Continuous Improvement for Veterans In Care-Mood Disorders
Amy M. Kilbourne PhD MPH
Center for Health Equity Research and Promotion
Pittsburgh, PA
Funding Period: April 2004 - September 2007

BACKGROUND/RATIONALE:
Bipolar disorder is one of the leading causes of morbidity worldwide, and is associated with significant personal and societal costs. However, there is a dearth of information on the quality, cost, and outcomes of care for veterans with bipolar disorder.

OBJECTIVE(S):
The goal of this study is to refine process and outcome measures for bipolar disorder and determine how patient factors (e.g., substance use, adherence, medical comorbidity) are associated with gaps in quality of care for bipolar disorder in the VA. This research will be accomplished using data from a cohort study of patients receiving care for bipolar disorder at the VA Pittsburgh Healthcare System. By identifying vulnerable populations at increased risk of poor processes and outcomes of care for bipolar disorder, the long-term goal of this research is to inform future patient, provider, and system-level interventions to improve quality of care for this group.

METHODS:
Approximately 500 veterans with an active diagnosis or treatment plan for bipolar disorder at the VA Pittsburgh Healthcare System in Pittsburgh, PA will be eligible for inclusion. Patients will complete a brief survey at the time of enrollment and one year later on socio-economic characteristics, substance use, adherence, and outcomes (e.g., symptoms, functioning). A chart review will be conducted to assess patients’ co-occurring psychiatric and substance use diagnoses, quality of care, and treatment preferences. We will assess the processes of care based on claims and chart review data using quality indicators previously derived from the American Psychiatric Association and VA clinical practice guidelines for bipolar disorder and co-occurring conditions (e.g., metabolic syndrome, substance use disorders). Data on adequate pharmacotherapy, drug level and safety monitoring, and outpatient continuity of care will be collected from the VA National Patient Care (NPCD) and Pharmacy Benefits Management databases. Additional data on medical comorbidity and inpatient use will be ascertained from the NPCD. Confirmatory data on quality of care for bipolar disorder, medical comorbidity, and patient factors (e.g., preferences, visit adherence) will be collected via CPRS chart review.

FINDINGS/RESULTS:
As of February 2006, data collection has been completed for 365 patients. Of the 365, 13% were African-American, the mean age was 49 years, and 30% were currently employed. Overall, 33% had >=5 or more drinks on a single occasion and 59% report that they currently smoke. About half (45%) relied on public transportation or VA buses to get to appointments. Overall, 81% were prescribed a mood stabilizer, 51% an atypical antipsychotic, and 31% were prescribed >=3 psychotropic medications from different drug classes. The majority of patients prescribed atypical antipsychotics received a cholesterol test (74%); 82% prescribed mood stabilizers received a toxicity test. The most common co-occurring diagnoses included obesity (26%), dyslipidemia (29%), hypertension (36%), and diabetes (15%). After adjusting for age, gender, living alone, non-VA healthcare, and substance abuse, African-Americans were less likely than non-African-Americans to receive mood stabilizers (OR=.29,p=.005), no less likely to receive atypical antipsychotics, cholesterol or mood stabilizer assays, but more likely diagnosed with obesity (OR=2.27,p=.03).

IMPACT:
Understanding variations in care as well as risk of co-occurring conditions can inform intervention strategies for patients with bipolar disorder. Findings from this research will also benefit VA mental health providers, program leaders, and policy makers, by implementing a feasible methodology for collecting and combining patient and administrative data to monitor the processes and outcomes of care for bipolar disorder.

PUBLICATIONS:
None at this time.

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DRA: Mental Illness
DRE: Resource Use and Cost
Keywords: Depression, Bipolar disorder
MeSH Terms: