IMPROVING THE EFFICACY OF A DEPRESSION REGISTRY FOR USE IN A COLLABORATIVE CARE MODEL

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1 IMPROVING THE EFFICACY OF A DEPRESSION REGISTRY FOR USE IN A COLLABORATIVE CARE MODEL Danielle F. Loeb, MD Katy E. Trinkley, PharmD Michael Yang, MS2 Andrew Sprowell, MS2 Donald Nease, MD

2 No COI to Report

3 Goals o Define and describe importance of registries o Describe the context for this registry o Outline the purpose of the registry o Describe the validation process for the registry o Describe significant barriers o Registry workflows o Review results

4 Definition and Importance of Registry Definition: "a tool for tracking the clinical care and outcomes of a defined patient population -AHRQ Importance: Chronic Care Model: Essential component of Clinical Information Systems PCMH: Using data for population health management is a must pass element for PCMH certification Copyright 2014 American College of Physicians

5 Setting and Context Since 2013, two large, academic, joint resident-faculty, internal medicine clinics at the University of Colorado have implemented a universal depression screening protocol Screening and diagnostic tools built into electronic medical record (EPIC TM ) A depression registry was developed as a part of PCMH certification Not functional for tracking patient outcomes or clinic processes In 2015, the physician payment organization (University Physicians Inc.) funded QI project to meet new Medicare quality metric guidelines for depression

6 Depression Screening and Diagnosis PHQ-2 o Two question version of the patient health questionnaire used as an initial screening tool for depression o Validated for use in the primary care setting PHQ-9 o Nine question version of the patient health questionnaire o Validated for: Detection of depression Changes in severity over time Monitoring of treatment outcomes Primary Care Setting

7 The Metric Medicare s Group Practice Reporting Option (GPRO) Depression remission at 12 months Adult patients 18 or older with a diagnosis of dysthymia or depression AND an initial PHQ-9 score >9 who demonstrate remission at 12 months defined as a PHQ-9 <5. Exclusions: Patients with diagnosis of bipolar disorder or personality disorder

8 The Intervention: Collaborative Care Model (CCM)

9 Purpose of Registry: 1. Identify patients to enroll in CCM intervention 2. Track patients in the CCM intervention 3. Identify patients with anti-depressant medication changes 4. Report on the quality metric (GPRO) Designed to measure the reach, effectiveness, and adoption of the CCM intervention- consistent with the RE-AIM model

10 The Stakeholders Funders: University Physicians, Inc. Medicare Patients Hospital Electronic Medical Record Administrators Clinic leadership Clinic providers Clinic staff

11 Registry Creation and Validation Process 1. Report runs weekly created to include All Patients with: Positive PHQ-9, OR Diagnosis of Depression or Dysthymia 2. Workflows were developed to sort patients into different categories based on the 4 identified specific purposes 3. Registry variables were validated through multiple Plan- Do-Study-Act (PDSA) cycles. Each iteration included: Chart reviews to refine the categories Searches for discrete criteria to be used to further sort patients 4. Worked closely with analyst to refine variables

12 Barriers After completing chart reviews on 150 distinct patients, we found five primary barriers: 1. EMR generated - PHQ-2 scores auto-populate PHQ-9 scores leading to inaccurate PHQ-9s 2. Registry generated - The registry was extracting diagnoses only from the Problem list and not from Visit Diagnoses 3. Provider diagnosis - Four patients in the registry had concurrent diagnoses of unipolar depression, bipolar depression and personality disorder. 4. Incomplete data - Many with depression had no PHQ Quality metric timeline - Challenges in creating automated process for identifying patients with positive PHQ-9 12 months ago and subsequent PHQ-9 <5

13 3 Workflows Using Registry 1. Identify patients for enrollment in CCM intervention 2. Identify patients for phone calls following antidepressant medication changes 3. Track patients 12 months after initial positive PHQ-9 Example Workflow: EPIC generates report of pts w/ PHQ9 and depression diagnosis a. The Supervisor will the CTA lead the Excel document for the Depression Registry - NEW Patients. b. The CTA lead will prepare the Depression Outreach list as follows: 1. Insert new column in Column L and paste formula =IF(OR(I2="Y",K2="Y"),"Include","Exclude") 2. Copy formula down column. 3. Filter column L to only show Include. 4. Filter column Q to only show Y. 5. Filter column R to exclude Y. 6. Filter column T to exclude Y. c. The CTA lead will evenly divide the number of pts and color code for the CTAs, then add the document to the UMA-Depression folder in the PCMH folder *Patients in CCM tracked within EMR rather than through registry

14 Results: Patients for CCM Enrollment 150 chart reviews over 11 iterations were completed 4975 patients had either a diagnosis of depression or dysthymia or a positive PHQ had no documented PHQ-9 in the last 12 months

15 Patients for Medication Phone Calls Patients identified for calls N=298 N (%) Calls needed 33 (11.1) Calls not needed No antidepressant change 196 (65.8) No diagnosis of depression/dysthymia 31 (10.4) Managed by psychiatry 26 (8.7) Diagnosis of bipolar/personality disorder 1 (0.3) Follow-up schedule with PCP same week 5 (1.7)

16 Conclusions Validation of both the registry and EHR is critical to ensure accuracy of the population health registry The desire for increased automation of registry functions presented challenges EHR systems are built to support billing optimization, not accurate clinical documentation

17 References Agency for Healthcare Research and Quality. Improving Chronic Illness Care. Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. American journal of public health. Jun 2013;103(6):e odel&s=2 Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27): Katon WJ, Von Korff M, Lin EH, Simon G, Ludman E, Russo J, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry. 2004;61(10): Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire- 2: validity of a two-item depression screener. Medical care. 2003;41(11): Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine. 2001;16(9):

18 Categories for sorting patients Internal medicine patients with (a) Diagnosis of depression or dysthymia or (b) PHQ-9 > 9 in last 36 Mo. Depression or Dysthymia NO Depression or Dysthymia Bipolar or Personality Disorder No Bipolar or Personality Disorder No PHQ-9 within Last year PHQ-9 in Last year All PHQ-9 scores < 9 In last year DYSTHYMIA or MAINTENANCE REMISSION Any PHQ-9 score > 9 within last year (CCD Population) CURRENT DEPRESSION

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