Depression Quality of Care: Measuring Quality Over Time Using VA Electronic Medical Record Data

Published in: Journal of General Internal Medicine, v. 31, Supplement 1, Apr. 2016, p. 36-45

Posted on RAND.org on May 19, 2016

by Melissa M. Farmer, Lisa V. Rubenstein, Cathy D. Sherbourne, Alexis K. Huynh, Karen Chu, Christine A. Lam, Jacqueline J. Fickel, Martin L. Lee, Maureen E. Metzger, Edward Post, Edmund Chaney

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Research Questions

  1. Is it feasible to develop and validate longitudinal electronic population-based measures?
  2. What proportion of veterans in primary care met those depression quality measures (detection, follow-up, and minimal appropriate treatment) at the Veterans Health Administration (VA) from 2000 to 2010?

BACKGROUND: The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA's depression initiatives. OBJECTIVE: Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000–2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment. DESIGN AND PARTICIPANTS: Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks. MEASURES: We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed. KEY RESULTS: Over the decade, the rates for detection of new episodes of depression remained stable at 7–8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82–84 %). CONCLUSIONS: The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.

Key Findings

  • It is possible, although challenging, to develop electronic population-based longitudinal depression quality measures that are meaningful, feasible, and actionable for assessing VA depression care over a decade.
  • Analysis of administrative data showed that VA improved depression follow-up between fiscal year (FY) 2000 and FY 2010, and treatment rates compared favorably with non-VA benchmarks.
  • Our methods can be adapted to incorporate more stringent definitions of treatment, depression symptom screening data, and future enhancements in care.
  • Our approach to addressing challenges in measure development could inform future performance measure development, especially for other chronic conditions where the trajectory of care must be captured.

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