few studies have reported on the relation of guideline-based depression process measures to patient outcomes in nonexperimental settings 21; however, the efficacy of timely recognition and appropriate treatment for depression is clear, 22-24 supporting the use of guideline-based process measures to assess the quality of depression care in naturalistic clinical settings.
Centralized pharmacy records can facilitate quality of care profiling 14,25-27; they have been studied in various disease models and validated as acceptable sources for assessing medication regimens. 28-30 The accuracy of automated pharmacy data in predicting sub-optimal dosing and premature discontinuation of medications was recently confirmed in a depressed cohort by comparing automated pharmacy data to patient self-report. 27 Guideline-based depression process measures that are derived from automated pharmacy data may be powerful tools for assessing adequacy of depression care.
Evaluating health system, provider, and patient-level predictors of quality health care is critical to quality assessment and improvement initiatives. Variations in the quality of depression care have been described among psychiatric and general medical practices, 31,32 across provider characteristics such as age, number of privately insured patients, 33 and specialty type, 34 and across patient characteristics such as comorbidity burden, 21 race, 35,36 socioeconomic status, 7 marital status, 31 and age. 37 To date, there has been little research on predictors of the quality of depression care in the VHA, 14 the nation's largest, integrated, single-payer health system. In an era of diminishing resources and health system reorganization, the VHA experience of health care delivery and quality improvement can be a leading teaching source for other health systems.
In this study, we describe the adequacy of depression care in the VHA using guideline-based process measures derived from administrative and centralized pharmacy records and seek to identify patient and provider characteristics that predict adequate depression care.