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

摘要 在患有抑郁症的青年中减少自杀死亡和过早死亡被认为是 卫生系统的国家优先事项和重要目标。有效、循证的药理学和 存在治疗儿童抑郁症的心理社会疗法和临床实践指南、质量指标和 已经开发了药物算法，以努力将基于证据的实践应用于其现实世界 管理层。不幸的是，公众对抑郁症的治疗程度知之甚少。 参保青年符合现有的质量标准，而这些被广泛接受的标准并没有得到适当的满足 经过验证，意味着满足质量标准的护理对重要患者结局的影响，例如 抑郁症的复发、自残、自杀和总体死亡率基本上是未知的。相关的是，尽管 具有里程碑意义的患者保护和平价医疗法案(ACA)扩大了医疗补助的资格，并要求 将精神健康服务纳入基本医疗补助服务，无论是否扩大保险覆盖范围 参加医疗补助的青年改善了抑郁症的护理质量和/或结果未知。的具体目标 这项拟议的研究有三个方面：1)确定与患者、提供者、社区和系统相关的因素 与指南一致的对患有严重抑郁障碍(MDD)的青少年的护理；2)确定 指南一致性护理与抑郁症复发、自残、自杀和全因死亡率相关； 以及3)确定在ACA下扩大州医疗补助对获得和护理质量的影响 医疗补助计划招募患有MDD的青年。我们建议进行一项回溯性纵向队列研究， 国家医疗补助数据与国家死亡指数记录相联系的10-17岁(N=350，00)所有新发青年 2015至2019年期间的MDD发作。这些年轻人将接受长达24个月的跟踪调查，直到2019年。考克斯 将使用回归模型来检验12个月死亡率和5个患者水平之间的关系 质量衡量，同时使用倾向计分方法对患者特征进行风险调整。质量 措施包括：1)急性期有效的抗抑郁药物管理；2)有效的抗抑郁药物 持续阶段的管理；3)足够的抗抑郁药剂量；4)最佳的提供者联系方式 那些服用抗抑郁药物的人；以及5)足够剂量的心理治疗。《纽约时报》的贡献 拟议的研究有望增加对影响对质量的遵守的因素的理解 抑郁症的护理治疗指南。此外，拟议的研究将有助于缩小 通过确定哪些推荐的临床实践指南可以改进社区实践和最佳护理 对患有MDD的青年的关键结果。这一贡献将是重大的，因为理解因素 与遵守指南相关联的一致性护理将增强我们开发模型的能力 采取干预措施，修改这些因素和流程，以提高遵从性。

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.