Improving Quality and Outcomes for Low Income Children with Depression in the US

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ABSTRACT Reducing suicide deaths and premature mortality among youth with depression has been identified as a national priority and important goal for health systems. Effective, evidence-based pharmacological and psychosocial therapies exist to treat pediatric depression and clinical practice guidelines, quality indicators, and medication algorithms have been developed in an effort to apply evidence-based practices to its real-world management. Unfortunately, little is known about the degree to which the depression care delivered to publicly insured youth meets existing quality standards, and these widely accepted standards have not been properly validated, meaning that the impact of care meeting quality standards on important patient outcomes such as recurrence of depression, self-harm, suicide, and overall mortality is essentially unknown. Relatedly, although the landmark Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility and mandated that mental health services be included as basic Medicaid services, whether expanded insurance coverage for Medicaid enrolled youth has improved depression care quality and/or outcomes is unknown. Specific aims of this proposed study are three-fold: 1) to identify patient, provider, community and system factors associated with guideline concordant care for youth with major depressive disorder (MDD); 2) to determine whether guideline concordant care is associated with depression recurrence, self-harm, suicide, and all-cause mortality; and 3) to determine the effect of state Medicaid expansion under ACA on access to and quality of care for Medicaid enrolled youth with MDD. We propose to conduct a retrospective longitudinal cohort study using national Medicaid data linked with National Death Index records of all youth aged 10-17 (N= 350,00) with new episodes of MDD between 2015 and 2019. These youth will be followed for up to 24 months up until 2019. Cox regression models will be used to examine the association between 12 -month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics using propensity score methods. Quality measures include: 1) effective antidepressant management during the acute phase; 2) effective antidepressant management during the continuation phase; 3) adequate antidepressant dosage; 4) optimal provider contacts among those taking antidepressants; and 5) adequate dose of psychotherapy. The contribution of the proposed research is expected to be an increased understanding of factors that impact adherence to quality of care treatment guidelines for depression. In addition, the proposed study will help narrow the gap between community practice and optimal care by determining which recommended clinical practice guidelines improve critical outcomes for youth with MDD. This contribution will be significant because understanding factors associated with adherence to guideline concordant care will enhance our ability to develop models of interventions to modify those factors and processes to increase adherence.