BACKGROUND/RATIONALE:
Bipolar disorder is one of the leading causes of morbidity worldwide, and is associated with significant personal and societal costs. However, there is a dearth of information on the quality, cost and outcomes of care for veterans with bipolar disorder.

OBJECTIVE(S):
The goal of this study was to refine process and outcome measures for bipolar disorder and determine how patient factors (e.g. substance use, adherence, medical comorbidity) are associated with gaps in quality of care for bipolar disorder in the VA. This research was accomplished using data from a cohort study of patients receiving care for bipolar disorder at a large VA healthcare system. By identifying vulnerable populations at increased risk of poor processes and outcomes of care for bipolar disorder, the long-term goal of this research was to inform future patient, provider, and system-level interventions to improve quality of care for this group.

METHODS:
Eligible patients with an active diagnosis and treatment plan for bipolar disorder completed a brief survey at the time of enrollment and one year later on socio-economic characteristics, substance use, adherence, and outcomes (e.g., symptoms, functioning). A chart review was conducted to assess patient's co-occurring psychiatric and substance use diagnoses, quality of care, and treatment preferences. We assessed the processes of care based on claims and chart review data using quality indicators previously derived from the American Psychiatric Association and VA clinical practice guidelines for bipolar disorder and co-occurring conditions (e.g., metabolic syndrome, substance use disorders). Data on adequate pharmacotherapy, drug level and safety monitoring, and outpatient continuity of care was collected from the VA National Patient Care (NPCD) and Pharmacy Benefits Management databases. Additional data on medical comorbidity and inpatient use was ascertained from the NPCD. Confirmatory data on quality of care for bipolar disorder, medical comorbidity, and patient factors (e.g., preferences; visit adherence) was collected via CPRS chart review.

FINDINGS/RESULTS:
Between July 2004 and July 2006, 435 veterans were eligible and completed surveys (mean age=49, 14.3% female, 23% non-white). Of the 435, 22% were currently employed, 55% were homeless at some point, and 28% used illicit drugs within the past year. Most (68%) were currently experiencing a manic, hypomanic, or mixed episode (55%). Mean SF-12 scores were 37.9 (physical health) and 31.8 (mental health). Compared to psychiatric care, patients reported greater difficulty accessing medical services, including specialist visits (19% versus 9%) and overall care when needed (17% versus 11%). In additional 60.3% were currently prescribed mood stabilizers and 65.5% were prescribed atypical antipsychotics. Overall, based on quality indicators we derived for this study, 39.7% received adequate serum drug level for mood stabilizers; 38.8% received a thyroid function test for lithium; and the majority (71.4% -75.9%) received complete blood counts and hepatic function tests for valproate or carbamazepine. Based on quality indicators representing current practice guidelines, about half of patient prescribed atypical antipsychotics received cholesterol counts (49.6%) and 68.7% received serum glucose levels. Nearly half of the respondents reported adherence difficulty. Patients experienced an average of 2.8 barriers, with 41 percent perceiving at least three. Minority veterans reported poorer adherence than white patients (56 percent versus 40 percent, p=.01), while claiming more overall barriers, particularly financial burden, binge drinking, and difficulty obtaining psychiatric care when needed. Multivariable models revealed that the total number of barriers was significantly associated with poor adherence (OR=1.24 per barrier). The most significant were low medication insight, binge drinking, and difficulty accessing psychiatric care (ORs of 2.41, 1.95 and 1.73, respectively). Multivariate results indicated that positive therapeutic alliance was associated with better adherence (Health Care Climate Questionnaire effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress".

IMPACT:
Understanding variations in quality of care as well as risk of co-occurring conditions can inform intervention strategies for patients with bipolar disorder. Based on our findings from CIVIC-MD, we conducted an intervention designed to improve medical care access and outcomes among veterans with bipolar disorder. Findings from this research will also benefit VA mental health providers, program leaders, and policy makers, by implementing a feasible methodology for collecting and combining patient and administrative data to monitor the processes and outcomes of care for bipolar disorder.

---

External Links for this Project

---

PUBLICATIONS:

Journal Articles

1. Perron BE, Zeber JE, Kilbourne AM, Bauer MS. A brief measure of perceived clinician support by patients with bipolar spectrum disorders. The Journal of nervous and mental disease. 2009 Aug 1; 197(8):574-9. [view]
2. Kilbourne AM, Fullerton C, Dausey D, Pincus HA, Hermann RC. A framework for measuring quality and promoting accountability across silos: the case of mental disorders and co-occurring conditions. Quality & Safety in Health Care. 2010 Apr 1; 19(2):113-6. [view]
3. Goodrich DE, Kilbourne AM. A Long Time Coming - The Creation of an Evidence Base for Physical Activity Prescription to Improve Health Outcomes in Bipolar Disorder. Mental health and physical activity. 2010 Jun 1; 3(1):1-3. [view]
4. Pirraglia PA, Biswas K, Kilbourne AM, Fenn H, Bauer MS. A prospective study of the impact of comorbid medical disease on bipolar disorder outcomes. Journal of affective disorders. 2009 Jun 1; 115(3):355-9. [view]
5. Kilbourne AM, McCarthy JF, Post EP, Welsh D, Pincus HA, Bauer MS, Blow FC. Access to and satisfaction with care comparing patients with and without serious mental illness. International journal of psychiatry in medicine. 2006 Dec 1; 36(4):383-99. [view]
6. Perron BE, Jarman CN, Kilbourne AM. Access to conventional mental health and medical care among users of complementary and alternative medicine with bipolar disorder. The Journal of nervous and mental disease. 2009 Apr 1; 197(4):287-90. [view]
7. McCarthy JF, Valenstein M, Zivin K, Zeber JE, Kilbourne AM. Access-related measures and out-of-system utilization among veterans with bipolar disorder. Psychiatric services (Washington, D.C.). 2010 Oct 1; 61(10):1035-8. [view]
8. Mezuk B, Morden NE, Ganoczy D, Post EP, Kilbourne AM. Anticonvulsant use, bipolar disorder, and risk of fracture among older adults in the Veterans Health Administration. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2010 Mar 1; 18(3):245-55. [view]
9. Kilbourne AM, Brar JS, Drayer RA, Xu X, Post EP. Cardiovascular disease and metabolic risk factors in male patients with schizophrenia, schizoaffective disorder, and bipolar disorder. Psychosomatics. 2007 Sep 1; 48(5):412-7. [view]
10. Kilbourne AM, Keyser D, Pincus HA. Challenges and opportunities in measuring the quality of mental health care. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie. 2010 Sep 1; 55(9):549-57. [view]
11. Kilbourne AM, Goodrich D, Miklowitz DJ, Austin K, Post EP, Bauer MS. Characteristics of patients with bipolar disorder managed in VA primary care or specialty mental health care settings. Psychiatric services (Washington, D.C.). 2010 May 1; 61(5):500-7. [view]
12. Copeland LA, Miller AL, Welsh DE, McCarthy JF, Zeber JE, Kilbourne AM. Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder. American journal of public health. 2009 May 1; 99(5):871-7. [view]
13. Kilbourne AM, Haas GL, Mulsant BH, Bauer MS, Pincus HA. Concurrent psychiatric diagnoses by age and race among persons with bipolar disorder. Psychiatric services (Washington, D.C.). 2004 Aug 1; 55(8):931-3. [view]
14. Hunt J, Eisenberg D, Kilbourne AM. Consequences of receipt of a psychiatric diagnosis for completion of college. Psychiatric services (Washington, D.C.). 2010 Apr 1; 61(4):399-404. [view]
15. Kilbourne AM, Perron BE, Mezuk B, Welsh D, Ilgen M, Bauer MS. Co-occurring conditions and health-related quality of life in patients with bipolar disorder. Psychosomatic medicine. 2009 Oct 1; 71(8):894-900. [view]
16. Kilbourne AM, Copeland LA, Zeber JE, Bauer MS, Lasky E, Good CB. Determinants of complementary and alternative medicine use by patients with bipolar disorder. Psychopharmacology Bulletin. 2012 Mar 13; 40(3):104-15. [view]
17. Kilbourne AM, McCarthy JF, Himelhoch S, Welsh D, Hauser P, Blow FC. Guideline-concordant hepatitis C virus testing and notification among patients with and without mental disorders. General hospital psychiatry. 2008 Nov 1; 30(6):495-500. [view]
18. Kilbourne AM, Biswas K, Pirraglia PA, Sajatovic M, Williford WO, Bauer MS. Is the collaborative chronic care model effective for patients with bipolar disorder and co-occurring conditions? Journal of affective disorders. 2009 Jan 1; 112(1-3):256-61. [view]
19. Kilbourne AM, Pincus HA, Schutte K, Kirchner JE, Haas GL, Yano EM. Management of mental disorders in VA primary care practices. Administration and policy in mental health. 2006 Mar 1; 33(2):208-14. [view]
20. Gildengers AG, Whyte EM, Drayer RA, Soreca I, Fagiolini A, Kilbourne AM, Houck PR, Reynolds CF, Frank E, Kupfer DJ, Mulsant BH. Medical burden in late-life bipolar and major depressive disorders. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2008 Mar 1; 16(3):194-200. [view]
21. Zeber JE, Miller AL, Copeland LA, McCarthy JF, Zivin K, Valenstein M, Greenwald D, Kilbourne AM. Medication adherence, ethnicity, and the influence of multiple psychosocial and financial barriers. Administration and policy in mental health. 2011 Mar 1; 38(2):86-95. [view]
22. Post EP, Kilbourne AM, Bremer RW, Solano FX, Pincus HA, Reynolds CF. Organizational factors and depression management in community-based primary care settings. Implementation science : IS. 2009 Dec 31; 4:84. [view]
23. Kilbourne AM, Pincus HA. Patterns of psychotropic medication use by race among veterans with bipolar disorder. Psychiatric services (Washington, D.C.). 2006 Jan 1; 57(1):123-6. [view]
24. Zeber JE, Copeland LA, McCarthy JF, Bauer MS, Kilbourne AM. Perceived access to general medical and psychiatric care among veterans with bipolar disorder. American journal of public health. 2009 Apr 1; 99(4):720-7. [view]
25. Jarman CN, Perron BE, Kilbourne AM, Teh CF. Perceived treatment effectiveness, medication compliance, and complementary and alternative medicine use among veterans with bipolar disorder. Journal of alternative and complementary medicine (New York, N.Y.). 2010 Mar 1; 16(3):251-5. [view]
26. Gold KJ, Kilbourne AM, Valenstein M. Primary care of patients with serious mental illness: your chance to make a difference. The Journal of family practice. 2008 Aug 1; 57(8):515-25. [view]
27. Kilbourne AM, Salloum I, Dausey D, Cornelius JR, Conigliaro J, Xu X, Pincus HA. Quality of care for substance use disorders in patients with serious mental illness. Journal of substance abuse treatment. 2006 Jan 1; 30(1):73-7. [view]
28. Kilbourne AM, Bauer MS, Han X, Haas GL, Elder P, Good CB, Shad M, Conigliaro J, Pincus H. Racial differences in the treatment of veterans with bipolar disorder. Psychiatric services (Washington, D.C.). 2005 Dec 1; 56(12):1549-55. [view]
29. Kilbourne AM, McCarthy JF, Welsh D, Blow F. Recognition of co-occurring medical conditions among patients with serious mental illness. The Journal of nervous and mental disease. 2006 Aug 1; 194(8):598-602. [view]
30. Kilbourne AM, Deeghan T, Jones KR. Serious mental illness and weight management interventions. Psychiatric services (Washington, D.C.). 2013 Sep 1; 64(9):931. [view]
31. Kilbourne AM. The burden of general medical conditions in patients with bipolar disorder. Current psychiatry reports. 2005 Dec 1; 7(6):471-477. [view]
32. Kilbourne AM, Lasky E, Pincus HA, Good CB, Cooley S, Basavaraju A, Greenwald D, Fine MJ, Bauer MS. The continuous improvement for veterans in care: Mood Disorders (civic-md) Study, a VA-academic partnership. Psychiatric services (Washington, D.C.). 2008 May 1; 59(5):483-5. [view]
33. Cruz M, Pincus HA, Welsh DE, Greenwald D, Lasky E, Kilbourne AM. The relationship between religious involvement and clinical status of patients with bipolar disorder. Bipolar disorders. 2010 Feb 1; 12(1):68-76. [view]
34. Zeber JE, Copeland LA, Good CB, Fine MJ, Bauer MS, Kilbourne AM. Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder. Journal of affective disorders. 2008 Apr 1; 107(1-3):53-62. [view]
35. Kilbourne AM, Post EP, Bauer MS, Zeber JE, Copeland LA, Good CB, Pincus HA. Therapeutic drug and cardiovascular disease risk monitoring in patients with bipolar disorder. Journal of affective disorders. 2007 Sep 1; 102(1-3):145-51. [view]
36. Copeland LA, Zeber JE, Salloum IM, Pincus HA, Fine MJ, Kilbourne AM. Treatment adherence and illness insight in veterans with bipolar disorder. The Journal of nervous and mental disease. 2008 Jan 1; 196(1):16-21. [view]
37. Himelhoch S, McCarthy JF, Ganoczy D, Medoff D, Kilbourne A, Goldberg R, Dixon L, Blow FC. Understanding associations between serious mental illness and hepatitis C virus among veterans: a national multivariate analysis. Psychosomatics. 2009 Jan 1; 50(1):30-7. [view]

Conference Presentations

1. Kilbourne AM, McCarthy JF, Post EP, Bauer MS, Welsh D, Pincus HA, Blow FC. Access to and satisfaction with medical care among patients with serious mental illness. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
2. Kilbourne AM. Applying VA Implementation Strategies in complex Organizations: Lessons for Accountable Care Organizations, Medicaid Health Homes, and PBRNs. Paper presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
3. Farmer TC, Kilbourne AM. Appropriate Processes of Care for Bipolar Disorder. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL. [view]
4. Kilbourne AM. Barriers to optimal outcomes for older patients with bipolar disorder [symposia presentation]. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2006 Mar 11; San Juan, Puerto Rico. [view]
5. Kilbourne AM, Cornelius J, Pincus HA, Han X, Shad M, Salloum I, Conigliaro J, Haas GL. Burden of medical comorbidity and survival in veterans with bipolar disorder. Paper presented at: VA Best Practices in Mental Healthcare Systems Annual Conference; 2004 Jun 25; Cambridge, MA. [view]
6. Bowersox NW, Kilbourne AM, Abraham K, Reck BH, Lai Z, Goodrich DE, Bohnert AS, Davis CL. Cause-specific mortality among Veterans with serious mental illness lost to follow-up. Poster session presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2012 Apr 4; Ann Arbor, MI. [view]
7. Kilbourne AM, Zeber JE. CIVIC-MD Project Team. Medication Adherence, Ethnicity, and the Influence of Multiple Psychosocial and Financial Barriers in Veterans with Bipolar Disorder. Paper presented at: Institute on Psychiatric Services Annual Meeting; 2009 Oct 4; Chicago, IL. [view]
8. Kilbourne AM. D&I Implementation Training Program Opportunities. Paper presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Policy and Practice Conference; 2013 Sep 12; Rockville, MD. [view]
9. Bauer MS, Sajatovic M, Kilbourne AM. Developing Collaborative Care Models for Bipolar Disorder: Workshop on Patient-Centered Changes to Improve Outcomes for Serious Mental Illness. Presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 2008 Oct 4; Chicago, IL. [view]
10. Kilbourne AM, Young A, Marder S. Emerging Strategies to Implement Cardiometabolic Management Guidelines in VHA. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD. [view]
11. Kilbourne AM, Waxmonsky J. Enhancing Research Opportunities through Measurement-based Care: The Role of the Mood Disorders Chronic Care Model. Paper presented at: National Network of Depression Centers Annual Meeting; 2011 Nov 3; Baltimore, MD. [view]
12. Zeber J, Copeland LA, Xu X, Good CB, Fine MJ, Kilbourne AM. Ethnicity, perceptions of therapeutic alliance, and adherence in patients with bipolar disorder. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
13. Kilbourne AM, Kirchner J, Post EP, Bauer MS. Evidence-based Implementation Models for the VA to Improve Veterans' Mental Health Care. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR. [view]
14. Kilbourne AM, Kirchner J, Post EP, Bauer MS. Implementation Techniques for Clinicians: Advancing the Uniform Mental Health Services Handbook. Poster session presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD. [view]
15. Kilbourne AM. Implementing medical care management for veterans with bipolar disorder. Paper presented at: VA Best Practices in Mental Healthcare Systems Annual Conference; 2006 Sep 1; Mesa, AZ. [view]
16. Kilbourne AM. Improving Medical Outcomes in Patients with Bipolar Disorder. Paper presented at: World Congress of Behavioral and Cognitive Therapies; 2010 Jun 5; Boston, MA. [view]
17. Kilbourne AM. Improving Outcomes in Bipolar Disorder. Paper presented at: Bipolar Disorder International Biennial Conference; 2013 Jun 16; Miami, FL. [view]
18. Kilbourne AM. Incorporating Health Services Research into Practice. Paper presented at: College of Psychiatric and Neurologic Pharmacists Annual Meeting; 2011 May 3; Phoenix, AZ. [view]
19. Kilbourne AM, Clogston J. Life Goals Collaborative Care. Paper presented at: Behavioral Health / Primary Care Integration Conference; 2011 Nov 16; Lansing, MI. [view]
20. Bowersox NW, Lai Z, Kilbourne AM. Mental health program organizational factors and risk of hospitalization among Veterans with serious mental illness. Poster session presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 2011 Oct 27; San Francisco, CA. [view]
21. Kilbourne AM, Good CB, Zeber JE, Copeland LA, Xu X, Fine MJ, HA Pincus. Race, polypharmacy, and metabolic risk factors in veterans with bipolar disorder. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
22. Goodrich DE, Kilbourne AM, Burghardt AR, Post EP, Schumacher K, Bramlet P, Lai Z, Bauer M. Randomized Trial Testing a Chronic Care Model to Reduce Cardiovascular Disease Risk in Patients with Bipolar Disorder. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2011 Apr 7; Washington, DC. [view]
23. Goodrich DE, Kilbourne AM, Bowersox NW, Visnic SL. Rapid translation of a quality improvement project into a national program to re-engage Veterans with serious mental illness. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2012 Apr 11; New Orleans, LA. [view]
24. McCarthy JF, Kilbourne AM, Welsh D, Blow FC. Recognition of medical comorbidities among patients with serious mental illness. Paper presented at: Albert J. Silverman Research Annual Conference; 2005 Jun 1; Ann Arbor, MI. [view]
25. Kilbourne AM, Goodrich DE, Post EP, Chermack ST, Schumacher K, Lai Z, Bramlet P, Bauer M. The Self-Management Addressing Heart Risk Trial (SMAHRT) Baseline Results of an Integrated Health Behavior Chronic Care Model. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; Washington, DC. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: none
Keywords: Bipolar disorder, Depression
MeSH Terms: none