Adjusting Antidepressant Quality Measures for Race and Ethnicity

Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

Association of Antidepressant Prescription Filling With Treatment Indication and Prior Prescription Filling Behaviors and Medication Experiences

BACKGROUND

Given the wide range of uses for antidepressants, understanding indication-specific patterns of prescription filling for antidepressants provide valuable insights into how patients use these medications in real-world settings.

OBJECTIVE

The objective of this study was to determine the association of antidepressant prescription filling with treatment indication, as well as prior prescription filling behaviors and medication experiences.

DESIGN

This retrospective cohort study took place in Quebec, Canada.

PARTICIPANTS

Adults with public drug insurance prescribed antidepressants using MOXXI (Medical Office of the XXIst Century)-an electronic prescribing system requiring primary care physicians to document treatment indications and reasons for prescription stops or changes.

MEASURES

MOXXI provided information on treatment indications, past prescriptions, and prior medication experiences (treatment ineffectiveness and adverse drug reactions). Linked claims data provided information on dispensed medications and other patient-related factors. Multivariable logistic regression models estimated the independent association of not filling an antidepressant prescription (within 90 d) with treatment indication and patients' prior prescription filling behaviors and medication experiences.

RESULTS

Among 38,751 prescriptions, the prevalence of unfilled prescriptions for new and ongoing antidepressant therapy was 34.2% and 4.1%, respectively. Compared with depression, odds of not filling an antidepressant prescription varied from 0.74 to 1.57 by indication and therapy status. The odds of not filling an antidepressant prescription was higher among adults filling < 50% of their medication prescriptions in the past year and adults with an antidepressant prescription stopped or changed in the past year due to treatment ineffectiveness.

CONCLUSION

Antidepressant prescription filling behaviors differed by treatment indication and were lower among patients with a history of poor prescription filling or ineffective treatment with antidepressants.

Association of Race and Ethnicity With Late-Life Depression Severity, Symptom Burden, and Care

Importance

Knowledge gaps persist regarding racial and ethnic variation in late-life depression, including differences in specific depressive symptoms and disparities in care.

Objective

To examine racial/ethnic differences in depression severity, symptom burden, and care.

Design, Setting, and Participants

This cross-sectional study included 25 503 of 25 871 community-dwelling older adults who participated in the Vitamin D and Omega-3 Trial (VITAL), a randomized trial of cancer and cardiovascular disease prevention conducted from November 2011 to December 2017. Data analysis was conducted from June to September 2018.

Exposure

Racial/ethnic group (ie, non-Hispanic white; black; Hispanic; Asian; and other, multiple, or unspecified race).

Main Outcomes and Measures

Depressive symptoms, assessed using the Patient Health Questionnaire-8 (PHQ-8); participant-reported diagnosis, medication, and/or counseling for depression. Differences across racial/ethnic groups were evaluated using multivariable zero-inflated negative binomial regression to compare PHQ-8 scores and multivariable logistic regression to estimate odds of item-level symptom burden and odds of depression treatment among those with diagnosed depression.

Results

There were 25 503 VITAL participants with adequate depression data (mean [SD] age, 67.1 [7.1] years) including 12 888 [50.5%] women, 17 828 [69.9%] non-Hispanic white participants, 5004 [19.6%] black participants, 1001 [3.9%] Hispanic participants, 377 [1.5%] Asian participants, and 1293 participants [5.1%] who were categorized in the other, multiple, or unspecified race group. After adjustment for sociodemographic, lifestyle, and health confounders, black participants had a 10% higher severity level of PHQ-8 scores compared with non-Hispanic white participants (rate ratio [RR], 1.10; 95% CI, 1.04-1.17; P < .001); Hispanic participants had a 23% higher severity level of PHQ-8 scores compared with non-Hispanic white participants (RR, 1.23; 95% CI, 1.10-1.38; P < .001); and participants in the other, multiple, or unspecified group had a 14% higher severity level of PHQ-8 scores compared with non-Hispanic white participants (RR, 1.14; 95% CI, 1.04-1.25; P = .007). Compared with non-Hispanic white participants, participants belonging to minority groups had 1.5-fold to 2-fold significantly higher fully adjusted odds of anhedonia (among black participants: odds ratio [OR], 1.76; 95% CI, 1.47-2.11; among Hispanic participants: OR, 1.96; 95% CI, 1.43-2.69), sadness (among black participants: OR, 1.31; 95% CI, 1.07-1.60; among Hispanic participants: OR, 2.09; 95% CI, 1.51-2.88), and psychomotor symptoms (among black participants: OR, 1.77; 95% CI, 1.31-2.39; among Hispanic participants: OR, 2.12; 95% CI, 1.28-3.50); multivariable-adjusted odds of sleep problems and guilt appeared higher among Hispanic vs non-Hispanic white participants (sleep: OR, 1.24; 95% CI, 1.01-1.52; guilt: 1.84; 95% CI, 1.31-2.59). Among those with clinically significant depressive symptoms (ie, PHQ-8 score ≥10) and/or those with diagnosed depression, black participants were 61% less likely to report any treatment (ie, medications and/or counseling) than non-Hispanic white participants after adjusting for confounders (adjusted OR, 0.39; 95% CI, 0.27-0.56).

Conclusions and Relevance

In this cross-sectional study, significant racial and ethnic differences in late-life depression severity, item-level symptom burden, and depression care were observed after adjustment for numerous confounders. These findings suggest a need for further examination of novel patient-level and clinician-level factors underlying these associations.

Protocol for studying racial/ethnic disparities in depression care using joint information from participant surveys and administrative claims databases: an observational cohort study

INTRODUCTION

Current evidence indicates that older racial/ethnic minorities encounter disparities in depression care. Because late-life depression is common and confers major adverse health consequences, it is imperative to reduce disparities in depression care. Thus, the primary objectives of this protocol are to: (1) quantify racial/ethnic disparities in depression treatment and (2) identify and quantify the magnitude of these disparities accountable for by a multifactorial combination of patient, provider and healthcare system factors.

METHODS AND ANALYSIS

Data will be derived from the Vitamin D and Omega-3 Trial-Depression Endpoint Prevention (VITAL-DEP) study, a late-life depression prevention ancillary study to the VITAL trial. A total of 25 871 men and women, aged 50+ and 55+ years, respectively, were randomised in a 2×2 factorial randomised trial of heart disease and cancer prevention to receive vitamin D and/or fish oil for 5 years starting from 2011. Most participants were aged 65+ years old at randomisation. Medicare claims data for over 19 000 VITAL/VITAL-DEP participants were linked to conduct our study.The major study outcomes are depression treatment (antidepressant use and/or receipt of psychotherapy services) and adherence to medication treatment (antidepressant adherence and acceptability). The National Academy of Medicine framework for studying racial disparities was leveraged to select patient-level, provider-level and healthcare system-level variables and to address their potential roles in depression care disparities. Blinder-Oaxaca regression decomposition methods will be implemented to quantify and identify correlates of racial/ethnic disparities in depression treatment and adherence.

ETHICS AND DISSEMINATION

This study received Institutional Review Board (IRB) approval from the Partners Healthcare (PHS) IRB, protocol# 2010P001881. We plan to disseminate our results through publication of manuscripts patient engagement activities, such as study newsletters regularly sent out to VITAL participants, and presentations at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT01696435.

Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups

Objective

To compare patterns of health care utilization associated with first presentation of psychosis among different racial and ethnic groups of patients.

Design

The study was a retrospective observational design.

Setting

The study was conducted in five health care systems in the western United States. All sites were also part of the National Institute of Mental Health-funded Mental Health Research Network (MHRN).

Participants

Patients (n = 852) were aged 15 - 59 years (average 26.9 ± 12.2 years), 45% women, and primarily non-Hispanic White (53%), with 16% Hispanic, 10% non-Hispanic Black, 6% Asian, 1% Native Hawaiian/Pacific Islander, 1% Native American/ Alaskan Native, and 12% unknown race/ethnicity.

Main Outcome Measures

Variables examined were patterns of health care utilization, type of comorbid mental health condition, and type of treatment received in the three years before first presentation of psychosis.

Methods

Data abstracted from electronic medical records and insurance claims data were organized into a research virtual data warehouse (VDW) and used for analysis.

Results

Compared with non-Hispanic Whites, Asian patients (16% vs 34%; P=.007) and non-Hispanic Black patients (20% vs 34%; P=.009) were less likely to have a visit with specialty mental health care before their first presentation of psychosis.

Conclusions

Early detection of first episode psychosis should start with wider screening for symptoms outside of any indicators for mental health conditions for non-Hispanic Black and Asian patients.

Racial And Ethnic Differences In The Attainment Of Behavioral Health Quality Measures In Medicare Advantage Plans

As the Medicare population becomes more diverse and its demand for behavioral health care grows, a better understanding of racial/ethnic disparities in the quality of behavioral health care is crucial. Medicare Advantage (MA) plans are accountable through the public reporting of quality performance on measures, including the Healthcare Effectiveness Data and Information Set (HEDIS). We examined HEDIS data on eight MA behavioral health care quality measures, using mixed-effects logistic regressions to distinguish racial/ethnic differences within and between MA health plans. We found that performance differed across racial/ethnic groups by more than 10 percentage points on most quality measures. Significant within-plan disparities were found in twenty of twenty-four comparisons of racial/ethnic minority groups with whites. Within-plan disparities varied widely across plans, with performance being equivalent across racial/ethnic groups in some plans and widely divergent in others. Unlike other types of medical care, in behavioral health within-plan quality disparities are prominent in MA plans, which suggests a role for stratified reporting by racial/ethnic group.

Self-Reported Suicidal Ideation as a Predictor of Suicidal Behavior Among Outpatients With Diagnoses of Psychotic Disorders

OBJECTIVE

Individuals with psychotic disorders are at high risk of suicidal behavior. The study examined whether response to item 9 of the Patient Health Questionnaire (PHQ-9), which asks about thoughts of death or self-harm, predicts suicidal behavior among outpatients with diagnoses of psychotic disorders.

METHODS

Electronic health records (EHRs) from seven large integrated health systems were used to identify all outpatient visits by adults with a diagnosis of schizophrenia spectrum psychosis or unspecified psychosis from January 1, 2009, to June 30, 2015, during which a PHQ-9 was completed (N=32,982 visits by 5,947 patients). Suicide attempts over the 90 days following each visit were ascertained from EHRs and insurance claims. Suicide deaths were ascertained from state death certificate files.

RESULTS

Risk of suicide attempt within 90 days of an outpatient visit was .8% among patients reporting no thoughts of death or self-harm and 3.5% among those reporting such thoughts "nearly every day." Over 90 days of follow-up, 47% of suicide attempts occurred among those who reported any recent thoughts of death or self-harm at the sampled visit. Also, 59% of attempts occurred among those reporting thoughts of death or self-harm at the index visit or any visit in the prior year. The number of suicide deaths within 90 days (N=10) was too small to accurately assess the relationship between PHQ-9 item 9 response and subsequent suicide death.

CONCLUSIONS

Among outpatients with psychotic disorders, response to item 9 of the PHQ-9 accurately identified those at increased short-term risk of a suicide attempt.

Care Pathways Before First Diagnosis of a Psychotic Disorder in Adolescents and Young Adults

OBJECTIVE

The authors sought to describe patterns of health care use prior to first diagnosis of a psychotic disorder in a population-based sample.

METHOD

Electronic health records and insurance claims from five large integrated health systems were used to identify 624 patients 15-29 years old who received a first diagnosis of a psychotic disorder in any care setting and to record health services received, diagnoses assigned, and medications dispensed during the previous 36 months. Patterns of utilization were compared between patients receiving a first diagnosis of a psychotic disorder and matched samples of general health system members and members receiving a first diagnosis of unipolar depression.

RESULTS

During the year before a first psychotic disorder diagnosis, 29% of patients had mental health specialty outpatient care, 8% had mental health inpatient care, 24% had emergency department mental health care, 29% made a primary care visit with a mental health diagnosis, and 60% received at least one mental health diagnosis (including substance use disorders). Compared with patients receiving a first diagnosis of unipolar depression, those with a first diagnosis of a psychotic disorder were modestly more likely to use all types of health services and were specifically more likely to use mental health inpatient care (odds ratio=2.96, 95% CI=1.97-4.43) and mental health emergency department care (rate ratio=3.74, 95% CI=3.39-4.53).

CONCLUSIONS

Most patients receiving a first diagnosis of a psychotic disorder had some indication of mental health care need during the previous year. General use of primary care or mental health services, however, does not clearly distinguish people who later receive a diagnosis of a psychotic disorder from those who later receive a diagnosis of unipolar depression. Use of inpatient or emergency department mental health care is a more specific indicator of risk.

Mortality Rates After the First Diagnosis of Psychotic Disorder in Adolescents and Young Adults

IMPORTANCE

Individuals with psychotic disorders have increased mortality, and recent research suggests a marked increase shortly after diagnosis.

OBJECTIVE

To use population-based data to examine overall and cause-specific mortality after first diagnosis of a psychotic disorder.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used records from 5 integrated health systems that serve more than 8 million members in 5 states. Members aged 16 through 30 years who received a first lifetime diagnosis of a psychotic disorder from September 30, 2009, through September 30, 2015, and 2 comparison groups matched for age, sex, health system, and year of diagnosis were selected from all members making an outpatient visit (general outpatient group) and from all receiving a first diagnosis of unipolar depression (unipolar depression group).

EXPOSURES

First recorded diagnosis of schizophrenia, schizoaffective disorder, mood disorder with psychotic symptoms, or other psychotic disorder in any outpatient, emergency department, or inpatient setting.

MAIN OUTCOMES AND MEASURES

Death within 3 years after the index diagnosis or visit date, ascertained from health system electronic health records, insurance claims, and state mortality records.

RESULTS

A total of 11 713 members with first diagnosis of a psychotic disorder (6976 [59.6%] men and 4737 [40.4%] women; 2368 [20.2%] aged 16-17 and 9345 [79.8%] aged 18-30 years) were matched to 35 576 outpatient service users and 23 415 members with a first diagnosis of unipolar depression. During the year after the first diagnosis, all-cause mortality was 54.6 (95% CI, 41.3-68.0) per 10 000 in the psychotic disorder group compared with 20.5 (95% CI, 14.7-26.3) per 10 000 in the unipolar depression group and 6.7 (95% CI, 4.0-9.4) per 10 000 in the general outpatient group. After adjustment for race, ethnicity, and preexisting chronic medical conditions, the relative hazard of death in the psychotic disorder group compared with the general outpatient group was 34.93 (95% CI, 8.19-149.10) for self-inflicted injury or poisoning and 4.67 (95% CI, 2.01-10.86) for other type of injury or poisoning. Risk of death due to heart disease or diabetes did not differ significantly between the psychotic disorder and the general outpatient groups (hazard ratio, 0.78; 95% CI, 0.15-3.96). Between the first and third years after diagnosis, all-cause mortality in the psychotic disorder group decreased from 54.6 to 27.1 per 10 000 persons and injury and poisoning mortality decreased from 30.6 to 15.1 per 10 000 persons. Both rates, however, remained 3 times as high as in the general outpatient group (9.0 per 10 000 for all causes; 4.8 per 10 000 for injury or poisoning).

CONCLUSIONS AND RELEVANCE

Increases in early mortality underscore the importance of systematic intervention for young persons experiencing the first onset of psychosis. Clinicians should attend to the elevated suicide risk after the first diagnosis a psychotic disorder.

Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians?

OBJECTIVE

Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians.

METHODS

Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records.

RESULTS

Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians.

CONCLUSIONS

After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.

First Presentation With Psychotic Symptoms in a Population-Based Sample

OBJECTIVE

Increasing evidence supports the effectiveness of comprehensive early intervention at first onset of psychotic symptoms. Implementation of early intervention programs will require population-based data on overall incidence of psychotic symptoms and on care settings of first presentation.

METHODS

In five large health care systems, electronic health records data were used to identify all first occurrences of psychosis diagnoses among persons ages 15-59 between January 1, 2007, and December 31, 2013 (N=37,843). For a random sample of these putative cases (N=1,337), review of full-text medical records confirmed clinician documentation of psychotic symptoms and excluded those with documented prior diagnosis of or treatment for psychosis. Initial incidence rates (based on putative cases) and confirmation rates (from record reviews) were used to estimate true incidence according to age and setting of initial presentation.

RESULTS

Annual incidence estimates based on putative cases were 126 per 100,000 among those ages 15-29 and 107 per 100,000 among those ages 30-59. Rates of chart review confirmation ranged from 84% among those ages 15-29 diagnosed in emergency department or inpatient mental health settings to 19% among those ages 30-59 diagnosed in general medical outpatient settings. Estimated true incidence rates were 86 per 100,000 per year among those ages 15-29 and 46 per 100,000 among those ages 30-59.

CONCLUSIONS

When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimates based on surveys or inpatient data. Early intervention programs must accommodate frequent presentation after age 30 and presentation in outpatient settings, including primary care.