Incorporating Treatment Outcomes into Quality Measurement of Depression Care

将治疗结果纳入抑郁症护理的质量衡量

• 批准号: 10152358
• 负责人: Paul Nelson Pfeiffer
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-04-01 至 2020-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10152358
• 关键词: Address; Affect; Antidepressive Agents; Caring; Case Mixes; Case-Mix Adjustments; Characteristics; Clinic; Clinical; Collection; Computerized Medical Record; Data; Data Adjustments; Depressive disorder; Diagnosis; Elements; Enrollment; Evaluation; Goals; Health; Health system; Healthcare Systems; Individual; Institute of Medicine (U.S.); Longitudinal prospective study; Measurement; Measures; Mental Depression; Mental Health; Mental disorders; Methods; Modality; Modeling; Newly Diagnosed; Observational Study; Outcome; Patient Outcomes Assessments; Patient-Focused Outcomes; Patients; Performance; Pharmaceutical Preparations; Pharmacotherapy; Pharmacy facility; Primary Health Care; Process; Process Measure; Provider; Psychotherapy; Quality of Care; Questionnaires; Recommendation; Residual state; Resources; Sampling; Severities; Social support; Structure; Suicide; Symptoms; System; Telephone; Testing; Travel; Treatment outcome; Veterans Health Administration; Visit; Voice; base; clinical Diagnosis; comorbidity; depressive symptoms; disability; effective therapy; follow up assessment; improved; improved outcome; individual patient; meetings; member; multilevel analysis; patient population; prospective; response; severe mental illness; sociodemographic factors; suicidal morbidity; suicide mortality; treatment site

 DESCRIPTION (provided by applicant): Background: Depression affects an estimated one million Veterans Health Administration (VHA) patients each year and is a leading cause of disability and suicide death. There are several effective treatments for depression, including antidepressant medications and psychotherapy, yet the degree to which these treatments improve depression symptoms in clinical settings depends on the quality of care provided. Current VHA quality measures for depression mostly emphasize care processes, such as the number of days of medication dispensed or the number of psychotherapy sessions attended. However, comprehensive quality measurement should also include assessments of the clinic structures (e.g., staffing) that enable effective care processes and whether the ultimate goal of care-improved patient outcomes-is achieved. Incorporating patient-reported outcomes into quality improvement is a health system priority and has recently been recommended by the Institute of Medicine. Systematically collecting patient-reported outcomes in health care systems such as the VHA is challenging, particularly without burdening providers or introducing biases related to which patients receive follow-up assessments. This study will address these challenges by collecting depression symptom outcomes according to the Patient Health Questionnaire (PHQ-9) using an automated, telephone-based interactive voice response (IVR) system. PHQ-9 data collected across clinics in VISN 11 will be used to develop and test clinic-level outcome quality measures (OQMs). OQMs, after case-mix adjustment for differences in clinic patient populations, will allow determination of the structure and process measures (including a new measure of treatment intensification) associated with outcomes. Findings will enable leaders to identify under-performing clinics and the key aspects of care to address in order to achieve better depression outcomes for patients. Objectives: 1) Develop and assess outcome quality measures for depression from PHQ-9 and case-mix adjustment data collected by an automated IVR system, 2) assess the relationships between outcomes and care processes, including a new measure of treatment intensification, and 3) determine the association between facility characteristics (i.e., structures of care) and depression care processes and outcomes. Methods: This prospective longitudinal study will sample 2,500 VHA patients from 50 primary care and mental health clinics in VISN 11. Included patients will have a new clinical diagnosis of a depressive disorder and a PHQ-9 score ≥ 10. Patient characteristics (including duration of symptoms and socio-demographic factors) at baseline and PHQ-9 scores at 6 weeks, 12 weeks, 26 weeks and one year post-diagnosis will be collected via IVR. IVR data will be merged with health system electronic medical records of comorbid diagnoses, health system encounters, and pharmacy use. Threats to validity of IVR-based OQMs will be assessed by the percentage of enrolled patients who complete a 12-week PHQ-9 (i.e., response rate) and by predictors of call completion (i.e., response bias). Case-mix adjusted multilevel models will be used to determine reliability according to the intraclass correlation coefficient. OQMs will be defined as the clinic-level residuals in these models. Clinic-level residuals indicate an individua clinic's performance in comparison to the expected performance for the average clinic. The validity of current VHA depression care process measures (e.g., 84 days of antidepressant medication supply, 8 psychotherapy visits within 14 weeks) and a new measure of treatment intensification will be assessed by determining their association with depression outcomes at the individual and clinic-level. The association between care structures (e.g., mental health staff to-patient ratios, travel distance to clinic) and outcomes will similarly be examined, and separate models will examine the association between structures and care processes.

 描述（由申请人提供）： 背景：抑郁症每年影响大约 100 万退伍军人健康管理局 (VHA) 患者，是导致残疾和自杀死亡的主要原因。抑郁症有几种有效的治疗方法，包括抗抑郁药物和心理治疗，但这些治疗在临床环境中改善抑郁症状的程度取决于所提供的护理质量。目前针对抑郁症的 VHA 质量衡量标准主要强调护理过程，例如配药天数或参加心理治疗疗程的次数。然而，全面的质量衡量还应包括对诊所结构（例如人员配置）的评估，以实现有效的护理流程以及是否实现了护理改善患者结果的最终目标。将患者报告的结果纳入质量改进是卫生系统的优先事项，最近得到了医学研究所的建议。 在 VHA 等医疗保健系统中系统地收集患者报告的结果具有挑战性，特别是在不给提供者增加负担或引入与患者接受后续评估相关的偏见的情况下。本研究将通过使用基于电话的自动化交互式语音应答 (IVR) 系统根据患者健康问卷 (PHQ-9) 收集抑郁症状结果来应对这些挑战。 VISN 11 中跨诊所收集的 PHQ-9 数据将用于开发和测试诊所级结果质量衡量标准 (OQM)。在针对临床患者群体差异进行病例组合调整后，OQM 将允许确定与结果相关的结构和过程措施（包括治疗强化的新措施）。研究结果将使领导者能够识别表现不佳的诊所和需要解决的关键护理问题，以便为患者实现更好的抑郁症治疗结果。 目标：1) 根据 PHQ-9 和自动 IVR 系统收集的病例组合调整数据制定和评估抑郁症的结果质量测量，2) 评估结果和护理流程之间的关系，包括治疗强化的新衡量标准，3) 确定设施特征（即护理结构）与抑郁症护理流程和结果之间的关联。 方法：这项前瞻性纵向研究将对 VISN 11 中 50 个初级保健和心理健康诊所的 2,500 名 VHA 患者进行抽样。纳入的患者将有抑郁症的新临床诊断，且 PHQ-9 评分≥ 10。基线时的患者特征（包括症状持续时间和社会人口统计学因素）以及诊断后 6 周、12 周、26 周和一年时的 PHQ-9 评分将通过 IVR 收集。 IVR 数据将与医疗系统的共病诊断、医疗系统遭遇和药房使用的电子病历合并。基于 IVR 的 OQM 有效性的威胁将通过完成 12 周 PHQ-9 的入组患者百分比（即响应率）和呼叫完成的预测因素（即响应偏差）来评估。将使用案例组合调整的多级模型根据组内相关系数来确定可靠性。 OQM 将被定义为这些模型中的临床水平残差。诊所水平残差表明单个诊所的绩效与平均诊所的预期绩效相比。目前的 VHA 抑郁症护理流程措施（例如 84 天的抗抑郁药物供应、14 周内 8 次心理治疗就诊）和新的治疗强化措施的有效性将通过确定其与个人和诊所层面抑郁症结果的关联来评估。护理机构（例如心理健康人员）之间的关联 与患者的比率、到诊所的旅行距离）和结果将类似地进行检查，并单独进行 模型将检查结构和护理过程之间的关联。