Inadequate rates of concordance with VA guidelines for antidepressant treatment among depression patients seen in primary care settings are the norm, and the problem is even more pronounced for depression patients with coexisting chronic conditions because the competing demands model suggests that co-existing conditions compete with depression for attention during primary care visits. Little is known about why the majority of patients fail to receive guideline-concordant depression care.
The objective of this study was to determine what facility, system, and patient characteristics distinguish VA facilities that perform well in providing evidence-based depression care for persons with depression-MCC from VA facilities that are less successful in achieving high rates of concordance with the VA's guideline for depression care for patients with depression-MCC. This objective was accomplished through the following 2 specific aims: (1) Characterize the variation in facility performance in VA depression guideline care of patients with depression-MCC by identifying patient-level characteristics associated with receipt of VA depression guideline care and calculating risk-adjusted, facility-level performance on the VA depression guideline for patients with depression-MCC; and (2) Identify facility-level characteristics associated with high and low performing facilities, controlling for patient-level characteristics.
VA administrative data was used to determine performance on the VA's depression guideline for patients with depression-MCC. Performance rates were adjusted for patient demographic and clinical characteristics. Facility-level depression guideline data were merged with facility-level data from the VA Clinical Practice Organizational Survey. Descriptive, bivariate, and multivariate analyses, including hierarchical linear models, were used to describe the variation in facility-level performance on depression guideline adherence and identify significant organizational and patient predictors of depression guideline adherence for persons with depression-MCC.
The final study cohort included 37,345 patients that had a depressive episode treated in 287 VA facilities. The overall rate of unadjusted depression guideline concordance was 62.7%. Multivariate modeling indicated that several patient and clinical characteristics are significant risk factors associated with depression guideline concordance. Being female, married, from a rural or highly rural area, diagnosed at a CBOC, and having received 2 or more prescriptions during the 45 days prior to the depression episode were all associated with higher odds of depression guideline concordance. Being non-white, having a comorbid substance use disorder, and being diagnosed by a non-primary care provider were associated with lower odds of depression guideline concordance.
There was a great deal of variation in facility-level performance on the proportion of patients that were depression treatment guideline concordant after employing the risk adjustment model and calculating adjusted, facility-level guideline performance rates. Observed to expected ratios across facilities ranged from .471 to 1.52. Further analyses are ongoing to examine the organizational level factors associated with facility-level performance on depression guideline adherence.
Addressing inadequate depression care is a highly relevant issue for the VA. Depression-MCC is common among veterans, and improving depression care quality could improve quality of life, morbidity and mortality outcomes for this population. The VA has implemented several quality improvement initiatives in recent years, and has begun to develop a knowledge base through its depression care management efforts around best organizational practices for improving depression care. Our data show significant variation across facilities in performance on the VA's depression guideline. Identifying the facility, system, and patient characteristics associated with successful performance on the VA's depression guideline could help training and education efforts for underperforming VA facilities so that the VA can increase its overall performance on providing evidence-based depression care to veterans with depression-MCC.
- Jordan N, Bartle B, Sohn M, Lee TA. Impact of Depression on Mortality for Co-existing Illness. Poster session presented at: National Institute of Mental Health Mental Health Services Research Annual Conference; 2011 Jul 2; Washington, DC.