Understanding the current quality of care for posttraumatic stress disorder (PTSD) and depression delivered to service members is an important step toward improving care across the Military Health System (MHS). This report describes the characteristics of active-component service members who received care for PTSD or depression through the MHS and assesses the quality of care received using quality measures derived from administrative data.

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Quality of Care for PTSD and Depression in the Military Health System

Phase I Report

by Kimberly A. Hepner, Elizabeth M. Sloss, Carol P. Roth, Heather Krull, Susan M. Paddock, Shaela Moen, Martha J. Timmer, Harold Alan Pincus

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Research Questions

  1. What are the characteristics and patterns of care of service members who were seen in the Military Health System with a diagnosis of PTSD or depression?
  2. What is the quality of care delivered by the Military Health System for service members diagnosed with PTSD or depression?

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Given the rates of posttraumatic stress disorder (PTSD) and depression among U.S. service members, attention has been directed to ensuring the quality and availability of programs and services targeting these and other psychological health (PH) conditions. Understanding the current quality of care for PTSD and depression is an important step toward improving care across the MHS. To help determine whether service members with PTSD or depression are receiving evidence-based care and whether there are disparities in care quality by branch of service, geographic region, and service member characteristics (e.g., gender, age, pay grade, race/ethnicity, deployment history), DoD's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to conduct a review of the administrative data of service members diagnosed with PTSD or depression and to recommend areas on which the MHS could focus its efforts to continuously improve the quality of care provided to all service members. This report characterizes care for service members seen by MHS for diagnoses of PTSD and/or depression and finds that while the MHS performs well in ensuring outpatient follow-up following psychiatric hospitalization, providing sufficient psychotherapy and medication management needs to be improved. Further, quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting the need to ensure that all service members receive high-quality care.

Key Findings

Service Members with PTSD and Depression Have Complex Service Needs

  • Both cohorts suffer high rates of comorbid psychological health conditions.

Administrative Data–Based Quality Measures for PTSD and Depression Identified Important Strengths and Some Areas for Improvement

  • The Military Health System (MHS) generally performs well in the areas of initiating psychotherapy and follow-up after hospitalization, but is inconsistent or weaker in the areas of medication management and ongoing care.

Adequate Medication Trial Rate is Similar to or Higher than Estimates from Other Health Care Systems, and Rates of Follow-Up Medication Management are Similar but Low

A High Proportion of Service Members with PTSD or Depression Received at Least Some Psychotherapy, But the Number of Visits Appear to Be Inadequate to Allow Delivery of Evidence-Based Psychotherapy

  • The MHS largely succeeds in providing patients with an initial psychotherapy visit, but could improve rates of delivering ongoing treatment.

The MHS Is a Leader in Achieving High Rates of Follow-up After Psychiatric Hospitalization

  • High rates of follow-up after psychiatric hospitalization relative to other health care systems may be related to a 2011 MHS mandate describing follow-up procedures for missed behavioral health appointments.

Quality of Care for PTSD and Depression Varied by Service Branch, TRICARE Region, and Service Member Characteristics

  • For example, rates of follow-up within seven days after a mental health hospitalization differed across service branches by up to 14 percent, and rates of adequate filled prescriptions for targeted medications varied by pay grade by up to 29 percent.

Recommendations

  • Improve the quality of care for psychological health conditions delivered by the Military Health System.
  • Establish an enterprise-wide performance measurement, monitoring, and improvement system that includes high-priority standardized metrics to assess care for psychological health (PH) conditions.
  • Integrate routine outcome monitoring for service members with PH conditions as structured data in the medical record as part of a measurement-based care strategy.
  • Quality measure results for PH conditions should be routinely reported internally, enterprise-wide, and publicly to support and incentivize ongoing quality improvement and to facilitate transparency.
  • Investigate the reasons for significant variation in quality of care for PH conditions by service branch, region, and service member characteristics.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Characteristics of Service Members in PTSD and Depression Cohorts, and Their Care Settings and Treatments

  • Chapter Four

    Quality of Care for PTSD and Depression

  • Chapter Five

    Variations in Care for PTSD and Depression Based on Patient Characteristics

  • Chapter Six

    Summary and Recommendations

  • Appendix A

    Technical Specifications for Administrative Data Quality Measures for PTSD

  • Appendix B

    Technical Specifications for Administrative Data Quality Measures for Depression

  • Appendix C

    Rules for Processing Administrative Data for Inpatient Stays and Outpatient Visits

Research conducted by

This research was sponsored by Department of Defense's Centers of Excellence for Psychologic Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute.

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