Session number: 1068
Abstract title: Benchmarking Patterns in the Pharmacotherapy of Depression
Author(s):
A Charbonneau - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA; Boston University Section of General Internal Medicine, Boston, MA
A Rosen - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA; Boston University School of Public Health, Department of Health Services, Boston, MA
B Kader - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA
A Ash - Boston University Section of General Internal Medicine, Boston, MA
R Owen - Center for Mental Healthcare and Outcomes Research, N. Little Rock, AR
L Kazis - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA; Boston University School of Public Health, Department of Health Services, Boston, MA
A Spiro - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA; Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA
MJ Pugh - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA
D Berlowitz - Center for Health Quality, Outcomes, and Economic Research, Bedford, MA; Boston University Section of General Internal Medicine, Boston, MA
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Objectives: Depression is a common mental illness, and is associated with increased morbidity and mortality. Pharmacotherapy has proven effective, but is not adequately used among depressed patients. The VA Depression Guidelines were published in 1997 to promote effective treatment. The purpose of this study is to classify adherence to the guidelines, and to explore patient factors associated with non-adherence.
Methods: We identified all patients with depression in VISNs 1 & 2 during FY'98 and FY'99 from the Outpatient Care File and the Patient Treatment File. Patients had at least one diagnosis of depression (ICD-9-CM codes 296.2x, 296.3x, 311.xx); those with coexisting schizophrenia or bipolar disease were excluded. We identified patients who had antidepressant prescriptions from 6/1/99 through 8/31/99 in the Pharmacy Benefits Management file. Guideline adherence was measured using two criteria. Dosage adequacy was measured by comparing average strength (mg) per day over the three months with minimum recommended daily dosages. Duration adequacy was a dichotomous variable designed to capture whether or not patients missed more than 2 weeks of therapy. Multivariate regression models were used to assess predictors for each measure of guideline adherence.
Results: 12,667 patients had antidepressants prescribed from 6/1/99 through 8/31/99. Of these, 9,776 (77%) had adequate dosage; 4,371 (38%) had adequate duration. Only 3,467 (30%) had adequate dosage and duration. Dosage adequacy differed substantially among medication classes. Patients younger than 65 were less likely to have adequate dosage (OR .32, 95% CI .28,.35) and duration (OR .83, 95% CI .77, .91) compared to patients older than 65. Women were less likely to have adequate dosage (OR .82, 95% CI .71, .96) compared with men. Non-white patients were less likely to have adequate dosage (OR .83, 95% CI .71, .98) and duration (OR .69, 95% CI .58, .82) compared with white patients.
Conclusions: Under-treatment of depression in the VA is still substantial, despite the well-known risks of worse outcomes. Younger, women, and non-white patients are at especially high risk. Further work is needed to determine reasons for under-treatment.
Impact statement: Dissemination of guidelines for depression treatment does not necessarily lead to 100% adherence. The VA needs to translate guideline recommendations into practice.