Incorporating Treatment Outcomes into Quality Measurement of Depression Care

 描述(由申请人提供)： 背景：据估计，抑郁症每年影响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。有几种有效的治疗抑郁症的方法，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VHA对抑郁症的质量衡量主要强调护理过程，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实现有效护理过程的诊所结构(例如，人员配置)的评估，以及是否实现了护理的最终目标--改善患者结果。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是具有挑战性的，特别是在不给提供者带来负担或引入与患者接受后续评估相关的偏见的情况下。这项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，以应对这些挑战。在VISN 11个诊所收集的PHQ-9数据将用于开发和测试临床水平的结果质量衡量标准(OQM)。在对临床患者群体的差异进行病例组合调整后，OQM将能够确定与结果相关的结构和过程措施(包括新的强化治疗措施)。研究结果将使领导人能够确定表现不佳的诊所和需要解决的关键护理方面，以便为患者实现更好的抑郁结果。 目标：1)根据PHQ-9和自动IVR系统收集的病例组合调整数据，开发和评估抑郁症的结果质量测量；2)评估结果和护理过程之间的关系，包括新的治疗强化措施；3)确定设施特征(即，护理结构)与抑郁症护理过程和结果之间的关联。 方法：这项前瞻性纵向研究将从VISN11的50家初级保健和精神卫生诊所抽取2,500名VHA患者。纳入的患者将有新的抑郁障碍临床诊断和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学因素)以及诊断后6周、12周、26周和1年的PHQ-9评分将通过IVR收集。IVR数据将与卫生系统的电子病历合并，包括共病诊断、卫生系统遭遇和药房使用。对基于IVR的OQM有效性的威胁将通过完成12周PHQ-9的登记患者的百分比(即响应率)和呼叫完成的预测因素(即响应偏差)来评估。病例组合调整的多水平模型将被用来根据组内相关系数确定可靠性。在这些模型中，OQM将被定义为临床水平的残差。临床水平残差表示单个诊所的绩效与一般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次心理治疗访问)和强化治疗的新措施的有效性将通过确定它们与个人和临床层面的抑郁症结果的关联来评估。护理结构(例如，精神卫生工作人员)之间的关联 与患者比率、到诊所的旅行距离)和结果将进行类似的检查，并分开 模型将检验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.