How well do automated performance measures assess guideline implementation for new-onset depression in the Veterans Health Administration?

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

The association of antidepressant treatment with COPD maintenance medication use and adherence in a comorbid Medicare population: A longitudinal cohort study

The effect of treating comorbid depression to achieve optimal management of chronic obstructive pulmonary disease (COPD) has not yet empirically tested. We examined the association between antidepressant treatment and use of and adherence to COPD maintenance medications among patients with new-onset COPD and comorbid depression.

METHODS

Using 2006-2012 Medicare data, this retrospective cohort study identified patients with newly diagnosed COPD and new-onset major depression. Two exposures-antidepressant use (versus non-use) and adherence measured by proportion of days covered (PDC) (PDC ≥0.8 versus <0.8)-were assessed quarterly. We used marginal structural models to estimate the effects of prior antidepressant use and adherence on subsequent COPD maintenance inhaler use and adherence outcomes, accounting for time-varying confounders.

RESULTS

A total of 25 458 COPD-depression patients, 82% with antidepressant treatment, were followed for a median of 2.5 years. Nearly half (48%) used at least 1 COPD maintenance inhaler in any given quarter; among users, 3 in 5 (61%) had a PDC of <0.8. Compared to patients with no antidepressant treatment, those with antidepressant use were more likely to use (relative ratio [RR] = 1.15, 95% confidence interval [CI] = 1.12- 1.17) and adhere to (RR = 1.08, 95% = 1.03-1.14) their COPD maintenance inhalers. Patients who adhered to antidepressant treatment were more likely to use and adhere to COPD maintenance inhalers.

CONCLUSION

Regularly treated depression may increase use of and adherence to necessary maintenance medications for COPD. Antidepressant treatment may be a key determinant to improving medication-taking behaviors among COPD patients comorbid with depression.

Adherence to Maintenance Medications among Older Adults with Chronic Obstructive Pulmonary Disease. The Role of Depression

RATIONALE

Among individuals with chronic obstructive pulmonary disease (COPD), depression is one of the most common yet underrecognized and undertreated comorbidities. Although depression has been associated with reduced adherence to maintenance medications used in other conditions, such as diabetes, little research has assessed the role of depression in COPD medication use and adherence.

OBJECTIVES

The objective of this study was to assess the impact of depression on COPD maintenance medication adherence among a nationally representative sample of Medicare beneficiaries newly diagnosed with COPD.

METHODS

We used a 5% random sample of Medicare administrative claims data to identify beneficiaries diagnosed with COPD between 2006 and 2010. We included beneficiaries with 2 years of continuous Medicare Parts A, B, and D coverage and at least two prescription fills for COPD maintenance medications after COPD diagnosis. We searched for prescription fills for inhaled corticosteroids, long-acting β-agonists, and long-acting anticholinergics and calculated adherence starting at the first fill. We modeled adherence to COPD maintenance medications as a function of new episodes of depression, using generalized estimated equations.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was adherence to COPD maintenance medications, measured as proportion of days covered. The exposure measure was depression. Both COPD and depression were assessed using diagnostic codes in Part A and B data. Covariates included sociodemographics, as well as clinical markers, including comorbidities, COPD severity, and depression severity. Of 31,033 beneficiaries meeting inclusion criteria, 6,227 (20%) were diagnosed with depression after COPD diagnosis. Average monthly adherence to COPD maintenance medications was low, peaking at 57% in the month after first fill and decreasing to 35% within 6 months. In our adjusted regression model, depression was associated with decreased adherence to COPD maintenance medications (odds ratio, 0.93; 95% confidence interval, 0.89-0.98).

CONCLUSIONS

New episodes of depression decreased adherence to maintenance medications used to manage COPD among older adults. Clinicians who treat older adults with COPD should be aware of the development of depression, especially during the first 6 months after COPD diagnosis, and monitor patients' adherence to prescribed COPD medications to ensure best clinical outcomes.

Adherence and healthcare utilization among older adults with COPD and depression

BACKGROUND AND OBJECTIVE

Adherence to chronic obstructive pulmonary disease (COPD) maintenance medications and antidepressants may reduce healthcare utilization among multimorbid individuals with COPD and depression. We quantified the independent effects of adherence to antidepressants and COPD maintenance medications on healthcare utilization among individuals co-diagnosed with COPD and depression.

PROCEDURES

We conducted a retrospective cohort study using a 2006-2012 5% random sample of Medicare beneficiaries co-diagnosed with COPD and depression who had two or more prescription fills of both COPD maintenance medications and antidepressants. We measured adherence to medications using the proportion of days covered per 30-day period. The primary outcomes were all-cause emergency department (ED) visits and hospitalizations. Beneficiaries were followed over a minimum 12-month follow-up period.

RESULTS

Of the 16,075 beneficiaries meeting inclusion criteria, 21% achieved adherence ≥80% to COPD maintenance medications and 55% achieved adherence ≥80% to antidepressants. Compared to no use and controlling for antidepressant adherence and potential confounders, higher (≥80%) levels of adherence to COPD maintenance medications were associated with decreased risk of ED visits (hazard ratio (HR) 0.79; 95% CI 0.74, 0.83) and hospitalizations (HR 0.82; 95% CI 0.78, 0.87). Similarly, higher levels (≥80%) of adherence to antidepressants resulted in decreased risk of ED visits (HR 0.74; 95% CI 0.70, 0.78) and hospitalizations (HR 0.77; 95% CI 0.73, 0.81) compared to no use.

CONCLUSIONS

Clinicians can assist in the improved management of their multimorbid patients' health by treating depression among patients with COPD and monitoring and encouraging adherence to the regimens they prescribe.

New episodes of depression among Medicare beneficiaries with chronic obstructive pulmonary disease

OBJECTIVES

Depression is a common comorbidity of chronic obstructive pulmonary disease (COPD) and is associated with increased exacerbations, healthcare utilization, and mortality. Among Medicare beneficiaries newly diagnosed with COPD, the objectives of this study were to (1) estimate the rate of new episodes of depression and (2) identify factors associated with depression.

METHODS

We identified beneficiaries with a first diagnosis of COPD during 2006-2012 using a 5% random sample of Medicare administrative claims data by searching for ICD-9-CM codes 490, 491.x, 492.x, 494.x, or 496. We identified episodes of depression using ICD-9-CM codes 296.2x, 296.3x, and 311.xx. We calculated incidence rates and their 95% confidence intervals (95% CI) and used a discrete time analysis to identify factors associated with development of depression.

RESULTS

Between 2006 and 2012, 125,348 beneficiaries meeting inclusion criteria were newly diagnosed with COPD. Twenty-three percent developed depression following COPD diagnosis. The annualized incidence rate of depression per 100 beneficiaries following COPD diagnosis was 9.4 (95% CI 9.3, 9.5). Rates were highest in the first 2 months following COPD diagnosis. COPD diagnosis was associated with increased risk of depression (risk ratio 1.76; 95% CI 1.73, 1.79) as were COPD-related hospitalizations (risk ratio 4.59; 95% CI 4.09, 5.15), a measure of COPD severity.

CONCLUSIONS

Diagnosis of COPD increases the risk of depression. This study will aid in the allocation of resources to monitor and provide support for individuals with COPD at high risk of developing depression.

Using electronic medical records to determine prevalence and treatment of mental disorders in primary care: a database study

OBJECTIVES

With prevention and treatment of mental disorders a challenge for primary care and increasing capability of electronic medical records (EMRs) to facilitate research in practice, we aim to determine the prevalence and treatment of mental disorders by using routinely collected clinical data contained in EMRs.

METHODS

We reviewed EMRs of patients randomly sampled from seven general practices, by piloting a study instrument and extracting data on mental disorders and their treatment.

RESULTS

Data were collected on 690 patients (age range 18-95, 52% male, 52% GMS-eligible). A mental disorder (most commonly anxiety/stress, depression and problem alcohol use) was recorded in the clinical records of 139 (20%) during the 2-year study period. While most patients with the common disorders had been prescribed medication (i.e. antidepressants or benzodiazepines), a minority had been referred to other agencies or received psychological interventions. 'Free text' consultation notes and 'prescriptions' were how most patients with disorders were identified. Diagnostic coding alone would have failed to identify 92% of patients with a disorder.

CONCLUSIONS

Although mental disorders are common in general practice, this study suggests their formal diagnosis, disease coding and access to psychological treatments are priorities for future research efforts.

Emergent anxiety after antidepressant initiation: a retrospective cohort study of Veterans Affairs Health System patients with depression

BACKGROUND

Initiation of antidepressant treatment for depression may be associated with new onset (emergent) anxiety.

OBJECTIVE

The purpose of this study was to assess demographic and clinical factors associated with emergent anxiety following a new antidepressant start among Department of Veterans Affairs (VA) Health System patients with depression.

METHODS

Using a retrospective cohort design, we obtained data from 328,888 VA patients with depression who were newly prescribed 1 of the 7 most commonly used antidepressant drugs between April 1999 and September 2004 from the VA National Depression Registry. We examined the prevalence of emergent anxiety, defined as either a new anxiety diagnoses or by new antianxiety medication starts, during the 12 weeks following new antidepressant start. In multivariate analyses, we assessed the hazard ratios for emerging anxiety associated with patient characteristics and specific antidepressant agents.

RESULTS

Approximately 3% of patients developed clinically significant anxiety within 12 weeks of starting an antidepressant drug regimen. Younger age (age <45 years and 45-64 years) was associated with higher risks for emergent anxiety than older age (≥65 years) (hazard ratio [HR] = 1.72 and 1.55; 95% CI, 1.59-1.85, and 1.38-1.72, respectively). Female gender was associated with higher risks than male gender (HR = 1.17; 95% CI, 1.10-1.26), and white and other races compared with black race were associated with higher risks of emergent anxiety (HR = 1.49 and 1.13; 95% CI, 1.30-1.59 and 1.04-1.23, respectively). Finally, filling antidepressant drug prescriptions in years subsequent to 1999 was associated with lower risks of emergent anxiety.

CONCLUSIONS

Only a small proportion of patients developed emergent anxiety following a new antidepressant start, resulting in a new diagnosis or antianxiety medication use. Anxiety occurred more often in young adults, whites, and women.

Validation of key behaviourally based mental health diagnoses in administrative data: suicide attempt, alcohol abuse, illicit drug abuse and tobacco use

Background

Observational research frequently uses administrative codes for mental health or substance use diagnoses and for important behaviours such as suicide attempts. We sought to validate codes (International Classification of Diseases, 9^th edition, clinical modification diagnostic and E-codes) entered in Veterans Health Administration administrative data for patients with depression versus a gold standard of electronic medical record text ("chart notation").

Methods

Three random samples of patients were selected, each stratified by geographic region, gender, and year of cohort entry, from a VHA depression treatment cohort from April 1, 1999 to September 30, 2004. The first sample was selected from patients who died by suicide, the second from patients who remained alive on the date of death of suicide cases, and the third from patients with a new start of a commonly used antidepressant medication. Four variables were assessed using administrative codes in the year prior to the index date: suicide attempt, alcohol abuse/dependence, drug abuse/dependence and tobacco use.

Results

Specificity was high (≥ 90%) for all four administrative codes, regardless of the sample. Sensitivity was ≤75% and was particularly low for suicide attempt (≤ 17%). Positive predictive values for alcohol dependence/abuse and tobacco use were high, but barely better than flipping a coin for illicit drug abuse/dependence. Sensitivity differed across the three samples, but was highest in the suicide death sample.

Conclusions

Administrative data-based diagnoses among VHA records have high specificity, but low sensitivity. The accuracy level varies by different diagnosis and by different patient subgroup.

Using electronic medical records to determine the diagnosis of clinical depression

OBJECTIVE

To investigate the validity of using electronic medical records (EMR) database in a large health organization for identifying patients with clinical depression.

METHOD

The Massachusetts General Hospital EMR system was used to generate a sample of primary care patients seen in the primary care clinic in 2007. Using this sample, the validity of using certain fields in the EMR database (i.e., billing diagnosis, problem list, and medication list) to identify patients with clinical depression was compared to primary care physician (PCP) assessment by a written questionnaire. Based on this standard, the sensitivity, specificity, positive predictive value, negative predictive value, and the areas under receiver operating characteristic curve (AUC) of three specific EMR fields - individually and in combination - were calculated to identify which EMR field best predicted PCP classification.

RESULTS

The EMR fields "billing diagnosis", "problem list" and antidepressant in "medication list", were all able to identify patients' diagnosis of depression by their PCPs reasonably well. Having one or more "billing diagnosis" of depression had the highest sensitivity and highest AUC (77% sensitivity, 76% specificity, AUC 0.77) among any of the fields used alone.

CONCLUSION

The AUC for "billing diagnosis" of depression performed the best of the three single fields tested, with an AUC of 0.77, corresponding to a test with moderate accuracy. This analysis demonstrates that specific EMR fields can be used as a proxy for PCP assessment of depression for this EMR system. Limitations to our analysis include the physician response rate to our survey as well as the quality of the data, which is collected primarily for administrative and clinical purposes. When using administrative and clinical data in mental health studies, researchers must first assess the accuracy of choosing specific fields within their EMR system in order to determine the level of accuracy for them to be used as proxies for clinical diagnoses.

The Use of Health Information Technology in Publicly-Funded U. S. Substance Abuse Treatment Agencies

Drug and alcohol treatment agencies are challenged to improve their infrastructure to meet growing technological and organizational demands. Health care reform and increased emphasis on performance monitoring in the United States are leading to improvements in health information technology. We assess literature to: (1) survey opportunities for health information technology for publicly-funded substance abuse treatment; (2) describe the use of electronic medical records in U.S. substance use treatment programs; (3) identify barriers and facilitators to implementing technology in substance abuse treatment programs; and (4) discuss applications of these concepts to private and international substance abuse treatment. Although these technologies hold promise to improve outcomes in the areas of cost-effectiveness, provider time savings, and quality improvement, substantial barriers exist to implementing health information technology in substance abuse treatment programs. Increased incentives, evidence, and implementation guidance can facilitate health information technology infrastructure improvement in substance abuse treatment to increase competitiveness in the U.S. health care market and improve the quality of care.

Case-finding algorithm for post-stroke depression in the veterans health administration

OBJECTIVES

Post-stroke depression (PSD) is prevalent, often undiagnosed, and undertreated. The accuracy of detecting patients with post-stroke depression in administrative databases has not been examined.The objective was to validate a case-finding algorithm for post-stroke depression (PSD) among veteran stroke survivors.

METHODS

We conducted a retrospective cohort study of veterans admitted to two local VHA facilities for an inpatient episode of care for acute ischemic stroke. Our cohort included all patients from two medical centers who were identified in the fiscal year (FY) 2001 VHA inpatient database using high specificity stroke ICD-9 codes. FY 2002 VHA and Medicare inpatient, outpatient, and pharmacy data were used to examine the patients' 12-month PSD status by using ICD-9 depression codes and antidepressant use. We assessed our accuracy about patients' PSD from the administrative databases through standardized chart reviews.

RESULTS

Of our 185 subject cohort, 50 (27%) were identified as having PSD. The most sensitive case-finding algorithm for PSD included having an ICD-9 code diagnosis for depression or receiving a prescription for an approved-dosage of antidepressant medication. However, the algorithm of receiving an ICD-9 code for primary or secondary diagnoses of depression revealed the largest positive predictive value.

CONCLUSIONS

A case-finding algorithm using outpatient ICD-9 codes or medication was the most sensitive in identifying cases of PSD. The use of ICD-9 codes alone may be adequate for characterizing a cohort with PSD. Intention for use should be considered when choosing an algorithm to detect PSD.

Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the Veterans Health Administration

OBJECTIVE

Our objective was to describe the adequacy of follow-up care for depression and its association with antidepressant treatment duration among veterans with and without diabetes mellitus (DM).

METHOD

This was a retrospective study (1997-2005) of 2178 veterans (33% with DM) in a Midwestern Veterans Health Administration facility who had a new episode of unipolar depression. Adequate follow-up care was defined by a health care visit within 7 and 14 days, and >/=3 visits following antidepressant treatment initiation. Adequate treatment duration was defined by a medication possession ratio of >/=80%. Multivariate logistic regression was used to calculate odds ratios (ORs) adjusted for demographic, clinical and health care utilization characteristics.

RESULTS

Only 27% received >/=3 follow-up visits within 12 weeks, and <23% received follow-up within 2 weeks of antidepressant initiation. Subjects with DM were 1.36-fold more likely [95% confidence interval (95% CI)=1.05-1.75] to have received >/=3 visits but were similarly likely to have received follow-up within 7 days (OR=1.02; 95% CI=0.74-1.41) or 14 days (OR=1.08; 95% CI=0.83-1.40) of antidepressant initiation. Adequate follow-up care was the most important predictor of adequate treatment duration (OR=2.10; 95% CI=1.54-2.88).

CONCLUSION

DM had little influence on the adequacy of follow-up care for depression, with few exceptions. Follow-up care for depression is underutilized and has a significant impact on antidepressant treatment duration. Strategies to more effectively manage depression treatment are required.

Are claims data accurate enough to identify patients for performance measures or quality improvement? The case of diabetes, heart disease, and depression

The objective of this study was to demonstrate a method to accurately identify patients with specific conditions from claims data for care improvement or performance measurement. In an iterative process of trial case definitions followed by review of repeated random samples of 10 to 20 cases for diabetes, heart disease, or newly treated depression, a final identification algorithm was created from claims files of health plan members. A final sample was used to calculate the positive predictive value (PPV). Each condition had unacceptably low PPVs (0.20, 0.60, and 0.65) when cases were identified on the basis of only 1 International Classification of Diseases, ninth revision, code per year. Requiring 2 outpatient codes or 1 inpatient code within 12 months (plus consideration of medication data for diabetes and extra criteria for depression) resulted in PPVs of 0.97, 0.95, and 0.95. This approach is feasible and necessary for those wanting to use administrative data for case identification for performance measurement or quality improvement.

Use of electronic medical record data for quality improvement in schizophrenia treatment

An understanding of the strengths and limitations of automated data is valuable when using administrative or clinical databases to monitor and improve the quality of health care. This study discusses the feasibility and validity of using data electronically extracted from the Veterans Health Administration (VHA) computer database (VistA) to monitor guideline performance for inpatient and outpatient treatment of schizophrenia. The authors also discuss preliminary results and their experience in applying these methods to monitor antipsychotic prescribing using the South Central VA Healthcare Network (SCVAHCN) Data Warehouse as a tool for quality improvement.