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Measuring the Quality of Depression Care in a Large Integrated Health System

Charbonneau, Andrea MD, MSc*†; Rosen, Amy K. PhD; Ash, Arlene S. PhD; Owen, Richard R. MD; Kader, Boris PhD*; Spiro, Avron III PhD***; Hankin, Cheryl PhD; Herz, Lawrence R. MD*; Pugh, Mary Jo V. PhD, RN*; Kazis, Lewis ScD; Miller, Donald R. ScD; Berlowitz, Dan R. MD, MPH

doi: 10.1097/01.MLR.0000062920.51692.B4
Original Articles

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.

*From the Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.

†From the Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.

‡From the Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.

¶From the Department of Outcomes Research, McNeil Pharmaceuticals, Fort Washington, Pennsylvania.

§From the Departments of Health Services and Epidemiology, Boston University School of Public Health, Boston, Massachusetts.

**From the Boston Veterans Affairs Healthcare System, Boston, Massachusetts.

This work was supported by the Department of Veterans Affairs, Health Services Research and Development Service, Grant # CPI 99-134, and MNH 98-001 (Mental Health QUERI). Dr. Charbonneau was supported by the Office of Academic Affiliations, Department of Veterans Affairs, and a National Research Service Award, #T32 PE10028-05 (Boston University).

Address correspondence and reprint requests to: Andrea Charbonneau, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Rd. (152), Bedford, MA 01730. E-mail

© 2003 Lippincott Williams & Wilkins, Inc.