Quality care is a priority in VA. Identifying subgroups of VA patients at risk of receiving lower quality care for chronic illness is an important step in VA’s quality improvement efforts. One large and particularly vulnerable subgroup of VA patients are those with mental illness; emerging evidence suggests that patients with mental health conditions (MHC) may receive less intensive medical care than those without MHC. This issue may be particularly important in the specific case of diabetes, a condition requiring very active patient participation in care.
We used existing databases to determine whether patients with MHC (and those with specific MHCs or with severe MHC) are over-represented among those not receiving guideline-recommended diabetes care, as defined by the Diabetes Quality Improvement Project (DQIP). We examined the additional effect of patient gender, case mix adjustment, and accounting for non-VA care.
We have drawn our data from a Diabetes Epidemiology Cohort which merged 4 databases needed to meet our analytic goals: VA’s Health Care Analysis Information Group Diabetes Cohort, VA administrative data from centralized files, 1999 Veterans SF36 Large Survey data, and Medicare claims data. We examined 5 DQIP-defined domains of care, each ascertained for FY99: whether the patient received HbA1c testing, LDL-cholesterol testing, eye examination, and whether the HbA1c was <9.5 and the LDL-cholesterol was <130. Presence of diabetes and presence of one or more MHCs were ascertained for FY98.
Failure to receive DQIP domains of diabetes care occurred more often for patients with MHC (N=76,799) than for those without MHC (N=236,787), both before and after case mix adjustment: unadjusted odds ratio was 1.24 for failure to receive HgbA1c testing, 1.25 for failure to receive LDL testing, 1.05 for failure to receive eye examination, 1.32 for poor glycemic control, and 1.17 for poor lipemic control. Disparities were larger in patients with several specific MHCs: psychosis, manic disorder, substance use disorder, and personality disorders. For each DQIP domain, percent of patients not receiving recommended care increased with increasing number of mental health conditions.
Our findings are highly relevant to VA policy-makers and clinicians: quality improvement efforts need to recognize that those with MHC represent a high-risk subgroup of patients with diabetes. Our findings also make clear the need for further evaluation of patient-level, provider-level and institution-level factors explaining this effect. Finally, since we selected diabetes only as a prototype condition, our findings raise the possibility that patients with MHC, who represent over a fourth of VA patients, receive lower quality care for a wide spectrum of medical conditions. This possibility requires immediate investigation, due to its potentially large clinical and economic implications within and outside of VA.
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Mental, Cognitive and Behavioral Disorders, Health Systems
Behavior (patient), Comorbidity, Diabetes