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The American Journal of Managed Care November 2004 - Part 2
Screening for Depression and Suicidality in a VA Primary Care Setting: 2 Items Are Better Than 1 Item
Kathryn Corson, PhD; Martha S. Gerrity, MD, MPH, PhD; and Steven K. Dobscha, MD
The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care
Jonathan B. Perlin, MD, PhD, MSHA; Robert M. Kolodner, MD; and Robert H. Roswell, MD
VA Health Services Research: Lessons for the World's Healthcare Organizations
Steven J. Bernstein, MD, MPH
Variation in Implementation and Use of Computerized Clinical Reminders in an Integrated Healthcare System
Constance H. Fung, MD, MSHS; Juliet N. Woods, MS; Steven M. Asch, MD, MPH; Peter Glassman, MBBS, MSc; and Bradley N. Doebbeling, MD, MSc
Dual-system Utilization Affects Regional Variation in Prevention Quality Indicators: The Case of Amputations Among Veterans With Diabetes
Chin-Lin Tseng, DrPH; Jeffrey D. Greenberg, MD, MPH; Drew Helmer, MD, MS; Mangala Rajan, MBA; Anjali Tiwari, MD; Donald Miller, ScD; Stephen Crystal, PhD; Gerald Hawley, RN, MSN; and Leonard Pogach, M
Assessing the Accuracy of Computerized Medication Histories
Peter J. Kaboli, MD, MS; Brad J. McClimon, MD, PharmD; Angela B. Hoth, PharmD; and Mitchell J. Barnett, PharmD, MS
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The Relationship of System-Level Quality Improvement With Quality of Depression Care
Andrea Charbonneau, MD, MSc; Victoria Parker, DBA; Mark Meterko, PhD; Amy K. Rosen, PhD; Boris Kader, PhD; Richard R. Owen, MD; Arlene S. Ash, PhD; Jeffrey Whittle, MD, MPH; and Dan R. Berlowitz, MD,
Problems Due to Medication Costs Among VA and Non-VA Patients With Chronic Illnesses
John D. Piette, PhD; and Michele Heisler, MD, MPA

The Relationship of System-Level Quality Improvement With Quality of Depression Care

Andrea Charbonneau, MD, MSc; Victoria Parker, DBA; Mark Meterko, PhD; Amy K. Rosen, PhD; Boris Kader, PhD; Richard R. Owen, MD; Arlene S. Ash, PhD; Jeffrey Whittle, MD, MPH; and Dan R. Berlowitz, MD,

Objective: To explore the relationship of systemwide continuous quality improvement (CQI) with depression care quality in the Veterans Health Administration (VHA).

Study Design: Observational study using data from 2 VHA studies.

Patients and Methods: The Depression Care Quality Study (DCQS) was a retrospective cohort study of depression care quality in the northeastern United States involving 12 678 patients cared for at 14 VHA facilities; it used guideline-based process measures (ie, dosage and duration adequacy). The VHA CQI survey was a cross-sectional survey of systemwide CQI among a representative sample of VHA hospitals; it assessed CQI and organizational culture (OC) at 116 VHA hospitals nationwide and provided data on the 14 study facilities. We used analysis of variance to identify differences in the adequacy of depression care among these facilities. Pearson's correlation was used to identify the relationship of CQI and OC with facility-level depression care adequacy.

Results : Mean depression care adequacy differed among the 14 DCQS facilities (P < .0001). Overall dosage adequacy was 90% (range: 87%-92%). Overall duration adequacy was 45% (range: 39%-64%). There was no correlation between CQI and either dosage adequacy (r = .004, P = .98) or duration adequacy (r = −.17, P = .55). Similarly, there was no correlation between OC and either dosage adequacy (r = −.35, P = .22) or duration adequacy (r = −.12, P = .68).

Conclusion: Although CQI may help bridge the healthcare quality gap, it may not be associated with higher disease-specific quality of care.

(Am J Manag Care. 2004;10(part 2):846-851)

Continuous quality improvement (CQI) has been defined as a "philosophy of continual improvement of the processes associated with providing a good or service that meets or exceeds customer expectations."1 Given the positive CQI experience of industries other than healthcare, CQI has been embraced as a key mechanism of enhancing quality of care while preserving cost-effectiveness. In a recent review, Shortell et al1 described how CQI has been implemented in varied healthcare settings and its diverse effects on healthcare processes and outcomes. These authors concluded that CQI is a potentially promising mechanism for bridging the existing gap in healthcare quality.

Key components necessary for successful implementation of CQI have been described for the private sector2 and the Veterans Health Administration (VHA).3 These include a dynamic, innovative quality leadership with representatives from top management, boards of trustees, and clinical arenas. An organizational culture (OC) that emphasizes teamwork and consensual decision making (ie, group culture), and innovation and risk taking (ie, developmental culture) has been linked to greater CQI implementation3 and to improved clinical outcomes.4 Furthermore, ongoing participation in quality improvement activities is a necessary element of a strong CQI leader and program. However, quality improvement activities alone are not sufficient to sustain overall organizational CQI.2 Thus, quality improvement and quality assurance (QI/QA) principles have remained conceptually distinct from CQI.1

There is considerable uncertainty in the literature regarding the link between CQI and specific healthcare quality domains. Understanding the relationship of systemwide CQI with disease-specific quality of care is important for targeting local CQI and QI/QA activities. Depression serves as a good disease role model for study because it is prevalent, disabling, and costly; lacks quality care; and has well-studied, guideline-based benchmarks that can serve as criteria for measuring the quality of care.

Depression is a prevalent medical condition with far-reaching and potentially serious consequences, especially if undertreated, yet gaps in the quality of depression care continue to be identified.5 To our knowledge, only 1 small study of the effect of CQI on depression care quality has been reported, and those results were equivocal.6 Nonetheless, the positive effect of QI/QA multidisciplinary teams who provided guideline-based depression care7,8 was recently described. These interventions have demonstrated remission of short- and long-term depression, and improved depressive symptoms, patient satisfaction, work-related performance, health-related quality of life, and cost-effectiveness.9-19 Although the design and implementation of these QI/QA depression interventions have been somewhat diverse, a commonality among all has been collaborative care delivered via multidisciplinary teams in a chronic-care model approach.20 In light of this evidence, the US Preventive Services Task Force recently recommended routine screening for depressive disorders in primary care settings with established systems for diagnosis, treatment, and follow-up.21,22

Central VHA leadership has strongly advocated for the development of local VHA CQI activities since the early 1990s. After the creation of 22 VHA healthcare administrative regions in 1995, local CQI activities remained diffuse.3 A large, nationally representative survey of 116 VHA hospitals was undertaken in 1998 to describe VHA CQI and to define predictors of successful CQI in the VHA. Details of this work have been described elsewhere (referred to herein as the VHA CQI survey).3

In this study, we examine facility-level differences in depression care quality and explore the relationship of CQI to depression care quality by using existing data from the VHA CQI survey and our past work evaluating depression care quality in the VHA.23,24 Although the optimal design for studying the effects of CQI is still under debate,25 these data presented a unique opportunity to conduct an observational study examining this crucial question. Because the VHA is the nation's largest managed healthcare system, its experience can serve as a leading example for other healthcare systems.


Study Design and Sample Definition

In previous work, we conducted a retrospective cohort study of 14 VHA hospitals in New England and upstate New York. For that study, we used VHA centralized data to define a depressed cohort, to assess depression care quality using guideline-based process measures, to identify predictors of depression care adequacy,23 and to determine the predictive validity of these guideline-based depression process measures by examining their relationship with subsequent overall and psychiatric hospitalizations.24 We now seek to assess the link between depression care quality as measured by those guideline-based process measures and CQI as measured by the VHA CQI survey.3 The methodologies of these studies are described in brief below.

Depression Care Quality Study

We used VHA administrative and centralized pharmacy records to define a depressed cohort of 12 678 patients who received antidepressant treatment during a 3-month period in 1999. Subject eligibility criteria were as follows: (1) at least 1 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code 296.2x or 296.3x (major depression single or recurrent episode, respectively) noted in a psychiatry, primary care, emergency, or social work clinical setting during October 1, 1997, through September 30, 1999 (fiscal year [FY] 1998 or FY 1999) at 1 of the 14 northeastern VHA hospitals, or at least 1 ICD-9-CM diagnosis code 311.xx (depression, not otherwise specified) noted in a primary care clinical setting during FY 1998 or FY 1999, exclusive of other depression diagnosis codes; (2) no comorbid schizophrenia and/or bipolar disorder; and (3) receipt of at least 1 antidepressant from a VHA pharmacy during the time that depression care was profiled (June 1, 1999, through August 31, 1999). These criteria produced the final sample for which the process of depression care can be linked to system-level CQI. The characteristics of the sample are reported elsewhere.23,24

Guideline-based Depression Process Measures

We compared 2 dimensions of antidepressant therapy with clinical guideline benchmarks using the 1997 VHA Depression Guidelines,26 a compilation of recommendations from the Agency for Healthcare Research and Quality and the American Psychiatric Association depression guidelines.7,8

We exclusively used centralized data sources, predominately automated pharmacy records, to profile depression care quality in this study. Centralized pharmacy records have been examined in various disease models and validated as acceptable sources for assessing medication regimens.27-29 The accuracy of centralized pharmacy records in predicting suboptimal dosing and premature discontinuation of medications was recently confirmed in a depressed cohort by comparing centralized pharmacy records with patient self-report of medication administration.30

We describe the guideline-based depression process measures in full in another paper.23 In short, dosage adequacy was achieved when the average daily dosage of antidepressant during the 3-month profiling period met the guideline-recommended minimum daily dosage. This resulted in a dichotomous outcome variable (ie, guideline-recommended minimum daily dosage, yes/no). Duration adequacy for each patient concerned the overall length of therapy with any eligible antidepressant during the profiling period. Antidepressant eligibility criteria are described elsewhere.23 Duration adequacy was defined as a dichotomy, with inadequate duration being >21% of the profiling period without antidepressants. This boundary (.21) translates into 3 weeks of the 3-month period (or 1 week per month), and is consistent with other definitions of continuous dosing in the literature.31

The VHA CQI Survey

From April through September 1998, a large, nationally representative number of hospital employees (9993/14 892; 67% response3), managers (2406/3400; 71% response), and hospital directors (130/155; 84% response) were sampled from 162 VHA hospitals for the VHA CQI survey. There were 116 hospitals with available data for final quantitative analysis. The 14 facilities examined in this paper had lower response rates for employees (532/1237, 43% response) and managers (152/258, 59% response) than overall. Developed in the VHA Office of Quality Management with assistance from a private-sector consultant, the VHA CQI survey is conceptually based on criteria from the Malcolm Baldridge Award, granted by the US Department of Commerce to companies excelling in quality assurance.3 Although each of these items has significant face validity, to our knowledge, neither their construct nor criterion validity has been formally tested.

The VHA CQI survey consisted of 42 items divided into 5 categories of CQI: role of managers, information and analysis, strategic quality planning, human resources development and management, and management of process quality. An example from the information and analysis category is the following item, to which respondents were asked to indicate their level of agreement on a 5-point Likert scale: "We try to use data about quality to prevent problems, not to just fix them after they have occurred." An overall CQI measure derived from these items was scored from 1 through 5, with higher scores indicating greater CQI implementation. In previous research at VA medical centers, the 5 subscales have demonstrated good internal consistency (Cronbach's alphas ranged from .89 to .92).32

The survey had 20 items divided into 4 dimensions of OC: group, developmental, hierarchical, and rational. These were assessed exclusively by hospital employees, who were asked to distribute 100 points among various statements best characterizing their organization. An example of a group-culture item is the following: "The hospital is a very personal place. It is a lot like an extended family; people seem to share a lot of themselves." The overall OC measure was derived by combining the average percentage of points respondents allocated to the group culture and developmental culture. Higher scores indicated greater innovation and teamwork (ie, a stronger group and developmental culture vs a hierarchical and rational culture).

Assessing the Link Between System-level CQI and Depression Care Quality

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