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

摘要 降低抑郁症青年的自杀死亡率和过早死亡率已被确定为 国家优先事项和重要目标。有效的、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， 药物算法已经被开发出来，以努力将基于证据的实践应用于其现实世界 管理不幸的是，很少有人知道抑郁症护理在多大程度上提供给公众 投保的青年符合现有的质量标准，这些广泛接受的标准尚未得到适当的 这意味着满足质量标准的护理对重要患者结局的影响， 抑郁症复发、自残、自杀和总体死亡率基本上是未知的。与此相关，虽然 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， 精神卫生服务应被列为基本医疗补助服务，无论是否扩大保险覆盖范围， 医疗补助登记的青年改善了抑郁症护理质量和/或结果尚不清楚。具体目标 这项拟议的研究有三个方面：1）确定患者，提供者，社区和系统相关因素 对患有重度抑郁症（MDD）的青少年进行指导一致的护理; 2）确定是否 指南协调治疗与抑郁复发、自伤、自杀和全因死亡率相关; 和3）确定ACA下的州医疗补助扩展对以下人群获得护理和护理质量的影响： 医疗补助计划招募了患有MDD的年轻人。我们建议进行一项回顾性纵向队列研究， 国家医疗补助数据与所有10 - 17岁青年（N = 350，00）的国家死亡指数记录相关联， 2015年至2019年期间的MDD发作。这些年轻人将被跟踪长达24个月，直到2019年。Cox 将使用回归模型检查12个月死亡率与5个患者水平之间的相关性 质量措施，同时使用倾向评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管理; 2）有效的抗抑郁药 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 服用抗抑郁药的人;和5）足够剂量的心理治疗。的贡献 拟议的研究预计将增加对影响坚持质量的因素的了解， 抑郁症的护理治疗指南此外，拟议的研究将有助于缩小以下方面的差距： 社区实践和最佳护理，通过确定推荐的临床实践指南改进 对患有MDD的年轻人的关键结果。这一贡献将是重要的，因为了解因素 与遵守指南一致的护理相关的，将提高我们开发模型的能力， 干预措施，以修改这些因素和过程，以增加遵守。

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.