WORKING P A P E R. Veterans Health Administration Mental Health Program Evaluation Technical Manual

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1 WORKING P A P E R Veterans Health Administratin Mental Health Prgram Evaluatin Technical Manual MARCELA HOROVITZ-LENNON, KATHERINE E.WATKINS, HAROLD ALAN PINCUS, LISA R. SHUGARMAN, BRAD SMITH, TERYN MATTOX, THOMAS E. MANNLE, JR. WR-682-VHA This prduct is part f the RAND Health wrking paper series. RAND wrking papers are intended t share researchers latest findings and t slicit infrmal peer review. They have been apprved fr circulatin by RAND Health but have nt been frmally edited r peer reviewed. Unless therwise indicated, wrking papers can be quted and cited withut permissin f the authr, prvided the surce is clearly referred t as a wrking paper. RAND s publicatins d nt necessarily reflect the pinins f its research clients and spnsrs. is a registered trademark. February 2009 Prepared fr the Veteran s Health Administratin

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3 Preface The Veterans Health Administratin (VHA) in the U.S. Department f Veterans Affairs (VA) prvides mental health and medical treatment fr veterans. In rder t deliver tp-quality medical care t veterans, VA must ensure that prgram gals are being met and that the services available are adequate. T this end, the VA Office f Plicy and Planning cntracted with Altarum Institute and the RAND University f Pittsburgh Health Institute (RUPHI) t cnduct an independent study t evaluate its mental health prgrams. This evaluatin is mandated by Cngress under the Gvernment Results and Perfrmance Act f 1993 and under Title 38 f the U.S. Cde (Veteran s Benefits). The results f this study will be used t infrm VHA plicy and peratinal decisins fr mental health. Critical t this evaluatin was the develpment f a cmprehensive set f mental health perfrmance indicatrs based upn available VHA administrative and medical recrd data. The team applied the Institute f Medicine quality f care framewrk in the identificatin f perfrmance measures. The Institute f Medicine has defined six quality dmains: effectiveness, efficiency, equitability, safety, and patient centered care. i Furthermre, VHA identified critical dmains f quality within its wn rganizatin, including: diagnsis and assessment, treatment, chrnic disease management and rehabilitatin. This reprt presents the technical specificatins fr the perfrmance indicatrs develped during the study. The prject team drew upn existing perfrmance indicatrs develped fr the mental health ppulatin, clinical practice guidelines fr mental health diagnses, and the clinical expertise f team members and advisrs in the develpment f the indicatrs. The strength f evidence fr each indicatr was assigned based upn guidelines frm the Agency fr Healthcare Research and Quality, as adpted by VHA. The VHA has cntributed directly t the develpment f the quality indicatrs described in this technical manual thrugh an advisry grup cmpsed f representatives frm the VHA Patient Care Services, the VHA Office f Mental Health, several field practitiners, and cntractrs. This advisry grup cllabrates with the evaluatin team thrugh input n the evaluatin s scpe and methdlgies. The cntents f this reprt will be f interest t plicymakers, health care rganizatins, and clinical practitiners wh are engaged in activities related t the imprvement f mental healthcare quality. 1

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5 TABLE OF CONTENTS SUMMARY... 4 INTRODUCTION... 9 PART I: Key Definitins Dcument Defining Study-Relevant Ppulatins Defining Study-Relevant Treatment Encunters Defining New Treatment Episdes Additinal Cncepts PART II: ADMINISTRATIVE DATA INDICATORS SCHIZOPHRENIA BIPOLAR I DISORDER POSTTRAUMATIC STRESS DISORDER MAJOR DEPRESSIVE DISORDER SUBSTANCE USE DISORDER CROSS-CUTTING INDICATORS Part III: Medical Recrds Review Indicatrs SCHIZOPHRENIA BIPOLAR DISORDER POST TRAUMATIC STRESS DISORDER (PTSD) MAJOR DEPRESSIVE DISORDER (MDD) SUBSTANCE USE DISORDER (SUD) CO-OCCURRING DISORDERS CROSS-CUTTING: PSYCHOSOCIAL NEEDS INDICATORS CROSS-CUTTING: SUICIDALITY INDICATORS CROSS-CUTTING INDICATORS REFERENCES

6 SUMMARY Questins are being raised natinally abut access t and quality f mental health care, bth within the Veterans Health Administratin (VHA) and in the public and private sectrs mre bradly. Numerus studies have dcumented the discrepancies between mental health care that is knwn t be effective and mental health care that is actually delivered. ii These gaps are imprtant because mental health cnditins are a leading cause f disability and death and have serius ecnmic, scial, and persnal cnsequences. iii Cncurrently, U.S. plicy makers and medical prfessinals are increasingly recgnize that quality mental health care can lead t better, healthier lives fr thse with mental illness, and that perfrmance measurement plays a key rle in imprving health care delivery and, ultimately, patient utcmes. In 2006, the U.S. Department f Veterans Affairs (VA) funded an independent study t evaluate the quality f mental health services prvided t veterans. This study is mandated by the Gvernment Results and Perfrmance Act f 1993, which requires federal agencies t independently evaluate high-vlume, high-cst prgrams, and Title 38 f the U.S. Cde, which regulates Veteran s Benefits. It represents ne f the largest and mst cmprehensive evaluatins f mental health services ever cnducted. The evaluatin fcuses n five highvlume, high-cst mental health diagnses that have the ptential t greatly impair quality f life fr veterans: Schizphrenia Biplar disrder Pst-traumatic stress disrder (PTSD) Majr depressive disrder Substance use disrder. This evaluatin f the VHA mental health services is designed t present new infrmatin abut hw well VA is translating the prmise f imprved mental health care int better, healthier lives fr veterans. In particular, the study team will examine whether specific gaps in services identified as targeted areas f imprvement in the MHSP have been reduced by the implementatin f the plan, and whether investments and/r ther enhancements in VA mental health and substance use treatment services under the plan have had a psitive impact n capacity, utilizatin, staffing, and individual users ver the study perid. In rder t develp and select measures that wuld be viewed as meaningful and useful in additin t valid, the team s wrk was guided by plicy dcuments that identified the aims and characteristics f high quality health care. The Institute f Medicine s quality f care paradigm was used explicitly t categrize all ptential measures and t ensure indicatrs cvered all six dmains f effectiveness, safety, efficiency, timeliness, patient-centeredness and equity. ivv The VHA Mental Health Strategic Plan was mdeled after the Reprt by the President s New Freedm Cmmissin n Mental Health; bth identified the cnsumer and family as the drivers f mental health care, fcusing attentin n the cncept f recvery and n the eliminatin f disparities in the availability and quality f mental health services. Tgether these dcuments prvided the scial and plitical cntext fr develpment and selectin f the measures herein. Belw we have dcumented the methdlgy emplyed in the develpment f mental health indicatrs. Indicatr develpment prcess 1. Cnduct a Systematic Search fr Previusly Identified, Grade I Perfrmance Indicatrs. We cnducted a systematic review f the literature including studies, technical reprts, reviews, electrnic databases, etc., manual review f relevant bibligraphies, and utreach t 4

7 experts and industry representatives t identify an exhaustive pl f relevant perfrmance indicatrs that were either in the public dmain r were being prepared fr near-term disseminatin. All relevant measures were retrieved and the team reviewed the methdlgy used in their design t assess their quality. We abstracted each perfrmance indicatr, nting its data surce, the disrder t which it applied the strength f the evidence fr the prcess measured by the indicatr, and IOM dmain. 2. Identify recmmendatins with empirical supprt that are nt cvered by the existing measures, and create new perfrmance indicatrs t address these gaps. We reviewed VA and APA Clinical Practice Guidelines fr the 5 disrders included in the prgram evaluatin (the VA CPG fr psychses includes recmmendatins fr bth schizphrenia and biplar disrder), and listed all individual recmmendatin statements. Multi-part recmmendatins were separated int individual parts and duplicative recmmendatins were deleted. We defined key terms, examined the recmmendatins fr incnsistency r ambiguity, and prduced a list f explicit, unambiguus measures that had empirical supprt fr the prcess-utcme link. Where discrepancies existed between the APA and VA guidelines the team cnsulted utside experts and discussed the discrepancy until cnsensus was reached. 3. Select measures fr further technical specificatin. Because f the large number f candidate measures, we engaged in a systematic selectin prcess. First, we identified whether the data needed t ppulate the indicatrs existed in the necessary frm in either the administrative r in the medical recrd, and recmmendatins that culd nt be defined peratinally because f lack f data were eliminated. Next, the research team reviewed the measures fr meaningfulness and feasibility, and described the measures predictive validity thrugh an evaluatin f the strength f the prcess-utcme link. A subset f measures was selected t be reviewed by external clinical experts wh further pruned them n the basis f clinical significance. All measures were reviewed with a VA clinical advisry grup, whse members were selected fr their clinical expertise and familiarity with the subject matter. The advisry grup evaluated recmmendatins fr validity and feasibility, and usefulness fr VA s peratinal management and strategic leadership. Lastly, VA and VHA leadership rated the indicatrs n their imprtance t the VHA and cntributin t presenting a cmprehensive quality prfile. As a result f this prcess, we identified a cre set f measures that were valid, feasible, and a VA pririty. Mst f them described prcesses that were identified with acute treatment. 4. Generate a new set f measures pertaining t the psychscial aspects f care. Because the prcess used abve required measures t have an empirical basis f supprt, the dmains f patient-centeredness and recvery were neglected. Althugh nt evidence-based r guideline-supprted, bth dmains are endrsed by the Institute f Medicine and the VA Mental Health Strategic Plan as critical t quality. We therefre used a cllabrative prcess between the research team and the VA clinical advisry grup t identify key cnstructs pertaining t patient-centeredness and recvery. Amng the many pssible cnstructs, we chse t fcus n the psychscial aspects f care such as attentin t scial supprts, husing and emplyment. Indicatr develpment invlved recruiting experts and engaging them in the prcess f identifying a cre set f crss-cutting psychscial indicatrs. Because f the difficulty evaluating the predictive validity f the psychscial aspects f care, they will be used descriptively. 5

8 5. Develp technical specificatins fr finalized indicatrs and categrize their strength f evidence We generated detailed technical specificatins fr all finalized perfrmance indicatrs with respect t VHA administrative data and electrnic medical recrds, and identified data surces that efficiently prvided the infrmatin necessary t ppulate the indicatrs. Each indicatr cntained an indicatr statement and executive summary describing the surce(s) f the specificatins and clinical ratinale fr the selected indicatr. We als included the indicatr grade, which reflected the strength f the prcess-utcme link, and whether the indicatr wuld be used as a benchmark r descriptively. We created numeratrs and denminatrs fr each indicatr based n the data that wuld be available, and defined the ppulatin t which the indicatr applied. Fr example, if the indicatr applied nly t peple in a new treatment episde, we defined the term new treatment episde. All clinical and measurement terms were defined peratinally, and we summarized anticipated data cllectin prblems and ther feasibility issues. These included any prblems that we culd fresee prir t starting abstractin, such as data elements that might be time-cnsuming t cllect r which required a judgement t be made by the abstractr. Fr cmplex prcesses f care with multiple cmpnents f varying clinical r utcme relevance (e.g., delivery f CBT/SST r assessment f mental status), we sught expert input t select and peratinalize critical cmpnents. Technical specificatins were reviewed by bth external clinical experts and the VA Advisry grup in rder t ensure that specificatins were bth feasible given the data available, and meaningful t this particular ppulatin. We categrized indicatrs accrding t the strength f the prcess-utcme link using the grading system develped by the AHRQ s US Preventive Services Task Frce. vi Grade I measures are thse where the link between prcess and utcme has been established thrugh randmized clinical trials, grade II measures are supprted by well-designed, nnrandmized trials, and grade III measures are supprted by expert pinin. A caveat t drawing cnclusins frm this grading system is that smetimes the utcmes literature may nt be specific enugh abut the ingredients f the interventin that are critical t its efficacy/effectiveness. Fr example, althugh randmized cntrlled trials have established the value f psychtherapy in the treatment f several disrders, nt enugh evidence exists t ascertain the minimum dse (r number f sessins) and duratin required fr the utcme advantage t emerge. We als nte that the grading des nt reflect translatinal validity, r the certainty that the technical specificatins accurately reflect the prcess f care they are trying t capture. 6. Determine data abstractin elements and sequence f abstractin Starting with the technical specificatins develped abve, we described the data abstractin elements and abstractin sequence fr each indicatr. Since many indicatrs required verlapping infrmatin, we remved redundancy and gruped questins fr efficiency. Fr example, all questins abut medicatins were placed tgether,, since the medicatins prescribed t a veteran are fund in a single sectin f the recrd. We created abstractin frms fr each diagnsis. 7. Pilt test indicatrs fr translatinal validity and perfrmance Clinical nurse abstractrs pilted each indicatr fr timing and perfrmance using pencil and paper and mdificatins were made in rder t keep data cllectin time t a minimum. We 6

9 fund that sme data elements were nt fund in the part f the medical recrd t which we had access, and, after review with the clinical advisry grup, deleted these indicatrs. After the initial paper and pencil pilt test, an electrnic abstractin frm was created and a secnd pilt test was perfrmed t make sure that the questins flwed crrectly and that there were n prgramming errrs. Discussin In this reprt we present a cmprehensive set f indicatrs fr evaluating the perfrmance f mental health care systems with tw different data surces, administrative and medical recrds. One f the greatest difficulties in evaluating mental health care is btaining meaningful data t measure the key elements f the system. In rder t evaluate the structure f care, we develped indicatrs that used a cmbinatin f bth data surces available, while recgnizing that bth surces f data, either singly r in cmbinatin, have inherent strengths and weaknesses. The main strength f using administrative data is their availability and cmprehensive enumeratin f the study ppulatin. vii Mrever, the databases were relatively large, enabling the study team t analyze ppulatin subgrups and specific gegraphic areas separately, which was particularly useful, since mst prblems related t access and availability are nt unifrm acrss ppulatins r within areas. In many cases, hwever, items were missing r the accuracy f the infrmatin prvided culd nt be guaranteed. This is nt uncmmn when data are cllected and used fr different purpses. Other studies als supprt the use f administrative data cmbined with chart review t assess perfrmance. viii While the structure-prcess-utcmes evaluatin mdel presented herein hlds prmise fr advancing the science f mental health care quality imprvement bth within and utside the VHA, a few final caveats are in rder. First, in any health care system, the prgressin frm evidence-based practice guidelines t perfrmance indicatrs t imprved patient utcmes is fraught with cmplexity. Great care must be taken t measure precisely what is intended t be measured thrugh effective and efficient dcumentatin s that the burden f measurement des nt utpace quality care prvisin. In additin, cntinued awareness f the cmplicated linkages between evidence-based practice and individual patient preferences and utcmes is essential. As recent studies amply demnstrate, even the mst basic f evidence-based practice imprvements can result in different utcmes fr different patients and fr different reasns. Attentin must als be paid t ensuring that quality imprvement becmes a part f the fabric f care at bth the rganizatinal and individual levels, thrugh resurce investment, staff training, etc. Secnd, nt all mental health care systems lk r perate like the VHA mental health care system. Public and private sectr mental health care functins largely as a cttage industry, with the majrity f psychiatrists practicing in sl r tw-physician practices; infrmatin technlgy is less well develped; there are few centralized administrative databases; and there is n single entity r rganizatin respnsible fr implementing and mnitring quality imprvement strategies. While these differences must be recgnized and addressed in the cntext f nging quality imprvement, the same high quality standards shuld nevertheless apply. Third, t what extent this mdel can be adapted fr use in ther systems and in ther cntexts is nt clear. It is pssible that certain cmpnents f the mdel will be mre suitable fr mental health quality imprvement effrts at the natinal r state levels r in large systems (e.g., managed care netwrks), while thers will wrk well in mre lcalized cntexts (e.g., cmmunity mental health centers). 7

10 VA has undertaken the mst extensive, systematic, and rigrus evaluatin f the mental health care delivery ever cnducted. Althugh this quality imprvement effrt is still in its early stages, and much remains t be learned, the framewrk, methdlgy, and preliminary results ffer a fertile grund upn which ther stakehlders in the mental health field can cntinue t build and expand bth in the near- and lnger-term. 8

11 INTRODUCTION This technical manual is presented in three main parts. Part I defines the key terms used in the descriptin f indicatrs, part II describes the administrative data indicatrs, and part III describes the medical recrd indicatrs. Part I, the Key Definitins Dcument (KDD) defines the relevant ppulatins, types f treatment encunters, treatment episdes fr each f six main diagnses (biplar disrder, schizphrenia, majr depressin disrder (MDD), pst-traumatic stress disrder (PTSD), substance use disrder (SUD), and c-ccurring disrders), and additinal cncepts such as specialty mental health, licensed mental health prvider, licensed mental health prescribing prvider, licensed prescribing prvider, and psychtherapy. This dcument is a cmpanin t supprt the use f any f the indicatrs in parts II and III. Part II describes 31 indicatrs designed fr administrative data analysis including indicatrs specific t the treatment f biplar disrder, schizphrenia, substance use disrder, majr depressive disrder, and pst-traumatic stress disrder as well as crss-cutting indicatrs that apply t tw r mre f the diagnses cnsidered. Part III describes 57 hybrid indicatrs that integrate data frm administrative and medical recrds. In additin t dcumenting indicatrs fr each f the six main diagnses and crsscutting indicatrs this sectin als includes suicide indicatrs t review assessment fr suicide ideatin and fllw-ups fr suicidal patients. And psychscial indicatrs t evaluate whether mental health patients receive mental status exams apprpriate t their diagnsis and psychscial assessments and supprt acrss the dmains f husing, scial supprt, and emplyment. Strength f evidence: The Altarum/RUPHI team has adpted the same grading system as the VHA in its Clinical Practice Guidelines, described in the fllwing table: Grade I II III Strength f Evidence Descriptin Evidence is btained frm at least ne prperly randmized cntrlled trial (RCT). Evidence is btained frm well-designed chrt, casecntrlled, cntrlled, r time series trials withut randmizatin. Opinins f respected authrities are based n clinical experience, descriptive studies and case reprts, r reprts f expert cmmittees. We used the strength f evidence linking the prcess f care t desired utcmes t define whether the indicatr wuld be used fr benchmark r descriptive purpses. Benchmark indicatrs are thse supprted by grade I evidence fr which data were available and culd be cllected. The remaining indicatrs are used fr descriptive purpses nly. Of the 88 indicatrs develped 21 are benchmark indicatrs and the remaining 67 are descriptive. 9

12 Study Perid: In several indicatrs, we use the term study perid, which in this analysis includes fiscal year (FY) In certain instances we have extended the scpe f analysis t include data frm FY 2008 r a lk-back perid int FY In thse cases, the change is nted in the text f the indicatr. Data Surces: Fr all indicatrs, we are relying n administrative and medical recrd data t define the numeratr and denminatr. Indicatrs that require pharmacy administrative data may be peratinalized n a smaller sample unless we gain apprval t receive the cmplete pharmacy file fr all patients in ur universe as defined in the Key Definitins Dcument. Industry standard indicatrs: Where pssible we have used indicatrs that have been cited by majr mental health care perfrmance indicatr clearinghuses. These indicatrs have been previusly develped and substantiated with evidence r clinical cnsensus. We will cite these clearinghuses in the ratinale statements fr many perfrmance indicatrs in this dcument. Belw we have included a brief summary f each f these clearinghuses frm their wn dcumentatin. Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) CQAIMH inventry f quality measures prvides a searchable database f mre than 300 prcess measures fr assessment and imprvement f mental health and substance abuse care. These measures have been develped by gvernment agencies, researchers, prfessinal rganizatins, accreditrs, health systems, emplyer purchasers, cnsumer calitins, and cmmercial vendrs. Each measure is accmpanied by a clinical ratinale, numeratr and denminatr specificatins and infrmatin n data surce, dmain f quality, evidence basis and develper. The inventry can be searched by these characteristics as well as by diagnsis, demgraphics, type f treatment and clinical setting. Funding fr the Inventry was prvided by the Agency fr Healthcare Research and Quality (AHRQ), Substance Abuse and Mental Health Services Administratin (SAMHSA), and the Evaluatin Surce: STABLE: Standards fr Biplar Excellence The STABLE Perfrmance Measures & Tlkit prvides rigrusly develped tls fr quality assessment and imprvement f care fr biplar disrder. Fifteen perfrmance measures were develped n the basis f research evidence, expert cnsensus and frmal testing f reliability and validity. Detailed specificatins, medical recrd abstractin frms and perfrmance results frm 80 utpatient sites are prvided. The tlkit prvides numerus resurces t imprve perfrmance in clinical practice including instruments t screen fr depressin and mania as well as t mnitr symptms and functining ver time. In additin, there are tls t assess fr suicide risk, c-mrbid substance use and medicatin side effects; t prvide patient educatin; and t assist with diagnstic cding. STABLE was led by a Natinal Crdinating Cuncil f biplar and measurement experts as well as leaders f natinal prfessinal assciatins. Funding was prvided by AstraZeneca LLP. Surce: Natinal Quality Frum (NQF) The Natinal Quality Frum (NQF) is a nt-fr-prfit membership rganizatin created t develp and implement a natinal strategy fr health care quality measurement and reprting. A shared sense f urgency abut the impact f health care quality n patient utcmes, wrkfrce 10

13 prductivity, and health care csts prmpted leaders in the public and private sectrs t create the NQF as a mechanism t bring abut natinal change. Surce: Healthcare Effectiveness Data and Infrmatin Set (HEDIS) and Natinal Cmmittee fr Quality Assurance (NCQA) Develped and maintained by NCQA, HEDIS is a tl used by mre than 90 percent f America's health plans t measure perfrmance n imprtant dimensins f care and service. Altgether, HEDIS cnsists f 71 measures acrss 8 dmains f care. Because s many plans cllect HEDIS data, and because the measures are s specifically defined, HEDIS makes it pssible t cmpare the perfrmance f health plans n an "apples-t-apples" basis. Health plans als use HEDIS results themselves t see where they need t fcus their imprvement effrts. T ensure that HEDIS stays current, NCQA has established a prcess t evlve the measurement set each year. NCQA s Cmmittee n Perfrmance Measurement, a brad-based grup representing emplyers, cnsumers, health plans and thers, debates and decides cllectively n the cntent f HEDIS. This grup determines what HEDIS measures are included and field tests determine hw it gets measured. Surce: 11

14 PART I: Key Definitins Dcument 12

15 Defining Study-Relevant Ppulatins Ia. Chrt diagnses In the fllwing table are ICD-9 cdes used t define each f ur chrts. T be included in the study ppulatin, clients must have at least tw utpatient encunters n different days r ne inpatient episde during the study perid fr any reasn. Patients are assigned t a diagnstic chrt based n the diagnsis cde frm Table 1A that appears in the greatest number f episdes f care during the study perid, either primary r secndary. T be eligible fr the c-ccurring disrders indicatrs clients must be assigned t ne f the fur mental health chrts (e.g., MDD, PTSD, schizphrenia, biplar disrder) and the SUD chrt. If a patient was assigned t ne f these chrts in FY06 and anther in FY07, they will still qualify fr the c-ccurring disrders chrt. TABLE 1A. COHORT DIAGNOSES Chrt ICD-9 Cde Descriptin Schizphrenia Schizphrenia, simple type Schizphrenia, disrganized type Schizphrenia, catatnic type Schizphrenia, paranid type Acute schizphrenic episde Latent schizphrenia Residual schizphrenia Schizphrenia, schiz-affective type Other specified types f schizphrenia Unspecified schizphrenia PTSD Prlnged psttraumatic stress disrder Biplar Manic disrder, single episde Manic disrder, recurrent episde Biplar affective disrder, manic Biplar affective disrder, depressed Biplar affective disrder, mixed Biplar affective disrder, unspecified Majr Depressive Majr depressive disrder, single episde Disrder Majr depressive disrder, recurrent episde Substance Use Other and unspecified alchl dependence Disrder Opiid type dependence Barbiturate and similarly acting sedative r hypntic dependence Ccaine dependence Cannabis dependence Amphetamine and ther psychstimulant dependence 13

16 Chrt ICD-9 Cde Descriptin Hallucingen dependence Other and unspecified drug dependence Cmbinatins f piid type with any ther Cmbinatins f drug dependence excluding piid type Unspecified drug dependence Alchl abuse Cannabis abuse Hallucingen abuse Barbiturate and similarly acting sedative r hypntic abuse Opiid abuse Ccaine abuse Amphetamine r related acting sympathmimetic abuse Other, mixed, r unspecified drug abuse C-Occurring Disrders Chrt Diagnsis f SUD and MDD, PTSD, SUD, Biplar r Schizphrenia Defining Study-Relevant Treatment Encunters Ib. Diagnstic cdes used t define treatment encunters The set f cdes in Table 1B will be used t describe encunters r episdes ccurring during treatment, t establish relevant treatment, and als t define the beginning f a new treatment episde. Cdes in italics represent additinal cdes frm thse used t define the diagnstic chrt. 14

17 TABLE 1B. DIAGNOSES FOR DEFINING TREATMENT ENCOUNTERS Diagnsis ICD-9 Cde Descriptin Schizphrenia Schizphrenia, simple type Schizphrenia, disrganized type Schizphrenia, catatnic type Schizphrenia, paranid type Acute schizphrenic episde Latent schizphrenia Residual schizphrenia Schizphrenia, schiz-affective type Other specified types f schizphrenia xx Unspecified schizphrenia Psychsis disrder, nt therwise specified Schizphrenifrm Disrder Brief psychtic disrder Psychtic disrder due t a general medical cnditin x Manic disrder, single episde Manic disrder, recurrent episde Biplar affective disrder, manic Biplar affective disrder, depressed Biplar affective disrder, mixed Biplar affective disrder, unspecified Manic-depressive psychses, ther and unspecified PTSD Prlnged psttraumatic stress disrder Biplar Manic disrder, single episde Manic disrder, recurrent episde Biplar affective disrder, manic Biplar affective disrder, depressed Biplar affective disrder, mixed Biplar affective disrder, unspecified 296.8x Manic-depressive psychses, ther and unspecified Schizphrenia, simple type Schizphrenia, disrganized type Schizphrenia, catatnic type Schizphrenia, paranid type Acute schizphrenic episde Latent schizphrenia Residual schizphrenia Schizphrenia, schiz-affective type Other specified types f schizphrenia Unspecified schizphrenia Psychsis disrder, nt therwise specified Schizphrenifrm Disrder Brief psychtic disrder 293.xx Psychtic disrder due t a (general medical cnditin) Majr depressive disrder, single episde 15

18 Diagnsis ICD-9 Cde Descriptin Majr Depressive Majr depressive disrder, single episde Disrder Majr Depressive Majr Depressive depressive Disrder disrder, NOS recurrent episde Disrder Dysthymia Md Disrder due t Medical Cnditin Md Disrder NOS Prlnged Depressive Reactin Other Specified Affective Disrders Substance Use Disrder Opiid related disrder NOS Other and unspecified alchl dependence Opiid type dependence Barbiturate and similarly acting sedative r hypntic dependence Ccaine dependence Cannabis dependence Amphetamine and ther psychstimulant dependence Hallucingen dependence Other and unspecified drug dependence Cmbinatins f piid type with any ther Cmbinatins f drug dependence excluding piid type Unspecified drug dependence Alchl abuse Cannabis abuse Hallucingen abuse Barbiturate and similarly acting sedative r hypntic abuse Opiid abuse Ccaine abuse Amphetamine r related acting sympathmimetic abuse Other, mixed, r unspecified drug abuse 16

19 Defining New Treatment Episdes IIa. Biplar Disrder The new treatment episde fr biplar disrder is defined as: OR A recent, diagnsis-related admissin 1 r transfer t an inpatient/residential mental health bed, An utpatient encunter where biplar disrder (Table 1B) is the primary diagnsis fllwing a break in care. Break in care is defined as: AND NO biplar-related medicatins fr 5 r mre mnths NO utpatient encunters where biplar disrder is either the primary r the secndary diagnsis fr 5 r mre mnths. 2 Patient chrts: All patients in the biplar disrder chrt (Table 1A). Definitins: Biplar Disrder Encunter: ICD-9 cdes including 296.0, 296.1, 296.4, 296.5, 296.6, 296.7, 296.8x, 295.0, 295.1, 295.2, 295.3, 295.4, 295.5, 295.6, 295.7, 295.8, 295.9, 298.9, , 298.8, 293.xx Biplar Medicatin: Any medicatins fr which a prescriptin was filled. These include drugs frm the fllwing VA Drug Class Cdes fund in VHA Pharmacy Prescriptin Data: CN400, Anticnvulsants CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics 1 The new episde f care begins n the date f admissin r transfer; hwever, the discharge diagnsis will be used fr purpses f describing the admissin/transfer. 2 A break in care is defined as 5 r mre mnths withut cnditin-related medicatins r cnditin-related utpatient encunters. The definitin f a break in care is fairly restrictive in rder t address cncerns that pr medicatin cmpliance culd include patients wh have a 90-day prescriptin and are still taking medicatins but incnsistently. 17

20 CN709, Antipsychtics, Other CN750, Lithium Salts Inpatient admissin 3 where any psychiatric diagnsis is the primary diagnsis (ICD- 9 cdes: 290.xx-319.xx) and, if the primary diagnsis is nt a diagnsis in Table 1B, at least ne secndary diagnsis cmes frm Table 1B. If it is impssible t determine which diagnsis fr an utpatient encunter is the primary diagnsis, then a diagnsis in Table 1B must be listed as ne f the diagnses fr the encunter. 4 Instructins: The start f the new treatment episde fr biplar disrder will be defined by: 1) The admissin date r transfer date fr any inpatient hspitalizatin as defined abve. OR 2) An utpatient encunter where biplar disrder (Table 1B) is the primary diagnsis fllwing a clean perid f five r mre mnths (based n a 90-day prescriptin) fr which there is: NO prescriptin filled fr selected medicatins, AND (in the same time perid f five r mre mnths) NO utpatient encunter in any clinic where biplar disrder is the primary r secndary diagnsis. The first visit after the clean perid in which biplar disrder is the primary diagnsis will indicate the start date fr the new treatment episde. IIb. Schizphrenia The new treatment episde fr schizphrenia is defined as: OR A recent, diagnsis-related admissin r transfer t an inpatient/residential mental health bed, An utpatient encunter where schizphrenia (Table 1B) is the primary diagnsis fllwing a break in care. 3 Defining the NTE based n inpatient discharges was mdified such that the primary diagnsis must be any psychiatric diagnsis (210.xx-319.xx) and, if the primary diagnsis was nt ne f thse in Table 1B, an added requirement is that a diagnsis frm Table 1B must be listed as a secndary diagnsis. 4 Definitin fr hw an utpatient encunter triggers a NTE was mdified t be made cnsistent with the practicalities f the data being extracted frm medical recrds by WVMI. It is nt always pssible t determine which f the diagnses listed fr an utpatient encunter is the primary diagnsis based n the clinical ntes. In these cases, a diagnsis frm Table 1B must be listed as ne f the diagnses fr the encunter. 18

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