Teh CF (University of Pittsburgh), Welsh DE
(COE - Ann Arbor), Lasky E
(COE- Ann Arbor), Kilbourne AM
(COE- Ann Arbor)
Studies regarding quality of care for mental health conditions generally focus on adherence to medication treatment guidelines. However, quality measures based solely on medication algorithms are difficult to operationalize because of the need for timely and accurate psychiatric diagnosis data. Moreover, patient-centered measures that reflect good clinical practice for the whole person, such as assessment of medication side effects, suicidal ideation, no-shows follow-ups, and comorbidities have not been operationalized. We used chart review methodology to define measurable aspects of patient-centered processes of care for bipolar disorder and examined whether veterans with bipolar disorder receive care concordant with these practices.
Data from the Continuous Improvement for Veterans in Care – Mood Disorders (CIVIC-MD) study were used to assess chart documentation of key processes of care for 435 veterans with bipolar disorder. Processes of care (good clinical practice) were defined as documentation of bipolar symptoms, current substance use comorbidities, medical assessment, and documentation of patient’s treatment engagement. Multivariate logistic regression models assessed the effects of income, use of non-VA health services, history of homelessness, service connection, and use of complementary therapies on appropriate processes of care.
Overall, 51% had documented assessment of bipolar symptoms, 78% had documented assessment of substance abuse, and 6% had documented screening for PTSD. Suicidal ideation was assessed in only 34% of patients. Side effects of bipolar medications were noted 48% of the time and no-show visits were followed up 45% of the time. Medical assessment was high--80% had documented weight, blood pressure, and pulse, though obesity was noted in only 46% of the charts of obese patients (BMI > = 30). In multivariate analyses, we found that homelessness (OR = 1.61; 95% CI = 1.05-2.46) and use of complementary therapies (OR = 1.90; 95%CI = 1.06-3.41) were associated with increased documentation of side effects, no-show visit, follow-up, and patient reasons for discontinuing medications.
Only half of veterans diagnosed with bipolar disorder received care concordant with good clinical practice. Of particular concern is the fact that assessments of suicidal ideation and PTSD were infrequent.
High quality treatment of bipolar disorder includes not only adherence to treatment guidelines but also the routine conduct of appropriate care processes. The development of interventions to routinize these care processes is essential in order to improve the quality of care for this group.