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IAE 05-255 – HSR&D Study

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IAE 05-255
Chronic Physical and Mental Illness Care in Women Veterans
Ranjana Banerjea PhD MBA
East Orange Campus of the VA New Jersey Health Care System, East Orange, NJ
East Orange, NJ
Funding Period: September 2006 - August 2009

BACKGROUND/RATIONALE:
Psychiatric conditions such as depressive disorders tend to co-occur with chronic medical illnesses. Chronic physical and mental illnesses are especially important among women veterans because of the high prevalence of these conditions among women in general and the higher prevalence of both among all veterans as a whole. Thus identifying and treating mental conditions and depressive disorders in a timely manner is very important to the quality of care of the treatment of underlying chronic conditions for women veterans. Further chronic conditions like diabetes tend to occur in clusters (with other cardiovascular conditions). These comorbid conditions have a high prevalence, increase illness burden and have a measurable impact on a patient's health care utilization. Treatment issues in women veterans with co-occurring physical and mental illnesses have remained an understudied area of research within the Veteran Health Administration (VHA).

OBJECTIVE(S):
The primary objective of the proposed project was to document the care patterns of veteran women with comorbid chronic physical and major mental illness: Objective 1. For women VHA users with cardiovascular conditions (CVC), we determined whether comorbid major depression (MDD) is associated with failure to receive guideline concordant CVC process of care measures (lipid tests and in the case of women with diabetes HbA1c testing and eye-exams). Objective 2. Among veteran women with CVC and MDD, we examined the association between individual and health system factors and pharmaco- and psycho-therapy using multivariate models. Objective 3. Among women with CVC and MDD, we examined the association between treatment for MDD and process of care measures ((lipid tests and in the case of women with diabetes HbA1c testing and eye-exam) Objective 4. Among VHA users with chronic physical and mental illness, we explored gender disparities in the association between mental health treatment and chronic physical illness care.

METHODS:
We used merged administrative data to study veteran clinic users longitudinally from patient treatment files from the VHA and claims from Medicare for the years from 1999 through 2005. Cardiovascular conditions and major depression was identified with already validated algorithms. To accomplish the objectives of the study, we used multivariate and robust regression techniques to control for correlated data due to clustering and repeated observations.

FINDINGS/RESULTS:
Using diagnostic codes, a majority of women were identified with diabetes, heart disease and hypertension (CVC) within 12 months of observation period (Tiwari al., 2008). Among women with diabetes, over a two year period, 45% of women had serious mental illness including major depression; substance use disorders were high among those with serious mental illness (Banerjea et al., 2007). Among women with CVC, restricting depression diagnostic codes to major depression (296.2 and 296.3) excluded majority of women (Shen et al., 2008). Women-specific practice structure was associated with greater recognition of depression among women veterans. Facility-specific practice structure with regard to the integration of mental health within primary care or vice versa did not affect diagnosed rates of depression across facilities (Banerjea et al., 2009). In general major depression identified with a wider net of diagnostic codes did not affect the process of care (lipid (LDL-C) testing and control) among veteran women with CVC (Rajan et al., 2007). However, incident depression was associated with poor lipid control (Tiwari et al., 2008). There were differences in lipid control by gender and nearly one-third of these differences by gender could be explained by modifiable factors (Sambamoorthi, 2009).

IMPACT:
Understanding the patterns of chronic and mental illness care and the interaction between them in veteran women and bench marking the care in relation to male veterans can lead to the development of better targeted quality improvement programs and care coordination by VHA clinicians and researchers, with the potential to impact even those veteran women who do not use the VHA clinical services. As we found in our work, a large number of women veterans suffered from a depressive disorder accompanied by a chronic illness as defined by a group of cardiovascular conditions. A large portion of these cardiovascular conditions can be treated together with depressive disorders at women's clinics with primary care services or integrated primary care services that have special women's clinics. The higher rates of diagnoses and treatment suggest beneficial effects of such integrated services for women though more research is awaited on the differences between the two types of integrated services.

PUBLICATIONS:

Journal Articles

  1. Sambamoorthi U, Bean-Mayberry B, Findley PA, Yano EM, Banerjea R. Organization of care and diagnosed depression among women veterans. The American journal of managed care. 2010 Sep 1; 16(9):657-65.
  2. Shen C, Findley P, Banerjea R, Sambamoorthi U. Depressive disorders among cohorts of women veterans with diabetes, heart disease, and hypertension. Journal of women's health (2002). 2010 Aug 1; 19(8):1475-86.
  3. Banerjea R, Pogach LM, Smelson D, Sambamoorthi U. Mental illness and substance use disorders among women veterans with diabetes. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2009 Nov 1; 19(6):446-56.
  4. Banerjea R, Sambamoorthi U, Smelson D, Pogach LM. Chronic illness with complexities: mental illness and substance use among Veteran clinic users with diabetes. The American journal of drug and alcohol abuse. 2007 Jan 1; 33(6):807-21.
Conference Presentations

  1. Sambamoorthi U, Banerjea R, Findley P, Pogach LM. Multimorbidity in Women Veterans with Cardio-metabolic Conditions. Poster session presented at: New Mexico Department of Veterans' Services Four Corners Women Veterans' Conference; 2010 Jul 23; Farmington, NM.
  2. Shen C, Findley PA, Banerjea R, Frayne SM, Pogach L, Sambamoorthi U. Treatment patterns for incident depression episode among women Veterans with or at risk for cardiovascular conditions. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2009 Nov 10; Philadelphia, PA.
  3. Tiwari A, Banerjea R, Pogach LM, Sambamoorthi U. Identifying prevalence of cardiovascular conditions in women Veterans with varying lengths of observation period. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2009 Oct 26; San Diego, CA.
  4. Sambamoorthi U, Mitra S, Pogach LM, Banerjea R. Decomposing Gender Differences in Low Density Lipoprotein Cholesterol among Patients with or at risk for Cardiovascular Conditions. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL.
  5. Banerjea R, Findley P, Sambamoorthi U, Bean-Mayberry B. Organization of Primary and Mental Health Care and Diagnosed Depression among Women Veterans with or at Risk for Cardiovascular Diseases. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 27; Chicago, IL.
  6. Banerjea R, Pogach LM, Sambamoorthi U, Shen C. Prevalence of Major and Non-major Depressive Disorders Among Women Veteran Clinic Users with Cardiovascular Conditions. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2008 Oct 25; San Diego, CA.
  7. Tiwari A, Walkup JT, Frayne S, Pogach L, Sambamoorthi U. Depressive disorders effecting healthcare and outcomes among veteran women with cardiovascular conditions. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  8. Banerjea R, Sambamoorthi U, Pogach LM. Mental health and substance abuse among women veteran clinic users with diabetes. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 4; Washington, DC.
  9. Rajan M, Tiwari A, Tseng C, Pogach LM, Sambamoorthi U. Chronic Illness Care among Veteran women with Cardiovascular Conditions. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2006 Nov 4; Boston, MA.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Cardiovasc’r disease, Depression, Outcomes
MeSH Terms: none

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