Incorporating Treatment Outcomes into Quality Measurement of Depression Care

 描述（由申请人提供）： 工作背景：据估计，每年有100万退伍军人健康管理局（VHA）患者患有抑郁症，抑郁症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症状的程度取决于所提供的护理质量。目前VHA对抑郁症的质量测量主要强调护理过程，例如分发药物的天数或参加心理治疗的次数。然而，全面的质量衡量还应包括对诊所结构的评估（例如，人员配备），使有效的护理过程和护理的最终目标，改善病人的结果是否得到实现。将患者报告的结果转化为质量改进是卫生系统的优先事项，最近已被医学研究所推荐。 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，特别是在不增加提供者负担或引入与患者接受随访评估相关的偏见的情况下。本研究将通过使用自动化的基于电话的交互式语音应答（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中在各诊所收集的PHQ-9数据将用于开发和测试临床水平的结局质量指标（OQM）。在对诊所患者人群的差异进行病例组合调整后，OQM将允许确定与结局相关的结构和过程措施（包括治疗强化的新措施）。调查结果将使领导者能够确定表现不佳的诊所和护理的关键方面，以实现更好的抑郁症患者的结果。 目的：1）根据PHQ-9和自动IVR系统收集的病例组合调整数据，开发和评估抑郁症的结局质量指标，2）评估结局和护理过程之间的关系，包括治疗强化的新指标，3）确定设施特征（即，护理结构）和抑郁症护理过程和结果。 方法：这项前瞻性纵向研究将从VISN 11的50个初级保健和精神卫生诊所抽取2,500名VHA患者。入选患者将有抑郁障碍的新临床诊断，且PHQ-9评分≥ 10。将通过IVR收集基线时的患者特征（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1年的PHQ-9评分。IVR数据将与共病诊断、卫生系统遭遇和药房使用的卫生系统电子病历合并。将通过完成12周PHQ-9（即，响应速率）和呼叫完成的预测器（即，响应偏差）。根据组内相关系数，使用病例组合调整的多水平模型确定可靠性。OQM将被定义为这些模型中的临床水平残差。诊所级残差表示与平均诊所的预期性能相比，个体诊所的性能。目前VHA抑郁症护理过程措施的有效性（例如，84天的抗抑郁药物供应，14周内8次心理治疗访视）和一种新的治疗强化措施，将通过确定其与个体和临床水平的抑郁结局的相关性进行评估。护理结构之间的关联（例如，精神卫生工作人员 与患者的比例，到诊所的旅行距离）和结果将进行类似的检查，并单独 模型将检查结构和护理过程之间的关联。

 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.