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

Transcription

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 Center@HSRI. 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

21 Break in care is defined as: AND NO schizphrenia-related medicatins fr 5 r mre mnths NO utpatient encunters where schizphrenia disrder is either the primary r the secndary diagnsis fr 5 r mre mnths. 5 Patient chrts: All patients in the schizphrenia disrder chrt (Table 1A). Definitins: Schizphrenia Encunter: ICD-9 cdes including 295.x, 298.9, , 298.8, 293.xx, 296.0, 296.1, 296.4, 296.5, 296.6, 296.7, 296.8x. Schizphrenia 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: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Inpatient/residential mental health admissin 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. Instructins: The start f the new treatment episde fr schizphrenia will be defined by: 1) The admissin date r transfer date fr any inpatient hspitalizatin as defined abve. OR 2) An utpatient encunter where schizphrenia (Table 1B) is the primary diagnsis fllwing 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 schizphrenia is the primary r secndary diagnsis. The first visit after the clean perid in which schizphrenia is the primary diagnsis will indicate the start date fr the new treatment episde. 5 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 a 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. 19

22 IIc. Majr Depressive Disrder (MDD) The new treatment episde fr MDD is defined as: OR A recent, diagnsis-related admissin r transfer t an inpatient/residential mental health bed, An utpatient encunter where MDD (Table 1B) is the primary diagnsis fllwing a break in care. Break in care is defined as: AND NO MDD-related medicatins fr 5 r mre mnths NO encunters where MDD disrder is either the primary r the secndary diagnsis fr 5 r mre mnths. 6 Patient chrts: All patients in the MDD chrt (Table 1A). Definitins: MDD Encunter: ICD-9 cdes including , 296.2, 296.3, , , 300.4, 309.1, 311, 300.4, , , 309.1, MDD 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: CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other CN750, Lithium Salts Inpatient/residential mental health admissin 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. Instructins: The start f the new treatment episde fr MDD will be defined by: 6 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 a 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. 20

23 1) The admissin date r transfer date fr any inpatient hspitalizatin as defined abve. OR 2) An utpatient encunter where MDD (Table 1B) is the primary diagnsis fllwing 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 MDD is the primary r secndary diagnsis. The first visit after the clean perid in which MDD is the primary diagnsis will indicate the start date fr the new treatment episde. IId. Pst-Traumatic Stress Disrder (PTSD) The new treatment episde fr PTSD is defined as: OR A recent, diagnsis-related admissin r transfer t an inpatient/residential mental health bed, An utpatient encunter where PTSD is the primary diagnsis fllwing a break in care. Break in care is defined as: AND NO PTSD-related medicatins fr 5 r mre mnths NO utpatient encunters where PTSD is either the primary r the secndary diagnsis fr 5 r mre mnths. 7 Patient chrts: All patients in the PTSD chrt (Table 1A). Definitins: PTSD Encunter: ICD-9 cdes including 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 a 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. Initially, a break in care was defined using a 12-mnth timeframe; we may mdify this timeframe pending a discussin with PTSD experts. 21

24 PTSD Medicatin: Any medicatins fr which a prescriptin was filled. These include drugs frm the fllwing VA Drug Class Cdes r NDC cdes fund in VHA Pharmacy Prescriptin Data: CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Prazsin (see Appendix A fr assciated NDC cdes) Inpatient/residential mental health admissin 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. Instructins: The start f the new treatment episde fr PTSD will be defined by: 1) The admissin date r transfer date fr any inpatient hspitalizatin as defined abve. OR 2) An utpatient encunter where PTSD is the primary diagnsis fllwing clean perid f 5 r mre mnths fr which there is: NO prescriptin filled fr selected medicatins, AND (in the same time perid f twelve r mre mnths) NO utpatient encunter in any clinic where PTSD is the primary r secndary diagnsis. The first visit after the clean perid in which PTSD is the primary diagnsis will indicate the start date fr the new treatment episde. IIe. Substance Use Disrder (SUD) The new treatment episde fr SUD is defined as: OR A recent, diagnsis-related admissin r transfer t an inpatient/residential mental health bed, An utpatient encunter where SUD is the primary diagnsis fllwing a break in care. Break in care is defined as: 22

25 AND NO SUD-related medicatins fr 5 r mre mnths NO utpatient encunters where SUD is either the primary r the secndary diagnsis fr 5 r mre mnths. 8 Patient chrts: All patients in the SUD chrt (Table 1A). Definitins: SUD Encunter: ICD-9 cdes including 303.9, 304.0x-304.9x, 305.0x-305.9x (where x equals 0, 1, r 2). SUD-Related Medicatin: Any medicatins fr which a prescriptin was filled. These include drugs frm the fllwing VA Drug Class Cdes r NDC cdes fund in VHA Pharmacy Prescriptin Data r frm stp cdes: AD100, Alchl Deterrents (fr alchl abuse/dependence, 303.9, 305.0) Naltrexne (fr alchl abuse/dependence, 303.9, 305.0): see Appendix A fr the assciated NDC cdes Methadne (fr piate addictin, 304.0, 304.7, 305.5): defined by stp cdes fr piid substitutin (stp cde: 523) Buprenrphine (fr piate abuse/dependence, 304.0, 304.7, 305.5): see Appendix A fr the assciated NDC cdes Inpatient/residential mental health admissin 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. Instructins: The start f the new treatment episde fr SUD will be defined by: 1) The admissin r transfer date fr any inpatient hspitalizatin as defined abve. OR 2) An utpatient encunter where SUD 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 SUD is the primary r secndary diagnsis. 8 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 a 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. 23

26 The first visit after the clean perid in which SUD is the primary diagnsis will indicate the start date fr the new treatment episde. IIf. Care fr C-Occurring Disrders 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. Defining an Index Visit fr thse with c-ccurring disrders: Fr relevant c-ccurring disrders perfrmance indicatrs, we will identify the start date fr evaluatin based n the identificatin f an index visit fr veterans identified as having a c-ccurring disrder as defined abve. The index visit is the first encunter during the study perid that meets ne f the fllwing criteria: 1. The first encunter in which bth the veteran s mental health cnditin and SUD are present amng the ICD-9 cdes listed n the administrative file (either the mental health cnditin r SUD shuld be primary). 2. If the first encunter f the study perid is fr a mental health encunter (primary diagnsis nly Table 1B) withut mentin f an SUD diagnsis, the previus 6 mnth perid and the 6 mnth perid fllwing that encunter are scanned fr evidence f an encunter fr SUD (primary r secndary diagnsis Table 1B). If the SUD encunter precedes the mental health encunter by less than six mnths, the mental health encunter is labeled the index visit fr purpses f evaluating the perfrmance indicatrs. If there is n prir SUD encunter but there is an SUD encunter within the six mnths fllwing the mental health encunter, that SUD encunter is labeled the index visit fr purpses f evaluating the perfrmance indicatrs. 3. Alternatively, if the first encunter f the study perid is an encunter fr SUD (primary diagnsis nly Table 1B) withut mentin f a mental health diagnsis, the six mnths prir t and fllwing that encunter are scanned t find evidence f a mental health encunter (primary r secndary diagnsis Table 1B). If the mental health encunter precedes the SUD encunter by less than six mnths, the SUD encunter is labeled the index visit fr purpses f evaluating the perfrmance indicatrs. If the mental health encunter fllws the SUD encunter by less than six mnths, the mental health encunter is labeled the index visit fr purpses f evaluating the perfrmance indicatrs. 4. If the first encunter f the study perid f either type (mental health r SUD withut mentin f the ther diagnsis) is nt preceded by r fllwed by anther relevant encunter within six mnths, the encunter stream is fllwed thrugh the study perid until the abve criteria are met. Nte: It may be pssible fr smene t be classified as having a cccurring disrder and nt have an index visit during the study perid. 24

27 IIIa. Specialty Mental Health Additinal Cncepts Includes diagnsis-related (either primary r secndary using Table 1B) visits t any specialty mental health prvider and includes bth psychiatry and substance abuse care. The fllwing cdes frm the Medical SAS Outpatient Datasets (PROV1-PROV10) define specialty mental health care: , , , , , , , , , , , , , , , , , , , IIIb. Licensed Mental Health Prvider Includes diagnsis-related (either primary r secndary using Table 1B) visits t physicians (MD, DO), physician assistants, nurse practitiners/clinical nurse specialists and psychlgists/psychanalysts with a mental health specialty. The fllwing cdes frm the Medical SAS Outpatient Datasets (PROV1-PROV10) define licensed mental health prviders: , , , , , , , MD/DO , Psychlgists/Psychanalysts , PA/CNS , NP , Clinical Scial Wrker IIIc. Licensed Mental Health Prescribing Prvider Includes diagnsis-related (either primary r secndary using Table 1B) visits t physicians (MD, DO), physician assistants, and nurse practitiners/clinical nurse specialists with a mental health specialty and can prescribe medicatins. The fllwing cdes frm the Medical SAS Outpatient Datasets (PROV1-PROV10) define licensed mental health prescribing prviders: , , , , , MD/DO , PA/CNS , NP 25

28 IIId. Licensed Prescribing Prvider Includes diagnsis-related (either primary r secndary using Table 1B) visits t physicians (MD, DO), physician assistants, and nurse practitiners/clinical nurse specialists with any specialty (nt limited t mental health) and can prescribe medicatins. The fllwing cdes frm the Medical SAS Outpatient Datasets (PROV1- PROV10) define licensed prescribing prviders: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , MD/DO , , , , PA/CNS , NP IIIe. Specialty SUD Care Defined as ne r mre SUD utpatient visits in the first 30 days fllwing the start f an new treatment episde. Apprpriate visits include stp cdes fr SUD treatment fund in the Medical SAS Outpatient Dataset: 513: Substance Abuse Individual 514: Substance Abuse Hme Visit 519: Substance Use Disrder/PTSD Teams 523: Opiid Substitutin 545: Telephne/Substance Abuse 547: Intensive Substance Abuse Treatment 560: Substance Abuse - Grup IIIf. Psychtherapy Any diagnsis-related (either primary r secndary using Table 1B) clinic encunters fr which the fllwing CPT cdes are present: 26

29 90806, 90807, 90808, Office r Other Outpatient Facility, Insight Oriented, Behavir Mdifying and/r Supprtive Psychtherapy, excluding psychtherapy with medical evaluatin and management services less than 30 minutes 90812, 90813, 90814, 90815, Office r Other Outpatient Facility, Interactive Psychtherapy (Nte: these cdes mst likely apply t psychtherapy with children but will be retained fr evaluatin purpses in case they may be used with adult patients), excluding psychtherapy with medical evaluatin and management services less than 30 minutes 90818, 90819, 90821, 90822, Inpatient Hspital, Partial Hspital r Residential Treatment Facility, excluding psychtherapy with medical evaluatin and management services less than 30 minutes 90826, 90827, 90828, 90829, Inpatient Hspital, Partial Hspital r Residential Treatment Facility, Interactive Psychtherapy (Nte: these cdes mst likely apply t psychtherapy with children but will be retained fr evaluatin purpses in case they may be used with adult patients), excluding psychtherapy with medical evaluatin and management services less than 30 minutes 90845, Psychanalysis 90853, Grup Psychtherapy (ther than f a multiple-family grup) 90857, Interactive Grup Psychtherapy (Nte: these cdes mst likely apply t psychtherapy with children but will be retained fr evaluatin purpses in case they may be used with adult patients.) 27

30 PART II: ADMINISTRATIVE DATA INDICATORS 28

31 SCHIZOPHRENIA Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f selected schizphrenia patients with apprpriate shrt-term utilizatin f antipsychtic medicatins Indicatr number: A Executive Summary: This indicatr is based n a quality measure cited by the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) and develped by Lehman et al (1998, updated 2004) fr the AHRQ-funded Schizphrenia PORT prgram. CQAIMH states that Antipsychtic medicatins have been shwn t be efficacius in the treatment f acute psychtic exacerbatins f schizphrenia and in reducing the likelihd f relapse. Accrding t the American Psychiatric Assciatin Clinical Practice Guidelines, The evidence supprting the effectiveness f first-generatin antipsychtic medicatins in reducing psychtic symptms in acute schizphrenia cmes frm studies carried ut in the 1960s as well as numerus subsequent clinical trials, and pharmaclgical treatments shuld be initiated as sn as is clinically feasible, because acute psychtic exacerbatins are assciated with emtinal distress, disruptin t the patient s life, and a substantial risk f [vilent] behavir. Numerus studies have shwn that antipsychtic treatments are effective in the acute phase f schizphrenia. The strength f the evidence led the researchers invlved in the AHRQfunded Schizphrenia Patient Outcmes Research Team (PORT) t recmmend this practice which they rated as having gd research-based evidence (Lehman et al, 1998, updated 2004). The VA Clinical Practice Guidelines als supprt the use f antipsychtic drugs in schizphrenia treatment. While antipsychtic medicatins have been clinically shwn t be effective in the treatment f schizphrenia, we cannt accunt fr medicatin refusals r cntraindicatins in this analysis. This indicatr addresses the fllwing IOM dmain: effectiveness References: Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Numeratr: a) Patients prescribed an antipsychtic fr 12 weeks fllwing the start f a new treatment episde 29

32 b) Patients prescribed an antipsychtic fr less than 12 weeks fllwing the start f a new treatment episde c) Patients with n filled prescriptin fr an antipsychtic during the 12 weeks fllwing the start f a new treatment episde Denminatr: All patients with schizphrenia in a new treatment episde Patient chrts: Patients with schizphrenia diagnsis. Definitins: New Treatment Episde: See the Key Definitins Dcument If the new treatment episde begins in the inpatient setting, the start f a new treatment episde is defined as the admissin date If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid 12 weeks f an antipsychtic: Defined as 60 r mre days supplied f an antipsychtic in the 12 weeks fllwing the date f the first filled prescriptin subsequent t the start f a new treatment episde If the new treatment episde begins in the inpatient setting, the patient is cnsidered t be fully cmpliant with their medicatins while in the hspital and s the number f days supplied shuld include the length f stay in the hspital that begins the new treatment episde (using the variable LS frm the Medical SAS Inpatient Dataset) The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Less than 12 weeks f an antipsychtic: Defined as at least ne filled prescriptin but with less than 60 days supplied in the 12 weeks fllwing the date f the first filled prescriptin subsequent t the start f a new treatment episde N filled prescriptin: Defined as n filled prescriptins fr any antipsychtic within 12 weeks f the start f the new treatment episde Antipsychtic medicatins: One r mre prescriptins filled fr a patient using the fllwing drug class and NDC cdes: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Strength f Evidence: Grade III This is the level f evidence fr the indicatr as specified, as we cannt accunt fr medicatin refusals, pr treatment adherence, and ther factrs beynd the cntrl f the prescriber in this analysis. Hwever, the evidence cited in the executive summary has a strength f evidence f Grade I. Feasibility/Data Cllectin Issues: We d nt include patients receiving dept antipsychtics in the numeratr f this indicatr. 30

33 Updates: The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 31

34 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f schizphrenia patients with lng-term utilizatin f antipsychtic medicatins Indicatr number: B Executive Summary: This indicatr is based n a quality measure cited by the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH), which states that Antipsychtic medicatins have been shwn t be efficacius in the treatment f acute psychtic exacerbatins f schizphrenia and in reducing the likelihd f relapse. Likewise, fr utpatients, Cntrlled trials have shwn that patients wh receive antipsychtic medicatin fr 1 year after an acute psychiatric episde experience a lwer likelihd f relapse cmpared t patients treated with a placeb. The evidence fr this indicatr was generated by Lehman et. al. (1998, updated 2004) fr the AHRQ-funded Schizphrenia PORT prgram wh reprt that n average, persns n maintenance therapy experienced symptm relapse ver a fllw-up year at a rate f abut 20 t 25 percent cmpared with abut 55 percent fr thse n placeb. The value f maintenance therapy beynd the first year has nt been studied extensively. Accrding t the American Psychiatric Assciatin Clinical Practice Guidelines, Antipsychtic medicatins substantially reduce the risk f relapse in the stable phase f illness and are strngly recmmended. The VA Clinical Practice Guidelines als supprt the use f antipsychtic drugs in schizphrenia treatment. While antipsychtic medicatins have been clinically shwn t be effective in the treatment f schizphrenia, we cannt accunt fr medicatin refusals r cntraindicatins in this analysis. This indicatr addresses the fllwing IOM dmain: effectiveness References: Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: Thse individuals wh received an antipsychtic medicatin fr the fllwing perids f time: a) Patients with 12 mnths supply f an antipsychtic medicatin during the study perid b) Patients with at least ne filled prescriptin f an antipsychtic during the study perid c) Patients with n filled prescriptin fr an antipsychtic during the study perid 32

35 Denminatr: All patients with a schizphrenia diagnsis Patient chrts: Patients with a diagnsis f Schizphrenia Definitins: 12 mnths f cntinuus antipsychtic medicatin: Defined as at least 300 days f the medicatin supplied during a 12-mnth perid fllwing the date f the first filled prescriptin during the study perid. The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Any use f an antipsychtic: Defined as at least ne filled prescriptin fr an antipsychtic during the study perid N antipsychtic: Defined as n filled prescriptins fr an antipsychtic during the study perid Antipsychtic medicatins: Defined as ne r mre prescriptins using the fllwing VA Drug Class Cdes fund in VHA Pharmacy Prescriptin Data: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Strength f Evidence: Grade III This is the level f evidence fr the indicatr as specified, as we cannt accunt fr medicatin cntraindicatins in this analysis. Hwever, the evidence cited in the executive summary has a strength f evidence f Grade I. Feasibility/Data Cllectin Issues: We d nt include patients receiving dept antipsychtics in the numeratr f this indicatr. Updates: The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 33

36 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f selected schizphrenia patients with antipsychtic plypharmacy utilizatin Indicatr number: C Executive Summary: This indicatr is based n a quality measure cited by the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) based n a study cnducted by Pplin et al (1998), and a recent reprt by Kreyenbuhl et. al. (2007). CQAIMH states, prescriptin f multiple medicatins requires cautin related t ptential drug interactins and side effects. Kreyenbuhl et. al. supprt this assertin, nting that treatment with multiple antipsychtic agents may present risks t patients, such as increased adverse effects and drug interactins, decreased treatment adherence, increased csts fr patients and health care systems, and a pssible increased risk f mrtality. As reprted by Ganguly et al (2004), antipsychtic plypharmacy is widely prevalent, is prescribed fr lng duratins, and is an increasing phenmenn amng (publicly insured) schizphrenia patients, indicating a significant discrepancy with treatment guidelines. The American Psychiatric Assciatin Clinical Practice Guidelines d nt supprt the use f multiple antipsychtic medicatins. There is hwever almst n rigrus research n the effects f antipsychtic plypharmacy: mst f the evidence has been generated by case reprts r pen, uncntrlled, nnrandmized studies (Waddingtn et. al. (1998); Centrrin et al (2004). Furthermre, there is sme dcumentatin that antipsychtic plypharmacy des nt increase side effects (Ganesan 2008), althugh there is n methdlgically sund empirical evidence that the practice is effective r free f safety cncerns. Fr these reasns, this indicatr will be used descriptively as an indicatin f practice variatin, rather than as a benchmark f quality f care. This indicatr addresses the fllwing IOM dmain: safety and effectiveness References: Am J Psychiatry, Apr 2004; 161: Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Centrrin Franca, Jessica L. Gren, Jhn Hennen, Pala Salvatre, James P. Kelleher, and Rss J. Baldessarini. Multiple Versus Single Antipsychtic Agents fr Hspitalized Psychiatric Patients: Case-Cntrl Study f Risks Versus Benefits. Ganesan, Sma. Antipsychtic plypharmacy des nt increase the risk fr side effects. Schizphrenia Research 98 (2008) Ganguly R., Ktzan J.A., Miller L.S., Kennedy K., Martin B.C. (2004). Prevalence, trends, and factrs assciated with Antipsychtic plypharmacy amng medicaideligible schizphrenia patients, J Clin Psychiatry, 65: Kreyenbuhl, Julie A., Valenstein, Marcia, McCarthy, Jhn F., Ganczy, Dara, Blw, Frederic C. Lng-Term Antipsychtic Plypharmacy in the VA Health System: Patient Characteristics and Treatment Patterns. Psychiatric Services : Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f 34

37 Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Ppkin, Michael K., Lurie, Nicle, Manning, Willard, Harman, Jeffrey, Callies, Allan, Gray, Dnald, Christiansn, Jn. Changes in the Prcess f Care fr Medicaid Patients With Schizphrenia in Utah's Prepaid Mental Health Plan Psychiatr Serv : Waddingtn, JL, Yussef, HA, Kinsella, A. Mrtality in schizphrenia. Antipsychtic plypharmacy and absence f adjunctive antichlinergics ver the curse f a 10- year prspective study. British Jurnal f Psychiatry : Numeratr: Thse patients in the denminatr with simultaneus prescriptins fr at least tw ral antipsychtic agents fr 90 r mre days during the study perid Denminatr: All patients diagnsed with Schizphrenia prescribed at least ne antipsychtic agent during the study perid Patient chrts: Patients with chrt diagnsis f Schizphrenia Definitins: Oral antipsychtic medicatins: Defined as ne r mre filled prescriptins fr ne f the fllwing medicatins (NDC cdes fr these medicatins can be fund in Appendix A t the Key Definitins Dcument). Chlrprmazine Thiridazine Mesridazine Thithixene Trifluperazine Perphenazine Mlindne Lxapine Fluphenazine Halperidl Clzapine Olanzapine Ouetiapine Risperidne Ziprasidne Aripiprazle Simultaneus prescriptins: Defined as 90 r mre days supplied fr tw r mre different ral antipsychtic agents during a single 120-day perid Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Nne. Updates: Even if there are mre than ne prescriptin filled in a single mnth, the ttal days supplied will be the sum f all prescriptins filled within the apprpriate time perid. 35

38 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f selected schizphrenia patients wh receive antidepressant medicatin fr cmrbid depressin in additin t their antipsychtic regimen Indicatr number: D Executive Summary: This indicatr is based n an indicatr cited by the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH). The evidence fr this indicatr was generated by Lehman et. al. (1998, updated 2004) fr the AHRQ-funded Schizphrenia PORT prgram wh reprt that antidepressants seem t benefit patients wh have episdic signs and symptms f depressive illness in additin t schizphrenia, if they are administered in phases f illness ther than the active, psychtic exacerbatin phase. Antidepressants can be efficacius withut exacerbating psychtic symptms when used adjunctively with antipsychtics. The CQAIMH indicatr statement ntes: depressive symptms r syndrmes are frequently seen amng individuals with schizphrenia. Research studies shw that depressin can be efficaciusly treated with an antidepressant medicatin in this ppulatin, and practice guidelines recmmend their use. Hwever, many such patients are nt treated. The American Psychiatric Assciatin ntes that Antidepressants are added as an adjunct t antipsychtics when the depressive symptms meet the syndrmal criteria fr majr depressive disrder, are severe and causing significant distress antidepressants have been fund t be useful in the treatment f depressin in schizphrenia. Hwever, very few studies have examined the effects f antidepressants in patients treated with secnd-generatin antipsychtic medicatins, making it difficult t evaluate the current utility f adjunctive antidepressant agents. We cannt accunt fr antidepressant medicatin refusals r cntraindicatins in this analysis. Fr this reasn, this indicatr will be used descriptively. This indicatr addresses the fllwing IOM dmain: effectiveness. References: Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Lehman Anthny F., Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT) Treatment Recmmendatins Schizphrenia Bulletin 24: 1-10 (1998); and Update (2003) Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Numeratr: Patients in the denminatr with simultaneus antidepressant and antipsychtic prescriptins in the study perid Denminatr: Patients diagnsed with schizphrenia and cmrbid depressin wh are nt in a new treatment episde 36

39 Patient chrts: Patients with a diagnsis f Schizphrenia Definitins: New Treatment Episde: See the Key Definitins Dcument Nte: Patients with ne r mre new treatment episdes during the study perid will be excluded frm the denminatr Cmrbid depressin: Defined as ne inpatient admissin and ne utpatient encunter r tw utpatient encunters with a primary r secndary diagnsis f depressin (ICD-9 cdes: 296.2, 296.3, 311) in the six mnths prir t the first encunter where schizphrenia is the primary r secndary diagnsis in the study perid Antidepressant medicatins: Defined as ne r mre filled prescriptins with the fllwing VA Drug Class Cdes fund in VHA Pharmacy Prescriptin Data: CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other Antipsychtic medicatins: Defined as ne r mre filled prescriptins with the fllwing VA Drug Class Cdes fund in VHA Pharmacy Prescriptin Data: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Simultaneus antidepressant and antipsychtic prescriptins: Defined as 90 r mre days supplied fr an antidepressant AND an antipsychtic agent during the same 120-day perid Strength f Evidence: Grade II Feasibility/Data Cllectin Issues: Nne Updates: Nne. 37

40 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f schizphrenia patients with an apprpriate frequency f visits with a licensed prescribing prvider r licensed mental health prescribing prvider Indicatr number: E Executive Summary: This indicatr is based n clinical expert recmmendatins supprted by the VA s Clinical Practice Guidelines fr psychses (CPG). The frequency f visits during maintenance-phase treatment is nt defined by the VA CPG r the American Psychiatric Assciatin s Clinical Practice Guidelines, althugh the APA Guidelines als stress the imprtance f cntinuity f treatment during the nn-acute phase f treatment fr schizphrenia. In additin, the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) cites the indicatr Availability f Medicatin Management & Psychtherapy fr Patients with Schizphrenia which states that because symptms can fluctuate ver time and because these medicatins can have adverse side effects, clinical practice guidelines recmmend regular mnitring f patients. There has been little research t assess what cnstitutes adequate r ptimal frequency f mnitring. The 1996 Expert Cnsensus Guideline fr Treatment f Schizphrenia recmmended mnthly visits, at a minimum, fr stable utpatients with schizphrenia and mre frequent cntact fr patients with unstable symptms r functining. This measure is part f a set f measures prpsed fr testing and has nt been adpted by the develping rganizatin. Described by CQAIMH as members frm the denminatr wh had at least fur medicatin management r psychtherapy visits with a psychiatrist during a 12 mnth perid (surce: NCQA, HEDIS 3.0. Test measures, 1999: This measure was never included in the HEDIS measure set).] We have used as a benchmark the frequency f visits fr similar diagnses suggested by NCQA as a guideline. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. This indicatr addresses the fllwing IOM dmain: effectiveness, timeliness, and safety. References: Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: Thse patients in the denminatr with at least ne visit per quarter (fur visits per year) during the study perid: a) With a licensed prescribing prvider b) With any mental health licensed prescribing prvider Denminatr: All patients in the schizphrenia diagnstic chrt 38

41 Patient chrts: Patients with a schizphrenia diagnsis Definitins: Licensed Prescribing Prvider: See the Key Definitins Dcument Licensed Mental Health Prescribing Prvider: See the Key Definitins Dcument Inclusin criteria fr denminatr: If the patient had at least ne diagnsis-related visit (primary r secndary using Table 1B frm the Key Definitins Dcument) in the furth quarter f FY06, begin cunting visits fr the numeratr with the first quarter f FY07. If the patient des nt have a relevant visit in the last quarter f FY06, begin with the first visit in FY07 and cunt frward fr fur quarters. Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Nne. Updates: Nne. 39

42

43 BIPOLAR I DISORDER Perfrmance Measure Technical Dcumentatin Mdule: Biplar I Disrder Indicatr Statement: Prprtin f selected biplar I disrder patients receiving bld level mnitring fr lithium Indicatr number: A Executive Summary: This indicatr is based n STABLE perfrmance measure number 10, Percent f patients treated fr biplar disrder wh have evidence f a serum medicatin level within 12 weeks f beginning treatment with lithium. In their practice guidelines, the American Psychiatric Assciatin supprts this indicatr, nting that fr many patients, the therapeutic range within which beneficial effects utweigh txic effects is quite narrw, s that small changes in serum level may lead t clinically significant alteratins in the beneficial and harmful effects f lithium...the frequency f mnitring...shuld be n less than every 6 mnths fr stable patients. The CANMAT guidelines fr the management f patients with biplar I disrder (Yatham and Kennedy 2005) nte that regular mnitring f serum medicatin levels is required fr patients n lithium r divalprex, and cmmn practice is t establish tw cnsecutive serum levels in the therapeutic range during the acute phase. Thereafter, serum levels shuld be repeated every 3-6 mnths unless the clinical situatin warrants therwise. This indicatr is based n rbust clinical evidence supprting the ideal therapeutic range f serum medicatin levels, and a clinical cnsensus regarding the frequency with which mnitring shuld take place. It is als an industry standard with regard t quality care fr biplar I disrder. This indicatr addresses the fllwing IOM dmains: effectiveness and safety. References: Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement Freeman M, Freeman S, Lithium: Clinical Cnsideratins in Internal Medicine, The American Jurnal f Medicine (2006) 119, Yatham LN, Kennedy, SH, et al.; Canadian Netwrk fr Md and Anxiety Treatments (CANMAT) guidelines fr the managements f patients with biplar disrder: cnsensus and cntrversies, Biplar Disrders 2005: 7(Suppl. 3): 5-69 STABLE Perfrmance Measures, published nline at Accessed Fall 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: Patients included in the denminatr wh have received serum drug level mnitring fr Lithium at least nce in the 12 weeks fllwing the start f a new prescriptin during the new treatment episde. 41

44 Denminatr: Patients diagnsed with biplar I disrder and at least ne filled prescriptin fr Lithium within fur mnths fllwing the start f a new treatment episde Patient chrts: Patients with a diagnsis f biplar I disrder Definitins: New Treatment Episde: See the Key Definitins Dcument Lithium can be identified by any prescriptin with a VA Drug Class Cde f CN750 (Lithium Salts) The date f the first prescriptin fr lithium fllwing the start f the new treatment episde begins the clck fr serum drug level mnitring in the apprpriate timeframe (12 weeks) If the new treatment episde begins in the inpatient setting, the date f the first filled prescriptin fllwing discharge starts the clck fr serum drug level mnitring in the apprpriate timeframe (12 weeks) Serum drug level mnitring: Defined as ne r mre lab tests (frm the DSS Clinical NDE; TESTNAME = 0004 ) in the 12 weeks fllwing the date that the first lithium prescriptin was filled Strength f Evidence: Grade I Feasibility/Data Cllectin Issues: Nne. Updates: Nne. 42

45 Perfrmance Measure Technical Dcumentatin Mdule: Biplar I Disrder Indicatr Statement: Prprtin f selected biplar I disrder patients treated with md stabilizer medicatins Indicatr number: B Executive Summary: This indicatr is based n STABLE perfrmance measure 6, Percent f patients with Biplar I disrder with depressive symptms with evidence f use f a md stabilizing r antimanic agent during the first 12 weeks f pharmactherapy treatment. The STABLE indicatr differs frm this specificatin in that it excludes frm the denminatr ppulatin thse patients fr whm an antimanic agent is cntraindicated r refused by the patient as dcumented in the chart. The American Psychiatric Assciatin (APA) guidelines supprt this measure, and state that the firstline f pharmaclgical treatment fr biplar I episdes, bth manic and depressive, includes the use f md stabilizers. Similarly, Smith et. al. (2007) review randmized cntrlled trials and find that md stabilizers were cnsistently effective at preventing relapse. A mdified versin f this indicatr is an industry standard, as it was apprved by NQF when STABLE included additinal specificatins relating t medical recrds review, such as allwing fr situatins when md stabilizing medicatin was nt clinically indicated r nt prescribed fr medical reasns. While md stabilizers have been clinically shwn t be effective at preventing relapse amng patients with biplar I disrder, we cannt accunt fr medicatin refusals r cntraindicatins in this analysis. This indicatr addresses the fllwing IOM dmain: effectiveness. References: Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Smith LA, Crnelius V, Warnck A, Bell A, Yung AH. Effectiveness f md stabilizers and antipsychtics in the maintenance phase f biplar disrder: a systematic review f randmized cntrlled trials. Biplar Disrder June 9(4): STABLE Perfrmance Measures, published nline at Accessed Fall 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: a) Patients prescribed a md stabilizer fr 12 weeks fllwing the start f a new treatment episde b) Patients prescribed a md stabilizer fr less than 12 weeks fllwing the start f a new treatment episde c) Patients with n filled prescriptin fr a md-stabilizing agent during the 12 weeks fllwing the start f a new treatment episde 43

46 Denminatr: All patients with biplar I disrder in a new treatment episde Patient chrts: Patients with biplar I disrder diagnsis. Definitins: New Treatment Episde: See the Key Definitins Dcument If the new treatment episde begins in the inpatient setting, the start f a new treatment episde is defined as the admissin date If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid 12 weeks f md stabilizers: Defined as 60 r mre days supplied f a md stabilizer in the 12 weeks fllwing the date f the first filled prescriptin subsequent t the start f a new treatment episde If the new treatment episde begins in the inpatient setting, the patient is cnsidered t be fully cmpliant with their medicatins while in the hspital and s the number f days supplied shuld include the length f stay in the hspital that begins the new treatment episde (using the variable LS frm the Medical SAS Inpatient Dataset) The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Less than 12 weeks f md stabilizers: Defined as at least ne filled prescriptin but with less than 60 days supplied in the 12 weeks fllwing the date f the first filled prescriptin subsequent t the start f a new treatment episde N filled prescriptin: Defined as n filled prescriptins fr any md stabilizer within 12 weeks f the start f the new treatment episde Md Stabilizer: One r mre prescriptins filled fr a patient using the fllwing drug class and NDC cdes: CN400, Anticnvulsants (the fllwing drugs will be identified by NDC cdes rather than VA Drug Class Cde see the Key Definitins Dcument fr relevant NDC cdes) Valpric Acid Carbamazepine Oxcarbazepine Lamtrigine CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other CN750, Lithium Salts Strength f Evidence: Grade I Feasibility/Data Cllectin Issues: Data will be presented fr all md stabilizers and then by drug class cde Updates: Deleted references t investigatinal drugs in the definitin f md stabilizers. 44

47 Days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 45

48 Perfrmance Measure Technical Dcumentatin Mdule: Biplar I Disrder Indicatr Statement: Prprtin f patients with biplar I disrder treated with md stabilizer medicatins during the curse f biplar I disrder treatment Indicatr number: C Executive Summary: This indicatr is reprted in CQAIMH and is based n the STABLE perfrmance measure 6, and the American Psychiatric Assciatin (APA) guidelines, which state that the first-line f pharmaclgical treatment fr the acute and maintenance phases f manic and depressive biplar episdes includes the use f md stabilizers. Similarly, Smith et. al. (2007) review randmized cntrl trials and find that md stabilizers were cnsistently effective at preventing relapse. While md stabilizers have been clinically shwn t be effective at preventing relapse amng patients with biplar disrder, we cannt accunt fr medicatin refusals r cntraindicatins in this analysis. Fr this reasn, this indicatr will be used fr descriptive purpses nly. This indicatr addresses the fllwing IOM dmain: effectiveness References: Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Smith LA, Crnelius V, Warnck A, Bell A, Yung AH. Effectiveness f md stabilizers and antipsychtics in the maintenance phase f biplar disrder: a systematic review f randmized cntrlled trials. Biplar Disrder June 9(4): STABLE Perfrmance Measures, published nline at Accessed Fall 2007 Numeratr: Patients included in the denminatr with evidence f a) 12 mnths f any md-stabilizing medicatin b) Any use f a md-stabilizing agent during the study perid c) N filled prescriptin fr a md stabilizer Denminatr: All patients with biplar I disrder Patient chrts: Patients with biplar I disrder diagnsis. Definitins: 12 mnths f md stabilizer medicatin: Defined as at least 300 days f the medicatin supplied during a 12-mnth perid fllwing the date f the first filled prescriptin during the study perid. The 300 days f medicatin shuld be sequential and shuld nt include simultaneus use f medicatins ver a shrter perid f time. 46

49 Any use f a md stabilizer: Defined as at least ne filled prescriptin fr a md stabilizer during the study perid N md stabilizer: Defined as n filled prescriptins fr a md stabilizer during the study perid Md Stabilizer: One r mre prescriptins filled fr a patient using the fllwing drug class and NDC cdes: CN400, Anticnvulsants (the fllwing drugs will be identified by NDC cdes rather than VA Drug Class Cde see the Key Definitins Dcument fr relevant NDC cdes) Valpric Acid Carbamazepine Oxcarbazepine Lamtrigine CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other CN750, Lithium Salts Strength f Evidence: Grade I Feasibility/Data Cllectin Issues: Data will be presented fr all md stabilizers and then by drug class cde We d nt include gabapentin and tpiramate in the list f md stabilizers that qualify, due t the limitatins f their evidence base Updates: The definitin f 12 mnths f md stabilizer medicatin shuld cnsider 300 cnsecutive days f medicatin prescribed rather than the sum ttal f all medicatin days. Fr example, we wuld include 300 ttal days f medicatin, regardless f whether they are the same medicatin r nt as lng as they are prescribed sequentially. If tw drug prescriptins verlap and the ttal number f days supplied equals 300 but is administered ver a shrter perid f time, we wuld nt cunt the patient as having 300 days f the medicatin supplied. We excluded investigatinal drugs frm the definitin f md stabilizers. 47

50 Perfrmance Measure Technical Dcumentatin Mdule: Biplar I Disrder Indicatr Statement: Prprtin f patients with biplar I disrder wh receive antidepressant treatment withut cncurrent antipsychtic treatment r ther md stabilizers Indicatr number: D Executive Summary: This indicatr is based n a STABLE perfrmance measure number 7 Avidance f antidepressant mntherapy in BDI. The STABLE indicatr differs frm this specificatin in that it excludes frm the denminatr ppulatin thse patients fr whm an additinal biplar I disrder pharmactherapy (lithium, anticnvulsant agent, antipsychtic) is cntraindicated r refused by the patient as dcumented in the chart. The STABLE indicatr als lks nly at the first 12 weeks f pharmactherapy treatment (numeratr a). The American Psychiatric Assciatin (APA) guidelines supprt this measure, stating that antidepressant mntherapy is nt recmmended fr patients with biplar I disrder. Furthermre, Suppes et. al. (2005) fr the Texas Implementatin f Medicatin Algrithms prject cnclude that, due t the risks f mania inductin and cycle acceleratin, antidepressant mntherapy is nt recmmended an apprpriate maintenance treatment fr patients with biplar disrder I, mst recent episde depressed. We cannt accunt fr patient refusals f additinal pharmactherapy r cntraindicatins t additinal pharmactherapy in this analysis. This indicatr addresses the fllwing IOM dmain: effectiveness and safety. References: Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Suppes T, Dennehy E, Hirschfeld R, Altshuler L, Bwden D, Calabrese J, Ketter T, Sachs G, Swann A, The Texas Implementatin f Medicatin Algrithms: Update t the Algrithms fr Treatment f Biplar I Disrder, J Clin Psychiatry 2005; 66: STABLE Perfrmance Measures, published nline at Accessed Fall 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: Patients wh receive nly antidepressant mntherapy a) In a 12 week perid fllwing the start f a new treatment episde b) During the study perid fr all patients Denminatr: a) All patients with biplar I disrder in a new treatment episde b) All patients with biplar I disrder during the study perid Patient chrts: Patients with biplar I disrder diagnsis 48

51 Definitins: New Treatment Episde: See the Key Definitins Dcument Antidepressant mntherapy in a new treatment episde: Defined as ne r mre prescriptins fr an antidepressant filled in the 12 weeks fllwing the start f a new treatment episde with n evidence f filled prescriptins fr any antipsychtics r ther md stabilizers during the same time perid Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument, and frm the definitin f an inpatient new treatment episde as defined in biplar B. ). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid Antidepressant mntherapy in the study perid: Defined as ne r mre prescriptins fr an antidepressant filled during the study perid with n evidence f filled prescriptins fr any antipsychtics r ther md stabilizers during the same time perid Antidepressant Medicatins: Patients with ne r mre filled prescriptins fr antidepressants during the specified time perid, defined by the fllwing drug class cdes: CN 600: Antidepressants CN 601: Tricyclic antidepressants CN 602: Mnamine Oxidase Inhibitr Antidepressants CN 609: Antidepressants, ther Antipsychtic Medicatins: Patients with ne r mre filled prescriptins fr antidepressants during the specified time perid, defined by the fllwing drug class cdes: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Md Stabilizers: Patients with ne r mre filled prescriptins fr antidepressants during the specified time perid, defined by the fllwing drug class cdes: CN750: Lithium salts Valpric acid, Carbamazepine, Lamtrigine, and Oxcarbazepine: see Appendix A f the Key Definitins Dcument fr assciated NDC cdes. Strength f Evidence: Grade I Feasibility/Data Cllectin Issues: Nne. Updates: We excluded investigatinal drugs frm the definitin f antipsychtic medicatins. 49

52 Perfrmance Measure Technical Dcumentatin Mdule: Biplar I Disrder Indicatr Statement: Prprtin f patients with biplar I disrder with an apprpriate frequency f visits with a licensed prescribing prvider r licensed mental health prescribing prvider Indicatr number: E Executive Summary: This indicatr is based n clinical expert recmmendatins supprted by the VA s Clinical Practice Guidelines (CPG). The frequency f visits during maintenance-phase treatment is nt defined by the clinical practice guidelines, but instead we have used the frequency f visits fr similar diagnses suggested by NCQA as a guideline. The American Psychiatric Assciatin des nt recmmend a specific frequency f visits, but ntes that establishing and maintaining a supprtive and therapeutic relatinship [between patient and physician] is critical t the prper understanding and management f an individual patient, and, the identificatin f early symptms f relapse is facilitated by the presence f a cnsistent relatinship between the psychiatrist and the patient. Suppes et. al. (2005), in the Texas Implementatin f Medicatin Algrithms, nte that in the maintenance phase f treatment, patients shuld be seen every tw t three mnths. The VA Clinical Practice Guidelines d nt prvide any specific recmmendatins regarding frequency f visits during the maintenance phase fr the treatment f psychsis. The VA CPG includes Biplar I Disrder as ne f the many disrders under the Psychses guidelines. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. This indicatr addresses the fllwing IOM dmain: effectiveness and safety. References: Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Natinal Cmmittee fr Quality Assurance (NCQA). The state f health care quality 2005: industry trends and analysis. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA); Suppes T, Dennehy E, Hirschfeld R, Altshuler L, Bwden D, Calabrese J, Ketter T, Sachs G, Swann A, The Texas Implementatin f Medicatin Algrithms: Update t the Algrithms fr Treatment f Biplar I Disrder, J Clin Psychiatry 2005; 66: Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Numeratr: Thse patients in the denminatr with at least ne visit per quarter (fur visits per year) during the study perid: a) With a licensed prescribing prvider b) With any mental health licensed prescribing prvider Denminatr: Patients diagnsed with biplar I disrder 50

53 Patient chrts: Patients with a biplar I disrder chrt diagnsis Definitins: Licensed Prescribing Prvider: See the Key Definitins Dcument Licensed Mental Health Prescribing Prvider: See the Key Definitins Dcument Inclusin criteria fr denminatr: If the patient had at least ne diagnsis-related visit (primary r secndary using Table 1B frm the Key Definitins Dcument) in the furth quarter f FY06, begin cunting visits fr the numeratr with the first quarter f FY07. If the patient des nt have a relevant visit in the last quarter f FY06, begin with the first visit in FY07 and cunt frward fr fur quarters. Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Data may be presented descriptively as frequency cunts f the number f visits per quarter in additin t thse patients meeting the threshld f ne visit per quarter Updates: Nne. 51

54 POSTTRAUMATIC STRESS DISORDER Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder Indicatr Statement: Prprtin f patients receiving any Specialized Intensive PTSD Prgrams (SIPP) Indicatr number: A Executive Summary: This indicatr is based n wrk by Rsenheck et. al. (2006), which states that the availability f specialized PTSD prgrams is an imprtant indicatr f the quality f health care prvided by the VA, and thus this indicatr will prvide descriptive evidence f the utilizatin f SIPP by veterans. The APA Clinical Practice guidelines als supprt the use f specialized therapies that use a range f psychtherapy, pharmactherapy, and ther interventins. Hwever, in a study f VA inpatient treatment facilities fr PTSD, Fntana and Rsenheck (1997) find that Veterans in the shrt-stay PTSD units and in the general psychiatric units shwed significantly mre imprvement during fllw-up than veterans in the lng stay PTSD units, hwever they d nt reprt the results f general and shrt-stay units separately. Of curse, patients being referred t lng term PTSD care are likely mre cmplicated cases, but nevertheless, the evidence is unclear as t the degree f benefit frm lngterm SIPP prgrams. The VA Clinical Practice Guidelines supprt the use f specialized PTSD prgrams where indicated. This indicatr addresses the fllwing IOM dmains: effectiveness. References: Practice Guideline fr the Treatment f Patients with Acute Stress Disrder and Psttraumatic Stress Disrder (2004); American Psychiatric Assciatin Fntana, Rsenheck, Spencer, Gray, The Lng Jurney Hme XIV: Treatment f Psttraumatic Stress Disrder in the Department f Veterans Affairs: Fiscal Year 2005 Service Delivery and Perfrmance. March 2006 Numeratr: Number f patients receiving any SIPP care a) In the 60 days fllwing the start f a new treatment episde b) During the study perid Denminatr: Patients diagnsed with PTSD a) In a new treatment episde b) All patients Patient chrts: Patients with chrt diagnsis f PTSD Definitins: New Treatment Episde: See Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f admissin t the hspital If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related 52

55 (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid SIPP care defined as the presence f tw r mre specialty PTSD utpatient encunters r ne r mre specialty PTSD inpatient admissins Specialty PTSD utpatient care: Defined as tw r mre diagnsis-related encunters (primary r secndary frm Table 1B in the Key Definitins Dcument) frm the fllwing stp cdes r bed sectins: Stp cdes: 542, 516, 562, 524, 589, 540, 561, 525, 519, 580, 581, Bed sectins: 26 (PTSD Residential Rehabilitatin Prgrams - PRRPs), 88 (PTSD Dmiciliary Units - PTSD Dm), 38 (PTSD CWT/TR) Specialty PTSD inpatient care: Defined as ne r mre diagnsis-related (primary diagnsis nly frm Table 1B in the Key Definitins Dcument) inpatient admissins usng the fllwing bed sectin cdes: Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Nne. Updates: Nne. 79 (Specialized Inpatient PTSD Units - SIPUSs) 91 (Evaluatin and Brief Treatment PTSD Units - EBTPUs) Nte: Fr patients wh begin a new treatment episde in the inpatient setting, specialty PTSD inpatient care cnsists f inpatient admissins that ccur after discharge frm the index admissin. 53

56 MAJOR DEPRESSIVE DISORDER Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder Indicatr Statement: Prprtin f selected MDD patients receiving apprpriate shrtterm antidepressant medicatin therapy Indicatr number: A Executive Summary: This indicatr is based n an indicatr cited by the Natinal Quality Measures Clearinghuse (als cited by CQAIMH) and develped by HEDIS (NCQA), in the three-part Antidepressant Medicatin Management (AMM) measures. The indicatr states that Early detectin and sustained interventin by primary care physicians and medical specialists can lead t increased use f apprpriate antidepressant treatment fr adults suffering frm depressive disrders. Many peple with a depressive illness d nt seek treatment r have difficulty staying n medicatin fr the necessary perids f time. Managed care rganizatins shuld examine the barriers that may be preventing patients frm receiving treatment fr depressive disrders fr the necessary duratin. Of particular imprtance is ensuring apprpriate fllw-up visits t imprve the effective use f antidepressant medicatins. The new treatment episde, which lasts thrugh the first 12 weeks f treatment, allws the clinician t mnitr drug respnse and assure a full remissin f symptms. Hwever, remissin may be fllwed by relapse unless a cntinuatin phase (4 t 9 mnths) is instituted. Finally, fr a select grup f patients with a majr depressive disrder, a maintenance phase must be adpted t prevent future recurrences f symptms and distress. Rst et. al. (2005), in a study f clinical utcmes fr depressin assciated with the AMM measures find that the HEDIS indicatr currently in use predicts a 23% imprvement in clinical utcmes in the brader ppulatin in need. Furthermre, As stated in the APA CPG, RCTs have established that acute respnse requires at least 4-6 weeks f treatment (Quitkin et al 1984). This measure is cnsistent with the VA Clinical Practice Guidelines fr the treatment f MDD, which state that a patient presenting with depressin shuld generally receive pharmactherapy with mderate t severe symptms, significant impairment f functining, and/r suicidal ideatin. The VA CPG suggests assessing the patients respnse t medicatin in six and twelve weeks. It is als cnsistent with the APA CPG (2002) which recmmends antidepressant pharmaclgical treatment with substantial clinical cnfidence (tp rating). This indicatr is a Grade I indicatr, supprted by RCT evidence, expert cnsensus and clinical evidence f its assciatin with imprved utcmes (Rst 2005). This indicatr addresses the fllwing IOM dmain: effectiveness. References: Kathryn Rst, L. Miriam Dickinsn, Jhn Frtney, Jhn Westfall, and Richard C. Hermann (2005). Clinical Imprvement Assciated with Cnfrmance t HEDIS- Based Depressin Care Ment Health Serv Res June ; 7(2): Natinal Cmmittee fr Quality Assurance (NCQA). The state f health care quality 2005: industry trends and analysis. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA);

57 Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Practice guideline fr the treatment f patients with majr depressive disrder, secnd editin. Am J Psychiatry Apr 2000 (supp);157:(4) Quitkin FM, Rabkin JG, Rss D, McGrath PJ: Duratin f antidepressant drug treatment: what is an adequate trial? Arch Gen Psychiatry 1984; 41: Numeratr: a) Thse patients in the denminatr prescribed an antidepressant fr 12 weeks fllwing the start f a new treatment episde b) Thse patients in the denminatr prescribed an antidepressant fr less than 12 weeks fllwing the start f a new treatment episde c) Thse patients with n filled prescriptin fr an antidepressant during the 12 weeks fllwing the start f a new treatment episde Denminatr: Patients diagnsed with MDD in a new treatment episde Patient chrts: Patients with chrt diagnsis f MDD Definitins: New Treatment Episde: See Key Definitins Dcument If the new treatment episde begins in the inpatient setting, the start f a new treatment episde is defined as the admissin date If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid 12 weeks f antidepressants: Defined as 84 r mre days supplied f an antidepressant in a 114 day perid beginning with the date f the first filled prescriptin fllwing the start f a new treatment episde If the new treatment episde begins in the inpatient setting, the patient is cnsidered t be fully cmpliant with their medicatins while in the hspital and s the number f days supplied shuld include the length f stay in the hspital that begins the new treatment episde (using the variable LS frm the Medical SAS Inpatient Dataset) The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Less than 12 weeks f antidepressants: Defined as at least ne filled prescriptin fr an antidepressant but with less than 84 days supplied in the 114 days fllwing the date f the first filled prescriptin subsequent t the start f a new treatment episde N filled prescriptin: Defined as n filled prescriptins fr any md stabilizer within 114 days f the start f the new treatment episde Antidepressant medicatin: prescriptins filled within 12 weeks f the start f the new treatment episde using the fllwing drug class cdes: CN600, Antidepressants CN601, Tricyclic Antidepressants 55

58 CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other Strength f Evidence: Grade III; this indicatr has been mdified frm its riginal specificatins in HEDIS based n its incmpatibility with ur definitin f a new treatment episde. Feasibility/Data Cllectin Issues: Length f antidepressant treatment will be used fr descriptive purpses nly. We can cnstruct the HEDIS measure f effective pharmaclgic treatment using numeratrs a and b: a/(a+b). This is the industry standard (adpted by NQF as indicatrs AMB5 12 weeks, AMB7 6 mnths) and we will measure it alng with the indicatr we have develped here. The three numeratrs represented in this indicatr are mutually exclusive and add up t 100%. In additin t cnstructing the HEDIS indicatr described abve, we will cnstruct this indicatr as a series f stacked bars s that each numeratr is reflected in a summary graphic. Updates: We have excluded investigatinal drugs frm the definitin f antidepressant medicatin. We have added additinal detail under the feasibility/data cllectin issues t reflect that this indicatr will be presented as bth the HEDIS indicatr cnstructin [a/(a+b)] and as stacked bars t incrprate all three numeratrs in data presentatin. We added a nte that the days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 56

59 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder Indicatr Statement: Effective cntinuatin phase pharmaclgic treatment fr MDD (AMM) Indicatr number: B Executive Summary: This indicatr is based n an indicatr cited by the Natinal Quality Measures Clearinghuse (als cited by CQAIMH) and develped by HEDIS (NCQA), in the three-part Antidepressant Medicatin Management (AMM) measures. The indicatr states, Depressive disrders can impair persnal, scial and family functining, decrease wrk prductivity, and increase the risk f suicide. Randmized clinical trials shw antidepressants t be efficacius fr treating majr depressin and preventing relapse. Hwever, antidepressants must be cntinued fr 4 t 9 mnths after initiatin t minimize the likelihd f relapse. Rst et. al. (2005), in a study f clinical utcmes fr depressin assciated with the AMM measures find that the HEDIS indicatr currently in use predicts a 23% imprvement in clinical utcmes in the brader ppulatin in need. This measure is cnsistent with the VA Clinical Practice Guidelines fr the treatment f MDD, which state that a patient presenting with depressin with mderate t severe symptms, significant impairment f functining, and/r suicidal ideatin shuld generally receive pharmactherapy. This indicatr addresses the fllwing IOM dmain: effectiveness. References: Kathryn Rst, L. Miriam Dickinsn, Jhn Frtney, Jhn Westfall, and Richard C. Hermann (2005). Clinical Imprvement Assciated with Cnfrmance t HEDIS- Based Depressin Care Ment Health Serv Res June ; 7(2): Natinal Cmmittee fr Quality Assurance (NCQA). The state f health care quality 2005: industry trends and analysis. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA); Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Practice guideline fr the treatment f patients with majr depressive disrder, secnd editin. Am J Psychiatry Apr 2000 (supp);157:(4) Numeratr: a) Thse patients in the denminatr prescribed an antidepressant fr 180 days fllwing the start f a new treatment episde b) Thse patients in the denminatr prescribed an antidepressant fr less than 180 days fllwing the start f a new treatment episde c) Thse patients with n filled prescriptin fr an antidepressant during the 180 days fllwing the start f a new treatment episde Denminatr: Patients diagnsed with MDD in a new treatment episde Patient chrts: Patients with chrt diagnsis f MDD 57

60 Definitins: New Treatment Episde: See Key Definitins Dcument Antidepressant medicatin: At least ne prescriptin filled using the fllwing drug class cdes: CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other 180 days f antidepressants: Defined as 180 r mre days supplied f an antidepressant in a 231 day perid beginning with the date f the first filled prescriptin fllwing the start f a new treatment episde If the new treatment episde begins in the inpatient setting, the patient is cnsidered t be fully cmpliant with their medicatins while in the hspital and s the number f days supplied shuld include the length f stay in the hspital that begins the new treatment episde (using the variable LS frm the Medical SAS Inpatient Dataset) The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Strength f Evidence: Grade I Feasibility/Data Cllectin Issues: Nne. Updates: We have excluded investigatinal drugs frm the definitin f antidepressant medicatins. We added a nte that the days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 58

61 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Prprtin f all patients with MDD diagnsis wh are receiving lng-term treatment with antipsychtics Indicatr Number: C Executive Summary: The fllwing indicatr is based n a number f indicatrs develped acrss rganizatins and surces, all f which supprt the avidance f plypharmacy and the avidance f antipsychtic use fr nn-psychtic cnditins. The dcumentatin fr this indicatr cmes frm a measure prpsed by American Managed Behaviral Healthcare Assciatin (AMBHA), which was riginally nt restricted nly t patients with a diagnsis f majr depressin. The current indicatr has been mdified accrdingly. The riginal title f the AMBHA-prpsed indicatr was Antipsychtic Use fr Nn-Psychtic Cnditins. AMBHA prvides the fllwing ratinale: Antipsychtic meds are effective in the treatment f psychtic symptms assciated w/ schizphrenia, affective disrders and ther cnditins. Over the past 2 decades there has been cncern abut use f these agents utside evidence-based indicatins. Antipsychtic drugs, particularly traditinal (nn-atypical) agents, have significant rates f disabling neurlgic side effects including tardive dyskinesia, extrapyramidal symptms, and cgnitive impairment. Observatinal studies have dcumented extensive antipsychtic use in ppulatins such as aggressive children and adlescents, elderly with behaviral dyscntrl, learning disabled individuals, and individuals with autism r ther pervasive develpmental disrders. Further research is needed n the efficacy and risks f antipsychtic drugs in these pps, and n the risk benefit rati f the newer, atypical agents. One study fund that decreasing use f antipsychtic drugs amng elderly nursing hme residents was assciated with better functining. This measure is part f a set f measures prpsed fr testing and has nt been adpted by the develping rganizatin. There is, hwever, preliminary evidence supprting the use f atypical antipsychtics, particularly Aripiprazle, t augment antidepressant pharmactherapy fr individuals with MDD (Philips 2008). The evidence in favr f this practice is limited. Because f the cntrversy surrunding this practice, we will use this indicatr as a descriptive indicatin f practice variatin. This indicatr addresses the fllwing IOM dmains: safety and effectiveness Numeratr: The number f patients frm the denminatr whse medicine regimen includes antipsychtic use fr lnger than 3 mnths during the study perid Denminatr: Patients with MDD diagnsis fr whm there is n diagnsis f psychsis and n diagnsis f dementia Patient chrts: Patients with MDD diagnsis Definitins: Psychsis diagnsis: Exclude frm the denminatr any patient wh has ne r mre utpatient encunters r any inpatient admissins with a primary diagnsis f psychsis, defined by the fllwing ICD-9 cdes: Paranid state, simple 59

62 297.1 Delusinal disrder Paraphrenia Shared psychtic disrder Other specified paranid states Unspecified paranid state Depressive type psychsis Excitative type psychsis Reactive cnfusin Acute paranid reactin Psychgenic paranid psychsis Other and unspecified reactive psychsis Unspecified psychsis Dementia diagnsis: Exclude frm the denminatr any patient wh has ne r mre utpatient encunters r an inpatient admissin with a primary r secndary diagnsis f dementia (ICD-9 cdes: 290.0, 290.1x, 290.2x, 290.3x, 290.4x, 291.2, 292.8, 294.1x, 294.9, 331.0, 436.xx) in the three mnths prir t and during the study perid. Antipsychtic use fr lnger than 3 mnths: Evidence f 90 r mre days supplied f an antipsychtic medicatin in a 120 day perid during the study perid using the fllwing VA Drug Class Cdes: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Patients with a ntatin r ICD-9 cde fr dementia r psychsis will be excluded frm the denminatr because antipsychtics may be apprpriate fr this ppulatin. There may be a bias in cding if there are fluctuatins in md, an antipsychtic may be apprpriate even if the patient is nt biplar. This indicatr is nt necessarily reflecting pr care. The days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. Updates: We have excluded investigatinal drugs frm the definitin f antipsychtic use. We added a nte that the days f medicatin shuld be sequential and shuld nt include simultaneus use f tw r mre qualifying medicatins ver a shrter perid f time. 60

63 SUBSTANCE USE DISORDER Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder Indicatr Statement: Prprtin f selected SUD patients with apprpriate initiatin f treatment fr alchl and ther drug dependence Indicatr number: A Executive Summary: This indicatr is based n the cnceptual mdel f the prcess f care fr AOD services develped by McCrry et. al., and adpted by the Washingtn Circle Plicy Grup in a paper by McCrry et al (2000), an rganizatin supprted by the Center fr Substance Abuse Treatment. The Washingtn Circle indicatrs have been adpted by the Natinal Cmmittee fr Quality Assurance, the Department f Veterans Affairs, and the state f Oklahma Department f Mental Health and Substance Abuse Services (Garnick et al 2007), and the Healthcare Effectiveness data & infrmatin set (HEDIS) Vl. 2. McCrry et. al. (2000) state that Studies indicate that nly a small fractin f the ppulatin with AOD disrders enters treatment. Identificatin f individuals with AOD disrders is an imprtant first step in the prcess f care, but ne that des nt rutinely lead t initiatin f treatment. Plans must als ensure that individuals with an AOD diagnsis initiate treatment Studies indicate that a lack f immediately available treatment services may als pse a barrier t treatment initiatin. Furthermre, Garnick et al (2007) find that bth initiatin and engagement f alchl and ther drug dependence treatment was assciated with decreased criminal activity in the year fllwing treatment. On the ther hand, Harris et al (2007) examined the assciatin between adherence t the Washingtn Circle indicatrs and effectiveness amng a veteran ppulatin. They fund that identificatin and engagement rates were unrelated t 7-mnth utcmes initiatin rates were nt assciated with imprvement in alchl cmpsite scres but were mdestly assciated with greater imprvements in ASI drug cmpsite scres This indicatr is als cnsistent with the VA Clinical Practice guidelines, which emphasizes that substance use diagnsed in primary care shuld be fllwed up in primary care r with a referral t specialty care, suggesting that. Recent evidence suggests that appraches emphasizing engagement with the patient ver lng perids f time, case management, and integratin f substance abuse treatment interventins with treatment fr the cexisting cnditins result in reduced substance use and assciated cmplicatins. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. In fact, the evidence linking this indicatr with imprved utcmes is mixed. Hwever the Washingtn Circle indicatrs have becme an industry standard fr the treatment f substance abuse disrder, endrsed by bth the Natinal Quality Frum in its 2007 cnsensus dcument fr the treatment f substance use disrder, and in the HEDIS 2006 indicatrs. This indicatr addresses the fllwing IOM dmain: effectiveness and timeliness 61

64 References: American Psychiatric Assciatin, Practice Guidelines fr the Treatment f Patients with Substance Use Disrders, August 2005 Brwn BS, et al: The functining f individuals n a drug treatment waiting list. Am J Drug Alchl Abuse 15: , Harris AH, Humphreys K, Finney JW (2007). Veterans Affairs facility perfrmance n Washingtn Circle indicatrs and casemix-adjusted effectiveness. J Subst Abuse Treat Dec;33(4): HEDIS 2006: Health Plan Emplyer Data and Infrmatin Set McCrry, F., Garnick, D., Bartlett, J., Ctter, F., & Chalk, M. (2000). Develping Perfrmance Measures fr Alchl and Other Drug Services in Managed Care Plans. Jint Cmmissin Jurnal n Quality Imprvement, 26 (11), Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Natinal Cmmittee fr Quality Assurance (NCQA). The state f health care quality 2005: industry trends and analysis. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA); p. Natinal Quality Frum (2007). Natinal Vluntary Cnsensus Standards fr the Treatment f Substance Use Cnditins: Evidence-Based Treatment Practices, A Cnsensus Reprt. Natinal Quality Frum, Washingtn D.C. Numeratr: Thse patients in the denminatr with apprpriate treatment initiatin Denminatr: a) SUD patients with a new treatment episde fr SUD, where the initiatin f the new treatment episde is with any prvider b) SUD patients with a new treatment episde fr SUD, where the initiatin f the new treatment episde is in specialty mental health care; c) SUD patients with a new treatment episde fr SUD, where the initiatin f the new treatment episde is nt in specialty mental health care Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins Dcument Fr this indicatr, we will nly include thse wh have a new treatment episde in the utpatient setting. First SUD visit with any prvider: Defined as the first diagnsis-related visit (primary r secndary using Table 1B frm the Key Definitins Dcument) fllwing the clean perid (5 mnth break in care). Nte: The Key Definitins Dcument defines the start f an utpatient new treatment episde as the first diagnsis-related utpatient visit with a primary diagnsis f SUD. We expand the definitin here t reflect visits where SUD is either the primary r the secndary diagnsis because 62

65 amng thse with a c-ccurring disrder, the assignment f SUD t the primary r secndary diagnsis placehlder may be arbitrary. First SUD visit in Specialty Mental Health Care: See the Key Definitins Dcument fr the definitin f specialty mental health care prviders in the utpatient setting; defined as the first diagnsis-related visit (primary r secndary using Table 1B frm the Key Definitins Dcument) with a specialty mental health prvider fllwing the clean perid (5 mnth break in care) First SUD visit utside f specialty mental health care: Defined as any diagnsisrelated visit (primary r secndary using Table 1B frm the Key Definitins Dcument) with a prvider nt therwise included in the definitin f a specialty mental health care prvider (as defined in the Key Definitins Dcument) fllwing the clean perid (5 mnth break in care) Treatment initiatin: defined as any diagnsis-related visit (primary diagnsis nly using Table 1B frm the Key Definitins Dcument) in the 14 days fllwing the start f the new treatment episde, nt including visits ccurring n the same day as the start f the NTE; if the patient is hspitalized within 14 days f the start f the new treatment episde, the admissin date is the start f treatment initiatin Exclude: emergency rm visits using stp cdes 101 and 102 Feasibility/Data Cllectin Issues: This indicatr mirrrs the perfrmance measure used by the Pal Alt VA. Only Denminatr (a) is prescribed by the HEDIS/Washingtn Circle indicatr. Denminatrs (b) and (c) were added by the prject team. Updates: Added additinal instructins t the definitin f treatment initiatin treatment initiatin includes any visits that fllw the start date f the NTE but cannt include visits that ccur n that start date. 63

66 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder Indicatr Statement: Fr selected SUD patients, mean time t initiatin f apprpriate fllw-up SUD treatment Indicatr number: B Executive Summary: This indicatr is derived frm SUD indicatr A, which was based n the cnceptual mdel f the prcess f care fr AOD services develped by the Washingtn Circle Plicy Grup in a paper by McCrry et al (2000), an rganizatin supprted by the Center fr Substance Abuse Treatment. The Washingtn Circle indicatrs have been adpted by the Natinal Cmmittee fr Quality Assurance, the Department f Veterans Affairs, and the state f Oklahma Department f Mental Health and Substance Abuse Services (Garnick et al 2007). McCrry states that Studies indicate that nly a small fractin f the ppulatin with AOD disrders enters treatment. Identificatin f individuals with AOD disrders is an imprtant first step in the prcess f care, but ne that des nt rutinely lead t initiatin f treatment. Plans must als ensure that individuals with an AOD diagnsis initiate treatment Studies indicate that a lack f immediately available treatment services may als pse a barrier t treatment initiatin. A study by Brwn et. al. fund that a majrity f individuals n a waiting list (52%) reprted that their interest in entering treatment had decreased since they had been placed n the list, indicating a negative assciatin between wait times and mtivatin t treatment. This indicatr is als cnsistent with the VA Clinical Practice guidelines, which emphasizes that substance use diagnsed in primary care shuld be fllwed up in primary care r with a referral t specialty care, suggesting that Recent evidence suggests that appraches emphasizing engagement with the patient ver lng perids f time, case management, and integratin f substance abuse treatment interventins with treatment fr the cexisting cnditins result in reduced substance use and assciated cmplicatins. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. In this case we have mdified the indicatr t be descriptive f the average number f days t treatment initiatin rather than a benchmark number f days, as in SUD A. This indicatr addresses the fllwing IOM dmain: effectiveness and timeliness References: American Psychiatric Assciatin, Practice Guidelines fr the Treatment f Patients with Substance Use Disrders, August 2005 Brwn BS, et al: The functining f individuals n a drug treatment waiting list. Am J Drug Alchl Abuse 15: , Harris AH, Humphreys K, Finney JW (2007). Veterans Affairs facility perfrmance n Washingtn Circle indicatrs and casemix-adjusted effectiveness. J Subst Abuse Treat Dec;33(4): McCrry, F., Garnick, D., Bartlett, J., Ctter, F., & Chalk, M. (2000). Develping Perfrmance Measures fr Alchl and Other Drug Services in Managed Care Plans. Jint Cmmissin Jurnal n Quality Imprvement, 26 (11), Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, 64

67 Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Numeratr: Fr thse in the denminatr, a) Patients with any fllw up in the 90 days fllwing the start f the new treatment episde b) Fr thse patients with fllw up within 90 days, number f days until first utpatient fllw-up visit Denminatr: Patients with an SUD diagnsis in a new treatment episde Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins Dcument Fr this indicatr, we will nly include thse wh have a new treatment episde in the utpatient setting. Start f a New Treatment Episde (utpatient): Defined as the first diagnsisrelated visit (primary r secndary using Table 1B frm the Key Definitins Dcument) fllwing the clean perid (5 mnth break in care) Nte: The Key Definitins Dcument defines the start f an utpatient new treatment episde as the first diagnsis-related utpatient visit with a primary diagnsis f SUD. We expand the definitin here t reflect visits where SUD is either the primary r the secndary diagnsis because amng thse with a c-ccurring disrder, the assignment f SUD t the primary r secndary diagnsis placehlder may be arbitrary. Fllw-up care [Initiatin f AOD treatment] (numeratr a): Where patient starts new treatment episde in the utpatient setting: defined as any diagnsis-related visit (primary diagnsis using Table 1B frm the Key Definitins Dcument) in the 90 days fllwing the start f the new treatment episde; Exclude: emergency rm visits using stp cdes 101 and 102 Days until first fllw-up visit (numeratr b): defined as the difference between the date f the start f a new treatment episde and the date f the first fllw-up visit as defined fr numeratr a EXCLUDE patients wh d nt pass numeratr a Feasibility/Data Cllectin Issues: This indicatr may catch access as ppsed t perceived need Updates: Nne. 65

68 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder Indicatr Statement: Prprtin f selected SUD patients wh engage in timely treatment fr alchl and ther drug dependence Indicatr number: C Executive Summary: This indicatr is based n the cnceptual mdel f the prcess f care fr AOD services develped by the Washingtn Circle Plicy Grup in a paper by McCrry et al (2000), an rganizatin supprted by the Center fr Substance Abuse Treatment. The Washingtn Circle indicatrs have been adpted by the Natinal Cmmittee fr Quality Assurance, the Department f Veterans Affairs, and the state f Oklahma Department f Mental Health and Substance Abuse Services (Garnick et al 2007), and the Healthcare Effectiveness data & infrmatin set (HEDIS) Vl. 2. McCrry states that A review f length f stay studies fund that the length f time in treatment is related t pst-treatment reductin in drug use, reduced criminal activity, and imprved emplyment status. Studies f alchl-dependent clients have shwn that lnger stays in treatment and treatment cmpletin are assciated with greater reductin in alchl use, even after cntrlling fr severity at admissin. Thus, treatment engagement is psitively assciated with psitive treatment utcmes Given the psitive assciatin between retentin and treatment success, a plan s ability t engage clients in treatment is an imprtant intermediate measure that is clsely related t utcmes. This indicatr is als cnsistent with the VA Clinical Practice guideline fr the management f substance use disrder, which emphasizes that substance use diagnsed in primary care shuld be fllwed up in primary care r with a referral t specialty care. In an bservatinal study, Simpsn et al (1995) nted that client engagement in substance abuse treatment was assciated with better treatment utcmes, and Garnick et al (2007) find that bth initiatin and engagement f alchl and ther drug dependence treatment was assciated with decreased criminal activity in the year fllwing treatment. On the ther hand, Harris et al (2007) examined the assciatin between adherence t the Washingtn Circle indicatrs and effectiveness amng a veteran ppulatin. They fund that identificatin and engagement rates were unrelated t 7-mnth utcmes initiatin rates were nt assciated with imprvement in alchl cmpsite scres but were mdestly assciated with greater imprvements in ASI drug cmpsite scres. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. In fact, the evidence linking this indicatr with imprved utcmes is mixed. Hwever the Washingtn Circle indicatrs have becme an industry standard fr the treatment f substance abuse disrder, endrsed by bth the Natinal Quality Frum in its 2007 cnsensus dcument fr the treatment f substance use disrder, and in the HEDIS 2006 indicatrs. This indicatr addresses the fllwing IOM dmain: effectiveness and timeliness References: 66

69 Harris AH, Humphreys K, Finney JW (2007). Veterans Affairs facility perfrmance n Washingtn Circle indicatrs and casemix-adjusted effectiveness. J Subst Abuse Treat Dec;33(4): McCrry, F., Garnick, D., Bartlett, J., Ctter, F., & Chalk, M. (2000). Develping Perfrmance Measures fr Alchl and Other Drug Services in Managed Care Plans. Jint Cmmissin Jurnal n Quality Imprvement, 26 (11), Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Natinal Quality Frum (2007). Natinal Vluntary Cnsensus Standards fr the Treatment f Substance Use Cnditins: Evidence-Based Treatment Practices, A Cnsensus Reprt. Natinal Quality Frum, Washingtn D.C. Simpsn DD, Je GW, Rwan-Szal G, Greener J. Client engagement and change during drug abuse treatment. J Subst Abuse. 1995;7(1): Numeratr: Thse members in the denminatr wh within 30 days f the start f a new treatment episde have engaged with SUD treatment Denminatr: All patients with an SUD diagnsis in a new treatment episde Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins Dcument Start f a New Treatment Episde (utpatient): Defined as the first diagnsis-related visit (primary r secndary using Table 1B in the Key Definitins Dcument) fllwing the clean perid (5 mnth break in care) Nte: The Key Definitins Dcument defines the start f an utpatient new treatment episde as the first diagnsis-related utpatient visit with a primary diagnsis f SUD. We expand the definitin here t reflect visits where SUD is either the primary r the secndary diagnsis because amng thse with a c-ccurring disrder, the assignment f SUD t the primary r secndary diagnsis placehlder may be arbitrary. Start f a New Treatment Episde (inpatient): Defined as the date f a diagnsis-related inpatient admissin (primary diagnsis using Table 1B in the Key Definitins Dcument) Engagement f SUD treatment: Defined as tw r mre diagnsis-related utpatient encunters n separate days (primary diagnsis nly frm Table 1B in the Key Definitins Dcument) in the 30 days fllwing the start f a new treatment episde Fr patients wh start the new treatment episde in the inpatient setting, the 30 day fllw-up starts with the date f discharge frm the inpatient setting Feasibility/Data Cllectin Issues: This indicatr mirrrs the perfrmance measure used by the Pal Alt VA. 67

70 Updates: We have made explicit in ur definitin f engagement f SUD treatment that the tw encunters fllwing the start f a new treatment episde must be n separate days. 68

71 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder Indicatr Statement: Early discharge rates frm residential care fr Substance Use Disrder Indicatr number: D Executive Summary: This indicatr is based n findings frm Petersn et. al., wh find in a study f the determinants f readmissin in VA inpatient substance abuse prgrams that readmissin perfrmance in substance abuse treatment is psitively assciated with having fewer early discharges, and that patients wh drp ut f SAT early are likely t d s within the first week f treatment. In this study, prgrams that had mre patients discntinue treatment within ne week perfrmed mre prly in terms f a higher casemix-adjusted readmissin rate. The patients wh drp ut f these prgrams are nt likely t have received much f the intended treatment, and they may nt have adequately stabilized frm their brief stay. Je, Hubbard and Simpsn fund that retentin in methadne maintenance was assciated with mre experienced staff making the initial diagnsis and cnducting treatment planning, prviding mre frequent medical, psychlgical, and legal services early in treatment, and prviding a balanced cmbinatin f individual and grup cunseling. This indicatr is als supprted by the VA Clinical Practice Guidelines, which suggest that the prmtin f initial treatment engagement and retentin may lead t better substance use utcmes. This is a Grade III indicatr, supprted by clinical cnsensus and expert pinin rather than rbust clinical evidence. Fr this reasn, it will be a descriptive indicatr. This indicatr addresses the fllwing IOM dmain: effectiveness References: Petersn, Keith; Ralph Swindle, Ciaran Phibbs, Barbara Recine, Rudlph Ms, Determinants f Readmissin Fllwing Inpatient Substance Abuse Treatment: A Natinal Study f VA Prgrams, Medical Care, Vl 32, N. 6. (June 1994) Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Numeratr: a) Inpatient admissin in the denminatr where patient was discharged frm residential care fr SUD within ne week f admissin b) Ttal length f stay in days per related inpatient admissin fr patients in the denminatr discharged frm residential care fr SUD Denminatr: SUD-related inpatient admissins during the study perid fr patients with chrt diagnsis f SUD Patient chrts: Patients with SUD diagnsis Definitins: SUD-Related Residential Care: 69

72 All residential SUD admissins where the primary diagnsis is SUD (frm Table 1B in the Key Definitins Dcument) r, when SUD is the secndary diagnsis, the primary diagnsis is a mental health cnditin (ICD-9 cdes: 290.xx-319.xx) using the fllwing bed sectin cdes: 25, 26, 27, 37, 77, 85, 86, 87, 88, 89, 90 Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: This is a discharge-based indicatr and shuld include all inpatient discharges fr SUD patients Nte that this will include thse patients with c-ccurring disrders, and the subset f patients with c-ccurring disrders will be analyzed separately Updates: Nne. 70

73 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder Indicatr Statement: Duratin f piate agnist therapy fr selected SUD patients Indicatr number: E Executive Summary: This indicatr is based n the VA Clinical Practice Guidelines fr SUD, which state that OAT is inaccurately cnsidered by sme prviders t be a treatment f last recurse; hwever, evidence cnsistently shws that patients have better utcmes when maintained with an agnist than a placeb (Newman and Whitehall, 1979; Strain et al., 1993a; Strain et al., 1993b) r than when prvided lngterm detxificatin (Sees et al., 2000). Discharge frm OAT prgrams is generally fllwed by relapse and ther adverse utcmes (Gerstein et al., 1994; Magura & Rsenblum, in press). Unless there are legal r ther extenuating circumstances, (such as active duty in DD), OAT shuld be cnsidered fr any patient with a diagnsis f piid addictin. Fr patients wh previusly relapsed, re-treatment shuld be a cnsideratin. As part f the decisin prcess, it is imprtant t determine if apprpriate agnist dsing was utilized and whether there were psychscial barriers that culd be better addressed upn re-attempting OAT. The APA Clinical Practice Guidelines fr SUD state that, Numerus clinical trials have tested methadne fr the treatment f piid dependence...the number f studies examining methadne fr treating piid withdrawal is mre limited than the number examining methadne in maintenance treatment f piid dependence. Outcmes frm methadne withdrawal are generally pr, especially when cmpared with the success assciated with methadne maintenance treatment. Likewise, in the case f buprenrphine, Numerus randmized, duble-blind clinical trials have studied the efficacy and safety f sublingual buprenrphine fr the utpatient treatment f piid dependence, but buprenrphine has shwn similar utcmes t methadne in the treatment f piate withdrawal. This indicatr addresses the fllwing IOM dmain: Effectiveness References: American Psychiatric Assciatin, Practice Guidelines fr the Treatment f Patients with Substance Use Disrders, August 2005 Gerstein, D. R., Jhnsn, R. A., Harwd, H. J., et al. (1994). Evaluating recvery services: the Califrnia Drug and Alchl Treatment Assessment (CALDATA) general reprt. Califrnia Department f Drug and Alchl Prgrams, Sacrament. Magura, S., & Rsenblum, A. (in press). Leaving methadne treatment: lessns learned, lessn frgtten, lessns ignred. Mt. Sinai Jurnal f Medicine. Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Sees, K. L., Delucchi K. L., Massn, C., et al. (2000). Methadne maintenance versus 180-day psychscially enriched detxificatin fr treatment f piid 71

74 dependence: a randmized cntrlled trial. Jurnal f the American Medical Assciatin, 283 (10), Strain, E. C., Stitzer, M. L., Liebsn, I. A., et al. (1993a). Dse-respnse effects f methadne in the treatment f piid dependence. Annals f Internal Medicine, 119, Strain, E. C., Stitzer, M. I., Liebsn, I. A., et al. (1993b). Methadne dse and treatment utcme. Drug and Alchl Dependence, 33, Numeratr: Length (in days) f piate agnist treatment fr patients in the denminatr in the 12 mnths fllwing the start f treatment Denminatr: Veterans in the SUD chrt with piate dependence in a new treatment episde underging piate agnist treatment. Patient chrts: Patients with an SUD diagnsis Definitins: Opiate Dependence: Defined as the primary diagnsis (ICD-9 cde: , 304.7) n the first utpatient visit fllwing the start f the new treatment episde Opiate Agnist Treatment (Denminatr): Defined as having tw r mre encunters during the study perid with the 523 stp cde. Length f Opiate Agnist Treatment: Methadne: Number f days fr which patient has cnsecutive visits t the 523 stp cde, with cnsecutive visits defined as n mre than 3 skips between visits. Buprenrphine: Defined as days supplied f buprenrphine (see Appendix A f the Key Definitins Dcument fr assciated NDC cdes) in the 12 mnths fllwing the start f treatment Feasibility/Data Cllectin Issues: We will analyze the different piid agnists separately. Will nt be able t distinguish peple n these medicatins fr detxificatin versus maintenance. This will make interpretatin difficult, but the variatin in treatment length acrss VISNs is still f interest. Generally buprenrphine detxificatin is less than a week. Methadne detxificatin may be up t 6 mnths. Updates: Nne. 72

75 CROSS-CUTTING INDICATORS Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Prprtins f selected patients frm all chrts rutinely mnitred fr side effects f treatment with md stabilizer r anti-psychtic medicatins Indicatr number: A Executive Summary: This indicatr is based n an indicatr cited by the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) based n a study by Marcus et. al. (1999). The CQAIMH website states, Cntrlled studies have established the effectiveness f md stabilizers fr biplar I disrder and ther cnditins, hwever, they have als identified ptential fr adverse drug effects n specific rgan systems. [Md stabilizers] can cause thrmbcytpenia, hypthyridism and in rare cases hepatitis and pancreatitis. Because f the ptential fr these effects, practice guidelines recmmend annual bld tests t mnitr bld cell cunts and liver enzyme levels. Kilburne et. al. (2007) supprt this, stating that md stabilizers are assciated with increased risk f effects n liver functin, and thyrid and kidney abnrmalities. The APA Clinical Practice Guidelines fr Biplar I Disrder nte that bld cunt and liver functin tests shuld be perfrmed every three mnths n patients receiving treatment with carbamazepine, and renal and thyrid functin testing shuld take place every 6 mnths t 1 year in patients underging lithium treatment. Fr antipsychtics, the APA CPG fr Schizphrenia state, Mnitring f side effects based n the side effect prfile f the prescribed antipsychtic is warranted. During the stable phase f treatment it is imprtant t rutinely mnitr all patients treated with antipsychtics fr extrapyramidal side effects and the develpment f tardive dyskinesia [I]. Because f the risk f weight gain assciated with many antipsychtics, regular measurement f weight and bdy mass index (BMI) is recmmended [I]. Rutine mnitring fr besity-related health prblems (e.g., high bld pressure, lipid abnrmalities, and clinical symptms f diabetes) and cnsideratin f apprpriate interventins are recmmended particularly fr patients with BMI in the verweight and bese ranges [II]. Clinicians may cnsider regular mnitring f fasting glucse r hemglbin A1c levels t detect emerging diabetes, since patients ften have multiple risk factrs fr diabetes, especially patients with besity [I]. In additin, the VA CPG fr psychses recmmends baseline assessment f weight/bmi, glycemic cntrl, and lipids. Further, VA Clinical Practice Guidelines fr Psychses state that Patients n an antipsychtic shuld be assessed n a regular basis fr their respnse t an antipsychtic and the presence f side effects. Knwledge f the mst cmmn side effects f the agent(s) they are receiving shuld guide this evaluatin. There is n VA CPG particularly related t biplar I disrder and thus the use f md stabilizers. While there is n rbust evidence directly linking side effect mnitring with imprved utcmes (perhaps because side effect mnitring and effective side effect management may imprve adherence; see Reid 1990 fr a meta analysis that suggests 73

76 that there is a link), side effect mnitring is crucial t guarantee the safety f the patient, and there are well-established guidelines that state that side effect mnitring is a critical cmpnent f pharmactherapy fr these medicatins. Hwever, this indicatr has nt been adpted as an industry standard in the evaluatin f care. This indicatr addresses the fllwing IOM dmains: safety. References: Kilburne AM, Pst EP, Bauer MS, Zeber JE, Cpeland LA, Gd CB, Pincus HA. Therapeutic drug and cardivascular disease risk mnitring in patients with biplar disrder, Jurnal f Affective Disrder, 2007 Sep;102(1-3): Marcus, Steven C, Mark Olfsn, Harld A. Pincus, Debrah A. Zarin, and David J. Kupfer. Therapeutic Drug Mnitring f Md Stabilizers in Medicaid Patients With Biplar Disrder, American Jurnal f Psychiatry, 156: , July 1999 Reid LD, Hrn JR, McKenna DA. Therapeutic drug mnitring reduces txic drug reactins: A meta-analysis, Therapeutic Drug Mnitr 1990, 12:72-78 Center fr Quality Assessment and Imprvement in Health Care, Quality indicatrs published nline at Accessed in Octber 2007 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Numeratr: Patients frm the denminatr wh have undergne the fllwing testing during the study perid: Drug Lithium Valpric acid Carbamazepine Any antipsychtic medicatins Test Thyrid and renal functin, serum drug level mnitring fr Lithium Bld cunt, liver and serum drug level mnitring fr Valpric Acid Bld cunt, liver and serum drug level mnitring fr Carbamazepine Glycemic cntrl, lipids Denminatr: Individuals within patient chrts with ne r mre filled prescriptin fr the same medicatin in at least three ut f fur quarters (during the study perid, fr the fllwing medicatins): 1. Lithium 2. Valpric acid 3. Carbamazepine 4. Any antipsychtic medicatins Patient chrts: All patient chrts 74

77 Definitins: Md stabilizers: Defined as at least ne prescriptin filled in each quarter fr at least three quarters f the study perid (any three quarters they d nt need t be cntinuus): Lithium: Any prescriptins filled in the inpatient r utpatient setting using the VA Drug Class Cde CN750 Valpric Acid and Carbamazepine: Any prescriptins filled in the inpatient r utpatient setting (see Appendix A f the Key Definitins Dcument fr assciated NDC cdes). Any antipsychtic medicatins: Any prescriptins filled in the inpatient r utpatient setting using the fllwing VA Drug Class Cdes: CN700, CN701, CN709 Side effect mnitring: The fllwing cdes are derived frm the DSS Clinical Natinal Data Extracts fr labratry (LAB Extract): Bld cunt: TESTNAME cde = 0006 Liver test (Aspartate Transaminase AST; Transferase Alanine Amin ALT; Phsphatase Alkaline): Defined as ne r mre f these three tests during the 12 mnth perid (TESTNAME cde = 0009, 0045, 0048 ) Renal functin (Serum Creatinine): TESTNAME cde = 0031 Thyrid functin (TSH): Defined as at least ne f this test perfrmed during the 12 mnth perid (TESTNAME cde = 0024 ) Glycemic cntrl: Defined as at least ne f tw glucse tests r the hemglbin A1C test during the 12 mnth perid (TESTNAME [glucse] = 0010, 0057 ; OR TESTNAME [hemglbin A1C] = 0017 ) Lipids: Defined as at least tw f the fllwing fur tests during the 12 mnth perid (TESTNAME [LDLC] = 0027 ; [HDLC] = 0028 ; [ttal chlesterl] = 0029 ; [tryglicerides] = ( 0030 ) Serum drug level mnitring: TESTNAME (Carbamazepin) = 0016 ; TESTNAME (Lithium) = 0004 ; TESTNAME (Valpric acid) = 0015 Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Analyses can be cnsidered either at the persn-level r the drug-level t cnsider patients wh are n mre than ne f the drugs f interest. While this indicatr is nt an industry standard and thus will nt be cnsidered a benchmark f care, it has high face validity and is strngly endrsed. Updates: Definitins f medicatin prescriptins revised t include prescriptins filled in either the inpatient r utpatient setting. We crrected the lab test cde crrespnding t Phsphatase Alkaline. We mdified the drug test names in the numeratr t be mre specific abut the serum drug level mnitring required fr each drug. T pass this indicatr, the patient must have had each test perfrmed relevant t the drug they are taking. Having fewer than the full list f tests frm the list will nt be cnsidered passing fr this indicatr. 75

78 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Number f evaluatin and management visits with a prescribing prvider fllwing the start f a new treatment episde fr patients underging pharmactherapy Indicatr number: B Executive Summary: Biplar I and Schizphrenia: This indicatr is based n the VA s Clinical Practice Guidelines (VA CPG) fr Psychses. They state that patients shuld been seen every ne t tw weeks fr six weeks when patients have been prescribed secnd generatin antipsychtic medicatin ther than clzapine. After six t eight weeks, if there is nt an adequate respnse, r if there are significant side effects, these frequent visits will give the prescriber enugh infrmatin t make a decisin regarding a change in medicatin. SUD: The VA CPG fr the management f SUD in primary care encurages clse mnitring f patients underging pharmactherapy fr alchl and piid dependence. During initial treatment with piid agnist therapies, the VA CPG recmmends weekly mnitring fr piid use and mnthly evaluatins f bld levels. With regards t alchl dependence, the VA CPG ntes that mnitred naltrexne administratin significantly imprves cmpliance (Garbutt et al.,, 1999), stating that It is imprtant t mnitr the patient s clinical cnditin regularly. If the patient s drinking has wrsened r is unimprved frm baseline, alternative pharmactherapies shuld be cnsidered (e.g., disulfiram r pssibly a treatment fr cmrbid psychpathlgy). The Natinal Quality Frum, in their 2007 cnsensus reprt, als supprt frequent mnitring fr side effects, drug use, and medicatin respnse. Furthermre, the Center fr Substance Abuse Treatment, in their Treatment Imprvement Prtcl, emphasize the imprtance f clse mnitring by a physician during treatment with Naltrexne. F. Rtgers et al (1996), in a chapter titled Fstering Cmpliance with Pharmactherapy, nte that high rates f nncmpliance with pharmactherapy fr substance abuse can be amelirated with regular mnitring f medicatin cmpliance thrugh pill cunts r medicatin serum levels frequent cntact, and the prvisin f extensive supprt and encuragement t the patient and his r her family. MDD: This indicatr is a descriptive indicatr that will augment ur understanding f antidepressant medicatin management. It is based n an indicatr cited by the Natinal Quality Measures Clearinghuse and develped by HEDIS. It is the third indicatr in the three-part Antidepressant Medicatin Management measures. The indicatr states that Early detectin and sustained interventin by primary care physicians and medical specialists can lead t increased use f apprpriate antidepressant treatment fr adults suffering frm depressive disrders. Many peple with a depressive illness d nt seek treatment r have difficulty staying n medicatin fr the necessary perids f time. Managed care rganizatins shuld examine the barriers that may be preventing patients frm receiving treatment fr depressive disrders fr the necessary duratin. Of particular imprtance is ensuring apprpriate fllw-up visits t imprve the effective use f antidepressant medicatins The new treatment episde, which lasts thrugh the first 12 weeks f treatment, allws the clinician t mnitr drug respnse and assure a full remissin f symptms. Hwever, remissin may be fllwed by relapse unless a cntinuatin phase (4 t 9 mnths) is 76

79 instituted. Finally, fr a select grup f patients with a majr depressive disrder, a maintenance phase must be adpted t prevent future recurrences f symptms and distress. The APA CPG als addresses this issue: Patients wh have started taking an antidepressant medicatin shuld be carefully mnitred t assess their respnse t pharmactherapy as well as the emergence f side effects, clinical cnditin, and safety [I]. Factrs t cnsider in determining the frequency f patient mnitring include the severity f illness, the patient's cperatin with treatment, the availability f scial supprts, and the presence f cmrbid general medical prblems. Visits shuld als be frequent enugh t mnitr and address suicidality and t prmte treatment adherence. In practice, the frequency f mnitring during the acute phase f pharmactherapy can vary frm nce a week in rutine cases t multiple times per week in mre cmplex cases. PTSD: This indicatr is based upn a measure f cntinuity f care develped by Greenberg et. al. (2003), which was fund t be rbustly assciated with imprved PTSD utcmes. Regularity f care was defined as the number f mnths in the fur mnths fllwing a new treatment episde that the veteran had at least ne visit. These measures were particularly fund t be assciated with decreased prbability f drug and alchl abuse. Althugh this indicatr has substantial face validity and there are well-established guidelines that state that frequent prescriber mnitring is a critical cmpnent f pharmactherapy fr these medicatins, there is n rbust evidence linking frequency f evaluatin and management visits with a prescribing prvider during a new treatment episde with imprved utcmes. This indicatr addresses the fllwing IOM dmain: Safety and effectiveness. References: Center fr Substance Abuse Treatment (CSAT) (1998). Naltrexne and alchlism treatment. Treatment Imprvement Prtcl (TIP) Series, Number 28. DHHS Publicatin N. (SMA) Washingtn, DC: U.S. Gvernment Printing Office. Garbutt, J. C., West, S. L., Carey, T. S., et al. (1999). Pharmaclgical treatment f alchl dependence: a review f the evidence. Jurnal f the American Medical Assciatin, , Greenberg GA, Rsenheck RA, Fntana A (2003). Cntinuity f Care and Clinical Effectiveness: Treatment f Psttraumatic Stress Disrder in the Department f Veterans Affairs. The Jurnal f Behaviral Health Services and Research. Vlume 30, Issue 2. Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q- CPG/SUD-01 Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, 77

80 Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Natinal Cmmittee fr Quality Assurance (NCQA). The state f health care quality 2005: industry trends and analysis. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA); Natinal Quality Frum (2007). Natinal Vluntary Cnsensus Standards fr the Treatment f Substance Use Cnditins: Evidence-Based Treatment Practices, A Cnsensus Reprt. Natinal Quality Frum, Washingtn D.C. Petersn, Keith; Ralph Swindle, Ciaran Phibbs, Barbara Recine, Rudlph Ms, Determinants f Readmissin Fllwing Inpatient Substance Abuse Treatment: A Natinal Study f VA Prgrams, Medical Care, Vl 32, N. 6. (June 1994) Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement Practice guideline fr the treatment f patients with majr depressive disrder, secnd editin. Am J Psychiatry Apr 2000 (supp);157:(4) Practice Guideline fr the Treatment f Patients with Schizphrenia, Secnd Editin (February 2004); American Psychiatric Assciatin; Am J Psychiatry Treating Substance Abuse: Thery and Technique. Edited by F. Rtgers, D. S. Keller, and J. Mrgenstern. Guilfrd Press, New Yrk, 1996, 328 pp., ISBN Numeratr: Number f evaluatin and management visits by a licensed prescribing prvider fr patients in the denminatr: a) in the fur mnths fllwing a new treatment episde b) in the 12 mnths fllwing a new treatment episde Denminatr: Patients with a new treatment episde during the study perid wh have cntinuus treatment with a psychiatric medicatin a) fr at least fur mnths fllwing the start f a new treatment episde b) fr at least 12 mnths fllwing a new treatment episde Patient chrts: All patient chrts Definitins: New Treatment Episde: See the Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid. Evaluatin and management: Defined as the cunt f diagnsis-related (primary r secndary frm Table 1B in the Key Definitins Dcument) utpatient evaluatin and management encunters n separate days fllwing the start f the new treatment episde (index visit shuld nt be cunted) with a licensed prescribing prvider. Any encunter fr which ne f the fllwing CPT cdes are present with a crrespnding prvider cde fr a licensed prescribing prvider shuld be cunted: Office r Other Outpatient Facility: 78

81 Individual psychtherapy with medical evaluatin and management services 90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822,90824, 90827, Other evaluatin and management services: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, General ffice cnsultatin cdes: Pharmaclgic management, including prescriptin, use, and review f medicatin with n mre than minimal medical psychtherapy Licensed prescribing prvider: See the Key Definitins Dcument fr the relevant prvider cdes Cntinuus treatment with psychiatric medicatin (fur mnths): Defined as 90 r mre days supply f a psychiatric medicatin filled in the 120 days fllwing the start f a new treatment episde Cntinuus treatment with psychiatric medicatin (twelve mnths): Defined as 300 r mre days supply f a psychiatric medicatin filled in the 12 mnths fllwing the start f a new treatment episde Psychiatric medicatins: Drugs frm the fllwing VA Drug Class Cdes fund in VHA pharmacy prescriptin data (nte that piate agnist therapies are nt included in this analysis) AD100, Alchl Deterrents CN400, Anticnvulsants (the fllwing drugs will be identified by NDC cdes rather than VA Drug Class Cde see the Key Definitins Dcument fr relevant NDC cdes) Valpric Acid Carbamazepine Oxcarbazepine Lamtrigine CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other CN750, Lithium Salts Prazsin (See Appendix A f Key Definitins Dcument fr assciated NDC cdes) Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Nne. Updates: We emphasize that multiple encunters n the same day will be cunted within a single visit. The numeratr will reflect the number f separate days n which ne r mre E&M encunters ccurred that meet the apprpriate definitin. We nte that, althugh ur general definitin f psychtherapy has been mdified t exclude any encunters f 30 minutes r less, we will maintain psychtherapy E&M cdes fr encunters f 30 minutes r less. Medicatin management visits can ccur with r withut treatment and can be f any length. 79

82 We excluded investigatinal drugs frm the definitin f psychiatric medicatins. 80

83 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Prprtin f patients frm any chrt receiving any psychscial treatment r psychtherapeutic sessins in the utpatient setting Indicatr number: C Executive Summary: Biplar I: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins under a Biplar I diagnsis. The American Psychiatric Assciatin Clinical Practice Guidelines cite fur randmized studies that shw that psychscial interventins reduce recurrence f biplar symptms. Miklwitz et al (2007) in their large federally-funded STEP-BP study cnducted a randmized cntrlled trial f fifteen clinics, and fund that Intensive psychscial treatment as an adjunct t pharmactherapy was mre beneficial than brief treatment in enhancing stabilizatin frm biplar depressin. STABLE measure number 15, % f patients where apprpriate psychscial interventins are recmmended within 12 weeks f initiating treatment fr biplar disrder, is similar t this indicatr, and STABLE states in the ratinale statement that evidence-based psychscial interventins have been fund t imprve treatment adherence, reduce likelihd f recurrence and extend time t new episdes, and that many different types f psychscial interventins have been fund t be effective in achieving these utcmes. This indicatr will prvide descriptive data reflecting the American Psychiatric Assciatin s emphasis n psychscial interventins. The APA states, There are nw a range f specific psychtherapeutic interventins that have been shwn t be helpful when used in cmbinatin with pharmactherapy and psychiatric management fr treatment f biplar I disrder. The best-studied treatment appraches have been develped arund psych-educatinal, interpersnal, family, and cgnitive behavir therapies. Frmal studies have been cnducted fr these treatments, and additinal investigatins are underway. Further, psychdynamic and ther frms f therapy may be indicated fr sme patients. Schizphrenia: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins with a schizphrenia diagnsis. The American Psychiatric Assciatin als supprts this view, stating, as part f a cmprehensive treatment apprach, psychscial interventins can imprve the curse f schizphrenia when integrated with psychpharmaclgical treatments. These interventins can prvide additinal benefits fr patients in such areas as relapse preventin, imprved cping skills, better scial and vcatinal functining, and ability t functin mre independently. While pharmactherapy fcuses n symptm diminutin, psychscial interventins may prvide emtinal supprt and address particular deficits assciated with schizphrenia. The AHRQ-funded Schizphrenia Patient Outcmes Research Team (PORT) stated that fr mst persns, the cmbinatin f psychpharmaclgic and psychscial interventins imprves utcmes. The reprted that a number f psychscial treatments have demnstrated efficacy, and listed family interventins, SE, ACT, skills training, cgnitive behavirally riented psychtherapy and the tken ecnmy scial 81

84 learning interventin amng them (Lehman et al, 1998, updated 2004). Mjtabai et. al. prvided a cmprehensive review f the literature linking psychscial interventins t schizphrenia utcmes in cntrlled studies, cncluding ur results shw that psychscial treatments can play an imprtant rle in the cmprehensive management f schizphrenia nt nly t augment the effects f medicatins, but als t supplement these effects in areas where cnventinal medicatins alne are less effective (e.g., negative symptms) there is sme evidence that psychscial interventins may be mre effective in the mre chrnic stages f illness and, therefre, can play a mre prminent rle in the management f patients with chrnic schizphrenia. SUD: The American Psychiatric Assciatin Clinical Practice Guidelines state that Psychscial treatments are essential cmpnents f a cmprehensive treatment prgram Sustained mtivatin is required t frg the rewards f substance use, tlerate the discmfrts f early and prtracted withdrawal symptms, and gather the energy t avid relapse despite episdes f craving that can ccur thrughut a lifetime. Cping skills are required t manage and avid situatins that can place the individual at a high risk fr relapse. The APA cites extensive evidence fr the efficacy f psychscial interventins in patients with substance use disrders, summarizing: The majr psychtherapeutic treatments that have been studied in patients with substance use disrders are cgnitive-behaviral, behaviral, psychdynamic/interpersnal, and recvery- riented therapies. A grwing bdy f efficacy data frm cntrlled clinical trials suggests that psychtherapy is superir t cntrl cnditins as a treatment fr patients with a substance use disrder. Hwever, n particular type f psychtherapy has been fund t be cnsistently superir when cmpared with ther active psychtherapies fr treating substance use disrders. Even cmparatively brief psychtherapies appear t have durable effects amng patients with a substance use disrder. The Natinal Quality Frum, in its dcumentatin f evidence-based treatment practices, states that Evidence-based psychscial treatment interventins shuld be initiated fr all patients referred t specialty care treatment f SUDs. MDD: This indicatr is based n an indicatr cited by CQAIMH and develped by the APA, Treatment fr Mderate Depressin, which states that Majr depressive disrder is prevalent and disabling, ften accmpanied by impaired persnal, scial, ccupatinal and/r family functining. Research studies have fund that the disrder ges undetected r inadequately treated. Antidepressant medicatins and certain types f psychtherapy (e.g., cgnitive behaviral therapy, interpersnal therapy) have been shwn t be efficacius in the treatment f majr depressive disrder. The APA CPG fr schizphrenia als states: A specific, effective psychtherapy alne as an initial treatment mdality may be cnsidered fr patients with mild t mderate majr depressive disrder [II]. The cmbinatin f a specific effective psychtherapy and medicatin may be a useful initial treatment chice fr patients with psychscial issues, interpersnal prblems, r a cmrbid axis II disrder tgether with mderate t severe majr depressive disrder [I]. Cgnitive behaviral therapy and interpersnal therapy are the psychtherapeutic appraches that have the best dcumented efficacy in the literature fr the specific treatment f majr depressive disrder, althugh rigrus studies evaluating the efficacy f psychdynamic psychtherapy have nt been published [II]. Althugh there has been less study f the use f psychtherapy in the cntinuatin phase t prevent relapse, there is grwing evidence t supprt the use f a specific effective psychtherapy during the cntinuatin phase [I]. In general, the treatment that was effective in the acute and cntinuatin phases shuld be used in the maintenance phase [II]. 82

85 PTSD: This indicatr is based n findings by the Cmmittee n Treatment f Psttraumatic Stress Disrder, which states that the cmmittee finds that the evidence is sufficient t cnclude the efficacy f expsure therapies in the treatment f PTSD. Furthermre, Rsenberg et. al. (2001) find that A grwing bdy f evidence shws that well-delineated, theretically based interventins are effective in the treatment f PTSD Multiple cntrlled trials have shwn that the mst effective interventins fr PTSD are thse based n CBT appraches, including expsure therapy and cgnitive restructuring. Althugh there is fair t gd research evidence suggesting that Psychscial interventins are effective as adjuncts r mntherapy in the treatment f all five cnditins discussed abve, this indicatr des nt capture the type f PT ffered and it is met with just 1 PT sessin. Als nte that psychscial visits in this cntext is brader than psychscial rehabilitatin, which has a specific meaning within the VA. This indicatr addresses the fllwing IOM dmain: effectiveness. References: David J. Miklwitz, PhD; Michael W. Ott, PhD; Ellen Frank, PhD; Nreen A. Reilly- Harringtn, PhD; Stephen R. Wisniewski, PhD; Jane N. Kgan, PhD; Andrew A. Nierenberg, MD; Jseph R. Calabrese, MD; Lauren B. Marangell, MD; Laszl Gyulai, MD; Mak Araga, MS; Jdi M. Gnzalez, PhD; Edwin R. Shirley, PhD; Michael E. Thase, MD; Gary S. Sachs, MD (2007). Psychscial Treatments fr Biplar Depressin. Archives f General Psychiatry. 2007;64: Rbin B. Jarrett; Dlres Kraft; Jeanette Dyle; Barbara M. Fster; G. Greg Eaves; Paul C. Silver Preventing Recurrent Depressin Using Cgnitive Therapy With and Withut a Cntinuatin Phase: A Randmized Clinical Trial Arch Gen Psychiatry. 2001;58(4): Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 83

86 Mjtabai R, Nichlsn RA, Carpenter BN: Rle f psychscial treatments in management f schizphrenia: a meta-analytic review f cntrlled utcme studies. Schizphr Bull 1998; 24: Practice Guideline fr the Treatment f Patients with Biplar Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Numeratr: a) Patients in the denminatr (a) receiving any psychscial visits (individual r grup, includes psychtherapy) within fur mnths fllwing the start f a new treatment episde b) Patients in the denminatr (b) receiving any psychscial visits (individual r grup, includes psychtherapy) in the study perid. Denminatr: a) Individuals in all patient chrts in a new treatment episde b) Individuals in all patient chrts Patient chrts: All patient chrts Definitins: New Treatment Episde: See the Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid. Psychscial visits: Defined as ne r mre diagnsis-related (primary r secndary, based n Table 1.B in the Key Definitins Dcument) visits with the fllwing mental health stp cdes: Mental health stp cdes: All stp cdes beginning with 5, excluding 523, 533, 538, and 565 EXCLUDING thse visits with the fllwing CPT cdes: (Medicatin management withut psychtherapy), (ECT), and any encunters with CPT cdes that d nt begin with 9 r H Exclude the first visit which begins the new treatment episde if it meets the definitin fr psychscial visits Strength f Evidence: Grade III This is the level f evidence fr the indicatr as specified, since there is n evidence that any psychscial r psychtherapeutic sessins lead t imprved utcmes. Hwever, the evidence cited in the executive summary generally has a strength f evidence f Grade I. Feasibility/Data Cllectin Issues: While this indicatr is nt an industry standard and thus will nt be cnsidered a benchmark f care, it has high face validity. 84

87 A limitatin f this analysis is that psychscial visits that ccur in primary care, when nt cded with a crrespnding CPT cde, will be excluded. Updates: Nne. 85

88 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Amng thse with any psychscial visits r psychtherapeutic sessins, number f psychscial treatment r psychtherapeutic sessins per persn Indicatr number: D Executive Summary: Biplar I Disrder: This indicatr will prvide descriptive data reflecting the American Psychiatric Assciatin s emphasis n psychscial interventins. The APA states, There are nw a range f specific psychtherapeutic interventins that have been shwn t be helpful when used in cmbinatin with pharmactherapy and psychiatric management fr treatment f biplar I disrder. The best-studied treatment appraches have been develped arund psych-educatinal, interpersnal, family, and cgnitive behavir therapies. Frmal studies have been cnducted fr these treatments, and additinal investigatins are underway. Further, psychdynamic and ther frms f therapy may be indicated fr sme patients. They discuss several evaluatins shwing that brief interventins, between six t seven sessins, are assciated with imprved utcmes fr patients with biplar I disrder. The VA Clinical Practice Guidelines als emphasize the imprtance f therapy in reducing symptms, imprving self-esteem, and reducing cgnitive deficit. Schizphrenia: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins with a schizphrenia diagnsis. The American Psychiatric Assciatin als supprts this view, stating, as part f a cmprehensive treatment apprach, psychscial interventins can imprve the curse f schizphrenia when integrated with psychpharmaclgical treatments. These interventins can prvide additinal benefits fr patients in such areas as relapse preventin, imprved cping skills, better scial and vcatinal functining, and ability t functin mre independently. While pharmactherapy fcuses n symptm diminutin, psychscial interventins may prvide emtinal supprt and address particular deficits assciated with schizphrenia. The AHRQ-funded Schizphrenia Patient Outcmes Research Team (PORT) stated that fr mst persns, the cmbinatin f psychpharmaclgic and psychscial interventins imprves utcmes. The reprted that a number f psychscial treatments have demnstrated efficacy, and listed family interventins, SE, ACT, skills training, cgnitive behavirally riented psychtherapy and the tken ecnmy scial learning interventin amng them (Lehman et al, 1998, updated 2004). Mjtabai et. al. prvided a cmprehensive review f the literature linking psychscial interventins t schizphrenia utcmes in cntrlled studies, cncluding ur results shw that psychscial treatments can play an imprtant rle in the cmprehensive management f schizphrenia nt nly t augment the effects f medicatins, but als t supplement these effects in areas where cnventinal medicatins alne are less effective (e.g., negative symptms) there is sme evidence that psychscial interventins may be mre effective in the mre chrnic stages f illness and, therefre, can play a mre prminent rle in the management f patients with chrnic schizphrenia. SUD: The American Psychiatric Assciatin Clinical Practice Guidelines state that Psychscial treatments are essential cmpnents f a cmprehensive treatment 86

89 prgram Sustained mtivatin is required t frg the rewards f substance sue, tlerate the discmfrts f early and prtracted withdrawal symptms, and gather the energy t avid relapse despite episdes f craving that can ccur thrughut a lifetime. Cping skills are required t manage and avid situatins that can place the individual at a high risk fr relapse. The exact duratin f SUD behaviral interventins varies by the type f substance use and the type f interventin, but evidence shws that very shrt interventins (ne t fur sessins) can be effective in imprving utcmes fr alchl and cannabis dependence (Miller et al 2002, Cpeland et al 2001), hwever, lnger interventins are necessary in the treatment f piid and ccaine dependence (Wdy et al 1995, Carrll et al 1998). MDD: This indicatr is based n an indicatr cited by CQAIMH and develped by the APA, Treatment fr Mderate Depressin, which states that Majr depressive disrder is prevalent and disabling, ften accmpanied by impaired persnal, scial, ccupatinal and/r family functining. Research studies have fund that the disrder ges undetected r inadequately treated. Antidepressant medicatins and certain types f psychtherapy (e.g., cgnitive behaviral therapy, interpersnal therapy) have been shwn t be efficacius in the treatment f majr depressive disrder. The APA CPG fr schizphrenia als states: A specific, effective psychtherapy alne as an initial treatment mdality may be cnsidered fr patients with mild t mderate majr depressive disrder [II]. The cmbinatin f a specific effective psychtherapy and medicatin may be a useful initial treatment chice fr patients with psychscial issues, interpersnal prblems, r a cmrbid axis II disrder tgether with mderate t severe majr depressive disrder [I]. Cgnitive behaviral therapy and interpersnal therapy are the psychtherapeutic appraches that have the best dcumented efficacy in the literature fr the specific treatment f majr depressive disrder, althugh rigrus studies evaluating the efficacy f psychdynamic psychtherapy have nt been published [II]. Althugh there has been less study f the use f psychtherapy in the cntinuatin phase t prevent relapse, there is grwing evidence t supprt the use f a specific effective psychtherapy during the cntinuatin phase [I]. In general, the treatment that was effective in the acute and cntinuatin phases shuld be used in the maintenance phase [II]. PTSD: This indicatr is based n findings by the Cmmittee n Treatment f Psttraumatic Stress Disrder, which states that the cmmittee finds that the evidence is sufficient t cnclude the efficacy f expsure therapies in the treatment f PTSD. Furthermre, Rsenberg et. al. (2001) find that A grwing bdy f evidence shws that well-delineated, theretically based interventins are effective in the treatment f PTSD Multiple cntrlled trials have shwn that the mst effective interventins fr PTSD are thse based n CBT appraches, including expsure therapy and cgnitive restructuring. A meta-analysis by Bradley et al (2005) shwed that behaviral interventins fr PTSD were effective at a range f dses, hwever there have nt been enugh clinical trials t date t determine the differential efficacy f treatment at different dses. Althugh there is fair t gd research evidence suggesting that psychscial interventins are effective as adjuncts r mntherapy in the treatment f all five cnditins discussed abve, research is nt cnclusive regarding what cnstitutes an adequate dse f psychtherapy. Fr this reasn, this indicatr will prvide descriptive infrmatin nly abut mean/median dse f psychscial interventins fr each f the abve cnditins. Als nte that psychscial visits in this cntext is brader than 87

90 psychscial rehabilitatin, which has a specific meaning within the VA. This indicatr addresses the fllwing IOM dmain: effectiveness References: Bradley, Rebekah, Greene, Jamelle, Russ, Eric, Dutra, Lissa, Westen, Drew. A Multidimensinal Meta-Analysis f Psychtherapy fr PTSD. Am J Psychiatry : Carrll KM, Nich C, Ball SA, McCance E, Runsaville BJ: Treatment f ccaine and alchl dependence with psychtherapy and disulfiram. Addictin 1998; 93: Cpeland J, Swift W, Rffman R, Stephens R: A randmized cntrlled trial f brief cgnitive-behaviral interventins fr cannabis use disrder. J Subst Abuse Treat 2001; 21:55 64 David J. Miklwitz, PhD; Michael W. Ott, PhD; Ellen Frank, PhD; Nreen A. Reilly-Harringtn, PhD; Stephen R. Wisniewski, PhD; Jane N. Kgan, PhD; Andrew A. Nierenberg, MD; Jseph R. Calabrese, MD; Lauren B. Marangell, MD; Laszl Gyulai, MD; Mak Araga, MS; Jdi M. Gnzalez, PhD; Edwin R. Shirley, PhD; Michael E. Thase, MD; Gary S. Sachs, MD (2007). Psychscial Treatments fr Biplar I Depressin. Archives f General Psychiatry. 2007;64: Guld RA, Mueser KT, Bltn E, Mays V, Gff D: Cgnitive therapy fr psychsis in schizphrenia: an effect size analysis. Schizphr Res 2001; 48: Hansen Nathan B., Michael J. Lambert, Evan M. Frman. The Psychtherapy Dse- Respnse Effect and Its Implicatins fr Treatment Delivery Services. Clinical Psychlgy: Science and Practice :3 329 Hansen N.B.; Lambert M.J. (2003). An Evaluatin f the Dse Respnse Relatinship in Naturalistic Treatment Settings Using Survival Analysis. Mental Health Services Research, Vlume 5, Number 1, March 2003, pp. 1-12(12) Jarrett Rbin B., Dlres Kraft; Jeanette Dyle; Barbara M. Fster; G. Greg Eaves; Paul C. Silver Preventing Recurrent Depressin Using Cgnitive Therapy With and Withut a Cntinuatin Phase: A Randmized Clinical Trial Arch Gen Psychiatry. 2001;58(4): Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f 88

91 Defense, September Office f Quality and Perfrmance publicatin 10Q- CPG/SUD-01 Miller WR, Wilburne PL: Mesa Grande: a methdlgical analysis f clinical trials f treatments fr alchl use disrders. Addictin 2002; 97: Mjtabai R, Nichlsn RA, Carpenter BN: Rle f psychscial treatments in management f schizphrenia: a meta-analytic review f cntrlled utcme studies. Schizphr Bull 1998; 24: Practice Guideline fr the Treatment f Patients with Biplar I Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Wdy GE, McLellan AT, Lubrsky L, O Brien CP: Psychtherapy in cmmunity methadne prgrams: a validatin study. Am J Psychiatry 1995; 152: Numeratr: Number f psychscial visits during the study perid: a) Ttal psychscial visits in the 4 mnths fllwing the start f a new treatment episde b) Ttal psychscial visits during the study perid Denminatr: Patients with any study-relevant diagnsis with any psychscial visits a) In the fur mnths fllwing a new treatment episde b) During the study perid Patient chrts: All patient chrts Definitins: New Treatment Episde: See the Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid. Psychscial visits: Defined as the cunt f diagnsis-related (primary r secndary, based n Table 1.B in the Key Definitins Dcument) encunters with the fllwing mental health stp cdes, Mental health stp cdes: All stp cdes beginning with 5, excluding 523, 533, 538, and 565 EXCLUDING thse visits with the fllwing CPT cdes: (Medicatin management withut psychtherapy), (ECT), and any CPT cdes that d nt begin with 9 r H Exclude the first visit which begins the new treatment episde if it meets the definitin fr psychscial visits Strength f Evidence: Grade III This is the level f evidence fr the indicatr as specified, since we are cunting frequencies f visits, nt specifying what cnstitutes an adequate dse. Hwever, the evidence cited in the executive summary generally has a strength f evidence f Grade I. 89

92 Feasibility/Data Cllectin Issues: The VA des nt have standards regarding the ideal number f psychtherapy visits, due t the lack f an evidence base. Fr this reasn, we will lk at this indicatr descriptively. We will use these data t analyze the prprtin f grup vs. individual treatment taking place A limitatin f this analysis is that psychscial visits that ccur in primary care, when nt cded with a crrespnding CPT cde, will be excluded. Updates: Rather than cunting the number f days n which psychscial encunters ccurred, this indicatr will cunt the ttal number f psychscial encunters, even if there are multiple encunters n the same day. 90

93 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Prprtin f patients in all chrts receiving any psychtherapy treatment in the utpatient setting Indicatr number: E Executive Summary: Biplar I: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins under a Biplar I diagnsis. The American Psychiatric Assciatin Clinical Practice Guidelines cite fur randmized studies that shw that psychscial interventins reduce recurrence f Biplar I symptms. Miklwitz et al (2007) in their large federally-funded STEP-BP study cnducted a randmized cntrlled trial f fifteen clinics, and fund that Intensive psychscial treatment as an adjunct t pharmactherapy was mre beneficial than brief treatment in enhancing stabilizatin frm biplar I depressin. STABLE measure number 15, % f patients where apprpriate psychscial interventins are recmmended within 12 weeks f initiating treatment fr biplar I disrder, is similar t this indicatr, and STABLE states in the ratinale statement that evidence-based psychscial interventins have been fund t imprve treatment adherence, reduce likelihd f recurrence and extend time t new episdes, and that many different types f psychscial interventins have been fund t be effective in achieving these utcmes. This indicatr will prvide descriptive data reflecting the American Psychiatric Assciatin s emphasis n psychscial interventins. The APA states, There are nw a range f specific psychtherapeutic interventins that have been shwn t be helpful when used in cmbinatin with pharmactherapy and psychiatric management fr treatment f biplar I disrder. The best-studied treatment appraches have been develped arund psych-educatinal, interpersnal, family, and cgnitive behavir therapies. Frmal studies have been cnducted fr these treatments, and additinal investigatins are underway. Further, psychdynamic and ther frms f therapy may be indicated fr sme patients. Schizphrenia: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins with a schizphrenia diagnsis. The American Psychiatric Assciatin als supprts this view, stating, as part f a cmprehensive treatment apprach, psychscial interventins can imprve the curse f schizphrenia when integrated with psychpharmaclgical treatments. These interventins can prvide additinal benefits fr patients in such areas as relapse preventin, imprved cping skills, better scial and vcatinal functining, and ability t functin mre independently. While pharmactherapy fcuses n symptm diminutin, psychscial interventins may prvide emtinal supprt and address particular deficits assciated with schizphrenia. The AHRQ-funded Schizphrenia Patient Outcmes Research Team (PORT) stated that fr mst persns, the cmbinatin f psychpharmaclgic and psychscial interventins imprves utcmes. The reprted that a number f psychscial treatments have demnstrated efficacy, and listed family interventins, SE, ACT, skills training, cgnitive behavirally riented psychtherapy and the tken ecnmy scial 91

94 learning interventin amng them (Lehman et al, 1998, updated 2004). Mjtabai et. al. prvided a cmprehensive review f the literature linking psychscial interventins t schizphrenia utcmes in cntrlled studies, cncluding ur results shw that psychscial treatments can play an imprtant rle in the cmprehensive management f schizphrenia nt nly t augment the effects f medicatins, but als t supplement these effects in areas where cnventinal medicatins alne are less effective (e.g., negative symptms) there is sme evidence that psychscial interventins may be mre effective in the mre chrnic stages f illness and, therefre, can play a mre prminent rle in the management f patients with chrnic schizphrenia. SUD: The American Psychiatric Assciatin Clinical Practice Guidelines state that Psychscial treatments are essential cmpnents f a cmprehensive treatment prgram Sustained mtivatin is required t frg the rewards f substance use, tlerate the discmfrts f early and prtracted withdrawal symptms, and gather the energy t avid relapse despite episdes f craving that can ccur thrughut a lifetime. Cping skills are required t manage and avid situatins that can place the individual at a high risk fr relapse. The APA cites extensive evidence fr the efficacy f psychscial interventins in patients with substance use disrders, summarizing: The majr psychtherapeutic treatments that have been studied in patients with substance use disrders are cgnitive-behaviral, behaviral, psychdynamic/interpersnal, and recvery- riented therapies. A grwing bdy f efficacy data frm cntrlled clinical trials suggests that psychtherapy is superir t cntrl cnditins as a treatment fr patients with a substance use disrder. Hwever, n particular type f psychtherapy has been fund t be cnsistently superir when cmpared with ther active psychtherapies fr treating substance use disrders. Even cmparatively brief psychtherapies appear t have durable effects amng patients with a substance use disrder. The Natinal Quality Frum, in its dcumentatin f evidence-based treatment practices, states that Evidence-based psychscial treatment interventins shuld be initiated fr all patients referred t specialty care treatment f SUDs. MDD: This indicatr is based n an indicatr cited by CQAIMH and develped by the APA, Treatment fr Mderate Depressin, which states that Majr depressive disrder is prevalent and disabling, ften accmpanied by impaired persnal, scial, ccupatinal and/r family functining. Research studies have fund that the disrder ges undetected r inadequately treated. Antidepressant medicatins and certain types f psychtherapy (e.g., cgnitive behaviral therapy, interpersnal therapy) have been shwn t be efficacius in the treatment f majr depressive disrder. The APA CPG fr schizphrenia als states: A specific, effective psychtherapy alne as an initial treatment mdality may be cnsidered fr patients with mild t mderate majr depressive disrder [II]. The cmbinatin f a specific effective psychtherapy and medicatin may be a useful initial treatment chice fr patients with psychscial issues, interpersnal prblems, r a cmrbid axis II disrder tgether with mderate t severe majr depressive disrder [I]. Cgnitive behaviral therapy and interpersnal therapy are the psychtherapeutic appraches that have the best dcumented efficacy in the literature fr the specific treatment f majr depressive disrder, althugh rigrus studies evaluating the efficacy f psychdynamic psychtherapy have nt been published [II]. Althugh there has been less study f the use f psychtherapy in the cntinuatin phase t prevent relapse, there is grwing evidence t supprt the use f a specific effective psychtherapy during the cntinuatin phase [I]. In general, the treatment that was effective in the acute and cntinuatin phases shuld be used in the maintenance phase [II]. 92

95 PTSD: This indicatr is based n findings by the Cmmittee n Treatment f Psttraumatic Stress Disrder, which states that the cmmittee finds that the evidence is sufficient t cnclude the efficacy f expsure therapies in the treatment f PTSD. Furthermre, Rsenberg et. al. (2001) find that A grwing bdy f evidence shws that well-delineated, theretically based interventins are effective in the treatment f PTSD Multiple cntrlled trials have shwn that the mst effective interventins fr PTSD are thse based n CBT appraches, including expsure therapy and cgnitive restructuring. This indicatr is similar t anther indicatr in this dcument, Crss Cutting C, Any psychscial r psychtherapeutic sessins. This indicatr is different because the range f interventins has been narrwed t include nly psychtherapy, as defined in the Key Definitins Dcument. Althugh there is fair t gd research evidence suggesting that PT is effective as adjunct r mntherapy in the treatment f all five cnditins discussed abve, this indicatr des nt capture the type f psychtherapy ffered and the criteria are met with just 1 psychtherapy sessin. Fr this reasn this indicatr will nly be used descriptively, despite its high face validity. This indicatr addresses the fllwing IOM dmain: effectiveness. References: David J. Miklwitz, PhD; Michael W. Ott, PhD; Ellen Frank, PhD; Nreen A. Reilly- Harringtn, PhD; Stephen R. Wisniewski, PhD; Jane N. Kgan, PhD; Andrew A. Nierenberg, MD; Jseph R. Calabrese, MD; Lauren B. Marangell, MD; Laszl Gyulai, MD; Mak Araga, MS; Jdi M. Gnzalez, PhD; Edwin R. Shirley, PhD; Michael E. Thase, MD; Gary S. Sachs, MD (2007). Psychscial Treatments fr Biplar I Depressin. Archives f General Psychiatry. 2007;64: Rbin B. Jarrett; Dlres Kraft; Jeanette Dyle; Barbara M. Fster; G. Greg Eaves; Paul C. Silver Preventing Recurrent Depressin Using Cgnitive Therapy With and Withut a Cntinuatin Phase: A Randmized Clinical Trial Arch Gen Psychiatry. 2001;58(4): Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, 93

96 Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Mjtabai R, Nichlsn RA, Carpenter BN: Rle f psychscial treatments in management f schizphrenia: a meta-analytic review f cntrlled utcme studies. Schizphr Bull 1998; 24: Practice Guideline fr the Treatment f Patients with Biplar I Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Numeratr: a) Patients in the denminatr (a) receiving any psychtherapy within the fur mnths fllwing the start f a new treatment episde b) Patients in the denminatr (b) receiving any psychtherapy during the study perid Denminatr: a) Individuals in all patient chrts in a new treatment episde b) Individuals with a study relevant diagnsis in all patient chrts Patient chrts: All patient chrts Definitins: New Treatment Episde: See Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid. Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Strength f Evidence: Grade III Fr patients in a new treatment episde, lk fr evidence f any psychtherapy within fur mnths f the start f the new treatment episde (d nt cunt the initial visit if that invlves psychtherapy) Fr all patients with a study diagnsis, lk fr any evidence f psychtherapy during the study perid Feasibility/Data Cllectin Issues: We will use these data t analyze the prprtin f grup vs. individual treatment taking place 94

97 Updates: Nne. 95

98 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Amng thse with any psychtherapeutic sessins, number f psychtherapeutic sessins per persn Indicatr number: F Executive Summary: Biplar I: This indicatr will prvide descriptive data reflecting the American Psychiatric Assciatin s emphasis n psychscial interventins. The APA states, There are nw a range f specific psychtherapeutic interventins that have been shwn t be helpful when used in cmbinatin with pharmactherapy and psychiatric management fr treatment f biplar I disrder. The best-studied treatment appraches have been develped arund psych-educatinal, interpersnal, family, and cgnitive behavir therapies. Frmal studies have been cnducted fr these treatments, and additinal investigatins are underway. Further, psychdynamic and ther frms f therapy may be indicated fr sme patients. They discuss several evaluatins shwing that brief interventins, between six t seven sessins, are assciated with imprved utcmes fr patients with biplar I disrder. The VA Clinical Practice Guidelines als emphasize the imprtance f therapy in reducing symptms, imprving self-esteem, and reducing cgnitive deficit. Schizphrenia: This measure reflects standards enumerated in the VA Clinical Practice Guidelines fr Psychses, which recmmends psychtherapy interventins with a schizphrenia diagnsis. The American Psychiatric Assciatin als supprts this view, stating, as part f a cmprehensive treatment apprach, psychscial interventins can imprve the curse f schizphrenia when integrated with psychpharmaclgical treatments. These interventins can prvide additinal benefits fr patients in such areas as relapse preventin, imprved cping skills, better scial and vcatinal functining, and ability t functin mre independently. While pharmactherapy fcuses n symptm diminutin, psychscial interventins may prvide emtinal supprt and address particular deficits assciated with schizphrenia. The AHRQ-funded Schizphrenia Patient Outcmes Research Team (PORT) stated that fr mst persns, the cmbinatin f psychpharmaclgic and psychscial interventins imprves utcmes. They reprted that a number f psychscial treatments have demnstrated efficacy, and listed family interventins, SE, ACT, skills training, cgnitive behavirally riented psychtherapy and the tken ecnmy scial learning interventin amng them (Lehman et al, 1998, updated 2004). Mjtabai et. al. prvided a cmprehensive review f the literature linking psychscial interventins t schizphrenia utcmes in cntrlled studies, cncluding ur results shw that psychscial treatments can play an imprtant rle in the cmprehensive management f schizphrenia nt nly t augment the effects f medicatins, but als t supplement these effects in areas where cnventinal medicatins alne are less effective (e.g., negative symptms) there is sme evidence that psychscial interventins may be mre effective in the mre chrnic stages f illness and, therefre, can play a mre prminent rle in the management f patients with chrnic schizphrenia. SUD: The American Psychiatric Assciatin Clinical Practice Guidelines state that Psychscial treatments are essential cmpnents f a cmprehensive treatment 96

99 prgram Sustained mtivatin is required t frg the rewards f substance use, tlerate the discmfrts f early and prtracted withdrawal symptms, and gather the energy t avid relapse despite episdes f craving that can ccur thrughut a lifetime. Cping skills are required t manage and avid situatins that can place the individual at a high risk fr relapse. The exact duratin f SUD behaviral interventins varies by the type f substance use and the type f interventin, but evidence shws that very shrt interventins (ne t fur sessins) can be effective in imprving utcmes fr alchl and cannabis dependence (Miller et al 2002, Cpeland et al 2001), hwever, lnger interventins are necessary in the treatment f piid and ccaine dependence (Wdy et al 1995, Carrll et al 1998). MDD: This indicatr is based n an indicatr cited by CQAIMH and develped by the APA, Treatment fr Mderate Depressin, which states that Majr depressive disrder is prevalent and disabling, ften accmpanied by impaired persnal, scial, ccupatinal and/r family functining. Research studies have fund that the disrder ges undetected r inadequately treated. Antidepressant medicatins and certain types f psychtherapy (e.g., cgnitive behaviral therapy, interpersnal therapy) have been shwn t be efficacius in the treatment f majr depressive disrder. The APA CPG fr schizphrenia als states: A specific, effective psychtherapy alne as an initial treatment mdality may be cnsidered fr patients with mild t mderate majr depressive disrder [II]. The cmbinatin f a specific effective psychtherapy and medicatin may be a useful initial treatment chice fr patients with psychscial issues, interpersnal prblems, r a cmrbid axis II disrder tgether with mderate t severe majr depressive disrder [I]. Cgnitive behaviral therapy and interpersnal therapy are the psychtherapeutic appraches that have the best dcumented efficacy in the literature fr the specific treatment f majr depressive disrder, althugh rigrus studies evaluating the efficacy f psychdynamic psychtherapy have nt been published [II]. Althugh there has been less study f the use f psychtherapy in the cntinuatin phase t prevent relapse, there is grwing evidence t supprt the use f a specific effective psychtherapy during the cntinuatin phase [I]. In general, the treatment that was effective in the acute and cntinuatin phases shuld be used in the maintenance phase [II]. Hansen et al (2002), in a meta-analysis f psychtherapy dse-respnses, fund amng dse-respnse studies, that at least eight psychtherapy sessins were required fr a 50 percent imprvement rate, ranging up t 18 sessins in Hansen and Lambert s 2003 survival analysis f patients in a standard treatment setting. PTSD: This indicatr is based n findings by the Cmmittee n Treatment f Psttraumatic Stress Disrder, which states that the cmmittee finds that the evidence is sufficient t cnclude the efficacy f expsure therapies in the treatment f PTSD. Furthermre, Rsenberg et. al. (2001) find that A grwing bdy f evidence shws that well-delineated, theretically based interventins are effective in the treatment f PTSD Multiple cntrlled trials have shwn that the mst effective interventins fr PTSD are thse based n CBT appraches, including expsure therapy and cgnitive restructuring. A meta-analysis by Bradley et al (2005) shwed that behaviral interventins fr PTSD were effective at a range f dses, hwever there have nt been enugh clinical trials t date t determine the differential efficacy f treatment at different dses. 97

100 Nte that this indicatr is similar t Crss Cutting D, which measures the Number f psychscial treatment r psychtherapeutic sessins greater than 30 minutes per persn. In this case, hwever, we are nly measuring number f psychtherapy sessins, which is a mre limited range f cases in the denminatr. Althugh there is fair t gd research evidence suggesting that psychscial interventins are effective as adjuncts r mntherapy in the treatment f all five cnditins discussed abve, this indicatr may nt capture the type f psychtherapy ffered and it will nly describe the number f sessins, nt a rate f prviders ffering an adequate dse f a particular psychtherapy treatment. Fr this reasn, this indicatr will be a descriptive indicatr prviding infrmatin abut mean/median dse f psychtherapy fr each f the abve cnditins. This indicatr will address the fllwing IOM dmain: Effectiveness. References: Bradley, Rebekah, Greene, Jamelle, Russ, Eric, Dutra, Lissa, Westen, Drew. A Multidimensinal Meta-Analysis f Psychtherapy fr PTSD. Am J Psychiatry : Carrll KM, Nich C, Ball SA, McCance E, Runsaville BJ: Treatment f ccaine and alchl dependence with psychtherapy and disulfiram. Addictin 1998; 93: Cpeland J, Swift W, Rffman R, Stephens R: A randmized cntrlled trial f brief cgnitive-behaviral interventins fr cannabis use disrder. J Subst Abuse Treat 2001; 21:55 64 David J. Miklwitz, PhD; Michael W. Ott, PhD; Ellen Frank, PhD; Nreen A. Reilly-Harringtn, PhD; Stephen R. Wisniewski, PhD; Jane N. Kgan, PhD; Andrew A. Nierenberg, MD; Jseph R. Calabrese, MD; Lauren B. Marangell, MD; Laszl Gyulai, MD; Mak Araga, MS; Jdi M. Gnzalez, PhD; Edwin R. Shirley, PhD; Michael E. Thase, MD; Gary S. Sachs, MD (2007). Psychscial Treatments fr Biplar Depressin. Archives f General Psychiatry. 2007;64: Guld RA, Mueser KT, Bltn E, Mays V, Gff D: Cgnitive therapy fr psychsis in schizphrenia: an effect size analysis. Schizphr Res 2001; 48: Hansen Nathan B., Michael J. Lambert, Evan M. Frman. The Psychtherapy Dse- Respnse Effect and Its Implicatins fr Treatment Delivery Services. Clinical Psychlgy: Science and Practice :3 329 Hansen N.B.; Lambert M.J. (2003). An Evaluatin f the Dse Respnse Relatinship in Naturalistic Treatment Settings Using Survival Analysis. Mental Health Services Research, Vlume 5, Number 1, March 2003, pp. 1-12(12) Jarrett Rbin B., Dlres Kraft; Jeanette Dyle; Barbara M. Fster; G. Greg Eaves; Paul C. Silver Preventing Recurrent Depressin Using Cgnitive Therapy With and Withut a Cntinuatin Phase: A Randmized Clinical Trial Arch Gen Psychiatry. 2001;58(4): Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans 98

101 Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q- CPG/SUD-01 Miller WR, Wilburne PL: Mesa Grande: a methdlgical analysis f clinical trials f treatments fr alchl use disrders. Addictin 2002; 97: Mjtabai R, Nichlsn RA, Carpenter BN: Rle f psychscial treatments in management f schizphrenia: a meta-analytic review f cntrlled utcme studies. Schizphr Bull 1998; 24: Practice Guideline fr the Treatment f Patients with Biplar I Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Wdy GE, McLellan AT, Lubrsky L, O Brien CP: Psychtherapy in cmmunity methadne prgrams: a validatin study. Am J Psychiatry 1995; 152: Numeratr: Number f psychtherapy visits during the study perid: c) Ttal psychtherapy visits in the 4 mnths fllwing the start f a new treatment episde d) Ttal psychtherapy visits during the study perid Denminatr: Patients with a study-relevant diagnsis with any psychtherapy visits a) In the 4 mnths fllwing the start f a new treatment episde b) During the study perid Patient chrts: All patient chrts Definitins: New Treatment Episde: See Key Definitins Dcument Fr patients wh begin a new treatment episde in the inpatient setting, the start f the new treatment episde is the date f discharge frm the hspital (Nte: this definitin differs frm the general definitin f the start f an inpatient new treatment episde in the Key Definitins Dcument). If the new treatment episde begins in the utpatient setting, the start f the new treatment episde is defined as the first diagnsis-related (primary diagnsis nly using Table 1B in the Key Definitins Dcument) utpatient encunter fllwing the 5 mnth clean perid. Number f Psychtherapy Visits: Defined as the cunt f diagnsis-related psychtherapy encunters (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Fr patients in a new treatment episde, cunt psychtherapy visits that ccur within fur mnths f the start f the new treatment episde (d nt cunt the initial visit if that invlves psychtherapy) 99

102 Fr all patients with a study-relevant diagnsis, cunt all psychtherapy visits that ccur during the study perid Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: This indicatr will be used descriptively t cmpare rates f psychtherapy visits per patient acrss gegraphic regins and patient characteristics (e.g., gender, race, age, etc.). Updates: Rather than cunting the number f days n which psychscial encunters ccurred, this indicatr will cunt the ttal number f psychscial encunters, even if there are multiple encunters n the same day. 100

103 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Patients wh received adequate fllw-up after an inpatient psychiatric discharge Indicatr number: G Executive Summary: This is a measure develped by the Natinal Cmmittee fr Quality Assurance (NCQA) and cited by the healthcare Effectiveness data & infrmatin set (HEDIS) NCQA states in its ratinale statement, It is imprtant t prvide regular fllw-up therapy t patients after they have been hspitalized fr mental illness. An utpatient visit with a mental health practitiner after discharge is recmmended t make sure that the patient's transitin t the hme r wrk envirnment is supprted and that gains made during hspitalizatin are nt lst. It als helps health care prviders detect early pst-hspitalizatin reactins r medicatin prblems and prvide cntinuing care. Biplar I: The APA ntes that the psychiatrist shuld remain vigilant fr changes in psychiatric status. While this is true fr all psychiatric disrders, it is especially imprtant in biplar disrder because limited insight n the part f the patient is s frequent, especially during manic episdes. In additin, small changes in md r behavir may herald the nset f an episde, with ptentially devastating cnsequences. In a study f psychiatric hspital discharges, Rif et. al. find that One f the mst significant predictrs f prmpt rehspitalizatin fllwing psychiatric hspital discharge is missing fllw-up ut-patient appintments. Schizphrenia: This indicatr is based n the VA s Clinical Practice Guidelines (VA CPG). They state that patients shuld been seen every ne t tw weeks fr six weeks when patients have been prescribed secnd generatin antipsychtic medicatin ther than clzapine. The Expert Cnsensus Guidelines (1999) supprt this guideline, nting that fllwing an initial diagnsis and prescriptin, patients shuld be seen within a week t ensure cntinuity f care. This will assist the dctr in preventing relapse and watching fr critical warning signs f medicatin nncmpliance. PTSD: This indicatr is based n a measure develped by Rsenheck et. al. (1999), which fund that the number f utpatient visits in the six mnths fllwing inpatient care was psitively assciated with clinical utcmes such as PTSD symptmlgy, drug prblems, and vilence. On the ther hand, the measure f any utpatient visits within 30 days f discharge was negatively assciated with clinical utcmes, pssibly reflecting the fact that mre symptmatic clients are mst likely t return t treatment. SUD: This indicatr is based n a CQAIMH indicatr, which states that Cntinuing treatment after inpatient discharge is typically necessary t address nging prblems and decrease the likelihd f relapse. The American Psychiatric Assciatin Clinical Practice Guidelines als supprt this measure, indicating that frequency f relapse mnitring shuld be intensified during transitins frm higher t lwer levels f care. McCrry et. al. nte that, A detxificatin prgram is nt designed t reslve the lngstanding psychlgical, scial, and behaviral prblems assciated with AOD abuse. Detxificatin is mst effective when it is viewed as a first step t active treatment and is fllwed by assessment and referral t nging AOD treatment withut linkage t 101

104 treatment after detxificatin, research has fund n significant imprvements that are discernable frm untreated withdrawal. MDD: This indicatr (numeratrs a and b) was develped by the Natinal Cmmittee fr Quality Assurance (NCQA) as cited in HEDIS They state in the indicatr ratinale, It is imprtant t prvide regular fllw-up therapy t patients after they have been hspitalized fr mental illness. An utpatient visit with a mental health practitiner after discharge is recmmended t make sure that the patient's transitin t the hme r wrk envirnment is supprted and that gains made during hspitalizatin are nt lst. It als helps health care prviders detect early pst-hspitalizatin reactins r medicatin prblems and prvide cntinuing care. This indicatr has substantial face validity and it is the standard f care t prvide patients w/ adequate fllw-up after an inpatient psychiatric stay. Furthermre, this indicatr is an industry standard indicatr, as it has been adpted by HEDIS. This indicatr addresses the fllwing IOM dmain: effectiveness, safety and timeliness References: Kathryn Rst, L. Miriam Dickinsn, Jhn Frtney, Jhn Westfall, and Richard C. Hermann (2005). Clinical Imprvement Assciated with Cnfrmance t HEDIS- Based Depressin Care Ment Health Serv Res June ; 7(2): Hrgan C, Merrick EL, Stewart MT et al (2008), Imprving Medicatin Management f Depressin in Health Plans, Psychiatric Services 59:72-77 Natinal Cmmittee fr Quality Assurance (NCQA). HEDIS Healthcare Effectiveness data & infrmatin set. Vl. 2, Technical specificatins. Washingtn (DC): Natinal Cmmittee fr Quality Assurance (NCQA); p. Management f Psychses. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/PSY-04 McCrry, F., Garnick, D., Bartlett, J., Ctter, F., & Chalk, M. (2000). Develping Perfrmance Measures fr Alchl and Other Drug Services in Managed Care Plans. Jint Cmmissin Jurnal n Quality Imprvement, 26 (11), Management f Substance Use Disrder in the Primary Care Setting. Washingtn, DC: VA/DD Evidence-Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, September Office f Quality and Perfrmance publicatin 10Q-CPG/SUD-01 Management f Majr Depressive Disrder in Adults in the Primary Care Setting. Washingtn, DC: VA/DD Evidence Based Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs, and Health Affairs, Department f Defense, May Office f Quality and Perfrmance publicatin 10Q-CPG/MDD-00 Numeratr: 1) Thse individuals frm the denminatr whse discharge was fllwed by at least ne diagnsis-related nn-emergency fllw-up encunter: a) Within 7 days b) Within 30 days 2) Fr thse with any fllw-up, number f days until first fllw-up visit 102

105 Denminatr: a) Patients with a study-relevant diagnsis discharged frm any psychiatric inpatient care during the study perid b) Patients with a study-relevant diagnsis discharged frm acute psychiatric inpatient care during the study perid Patient chrts: All patient chrts Definitins: Any Psychiatric Inpatient Discharge: Any inpatient discharge where the primary diagnsis (DXLSF) is any psychiatric diagnsis (210.xx-319.xx). Select the first discharge in the study perid as the index discharge Exclude: Patients whse discharge status includes death r transfer t anther inpatient facility (DISTO = -2, 0, 1, 2, 3, 4) Acute Psychiatric Inpatient Discharge: Any inpatient discharge where the primary diagnsis (DXLSF) is any psychiatric diagnsis frm Table 1B in the Key Definitins Dcument frm the fllwing bed sectins: Bed Sectins: 70, 71, Select the first discharge in the study perid as the index discharge Exclude: Patients whse discharge status includes death r transfer t anther inpatient facility (DISTO = -2, 0, 1, 2, 3, 4) Fllw-up encunter: Defined as any diagnsis-related visits (primary r secndary frm Table 1B in the Key Definitins Dcument) fllwing the date f discharge frm the inpatient setting Within 7 days: where the difference between the date f the first fllwup encunter and the date f discharge frm inpatient setting is equal t r less than seven days Within 30 days: where the difference between the date f the first fllwup encunter and the date f discharge frm inpatient setting is equal t r less than thirty days Days until first fllw-up visit (numeratr b): Number f days frm discharge date until next utpatient encunter Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Nne. Updates: The definitin f time t fllw-up fr cunting days t fllw-up is mdified t include any fllw-up in the year fllwing discharge, rather than fllw-up nly in the study perid. This will make the perid f fllw-up equal fr all veterans, regardless f when during the study perid they were hspitalized. Diagnsis list fr qualifying inpatient discharges has been expanded t any psychiatric diagnsis (210.xx-319.xx) instead f nly thse in Table 1B. 103

106 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Prprtin f patients using Mental Health Intensive Case Management (MHICM) Indicatr number: H Executive Summary: This indicatr is based n a measure frm the FY 2006 Q4 Technical Manual fr the VHA Perfrmance Measurement System. The VA Technical Manual fr the VHA Perfrmance Measurement System describes the adptin f the MHICM prgram: A subset f the mst severely impaired mentally ill requires intensive cmmunity-based case management in rder t functin effectively utside f an institutin. There is a large bdy f scientific data establishing the efficacy and cst effectiveness f intensive cmmunity case management. The Clinical Care Subcmmittee f the Plicy Bard drafted VHA Directive n Mental Health Intensive Case Management (MHICM), issued Octber 2, It called fr the establishment f new MHICM prgrams in ppulatin areas where n such prgrams exist and the enhancement f existing prgrams that are undersized t meet current needs. These prgrams may be funded using dllars previusly devted t the institutinal supprt f the severely mentally ill. In any case, deplyment f intensive case management shuld nt cme at the expense f ther cmmunity-based and utpatient services fr the seriusly mentally ill." Nte that, accrding t Mueser et. al., Research shws that ACT (Assertive Cmmunity Treatment) is effective at reducing hspitalizatins, stabilizing husing in the cmmunity, reducing symptm severity, imprving quality f life, and lwering verall treatment csts. ACT services have typically been reserved fr cnsumers with severe mental illness and a recent histry f lng-term hspitalizatins r extremely impaired psychscial functining requiring daily assistance t live in the cmmunity. Research indicates that ACT is mst beneficial fr this subgrup f cnsumers and nt the entire ppulatin f cnsumers with severe mental illness. This indicatr attempts t measure enrllment bth amng all VHA patients, and thse VHA patients that are eligible fr MHICM. Hwever, because ur measurement f MHICM eligibility is based upn limited evidence available in administrative data and because n study has assessed the effect f time t enrllment n ACT utcmes (as in numeratr a), this indicatr will nt be a benchmark f quality f care, but rather a descriptive indicatr. This indicatr addresses the fllwing IOM dmain: effectiveness. References: Mueser KT, Trrey WC, Lynde D, Singer P and Drake RE. Implementing Evidence Based Practices fr Peple with Severe Mental Illness. Behavir Mdificatin 2003; 27; 387. Numeratr: Patients in the denminatr using MHICM Denminatr: Patients in all chrts Patient chrts: All patient chrts Definitins: 104

107 Mental Health Intensive Case Management utilizatin: Defined as 2+ utpatient encunters with MHICM during the study perid. The fllwing stp cdes shuld be used t define MHICM encunters: 546 Mental Health Intensive Case Management Telephne 552 Mental Health Intensive Case Management 568 Mental Health Intensive Case Management Grup Strength f Evidence: Grade III.The evidence supprting the effectiveness f assertive cmmunity treatment prgrams amng Biplar I, Schizphrenia, and MDD ppulatins is Grade I, hwever, there is n evidence evaluating the effectiveness f these types f treatments within 30 days f eligibility, a restrictin specified in this measure. Feasibility/Data Cllectin Issues: We have expanded this indicatr t assess MHICM enrllment acrss all ppulatins with the understanding that MHICM is nt an evidence based practice fr all f these ppulatins. We aim t assess the use f MHICM within ppulatins fr which there is an evidence base (Biplar I, Schizphrenia, and severe MDD) and ther ppulatins Updates: Nne. 105

108 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Fr selected patients, timeliness f engagement f Mental Health Intensive Case Management (MHICM) Indicatr number: I Executive Summary: This indicatr is based n a measure frm the FY 2006 Q4 Technical Manual fr the VHA Perfrmance Measurement System. The VA Technical Manual fr the VHA Perfrmance Measurement System describes the adptin f the MHICM prgram: A subset f the mst severely impaired mentally ill requires intensive cmmunity-based case management in rder t functin effectively utside f an institutin. There is a large bdy f scientific data establishing the efficacy and cst effectiveness f intensive cmmunity case management. The Clinical Care Subcmmittee f the Plicy Bard drafted VHA Directive n Mental Health Intensive Case Management (MHICM), issued Octber 2, It called fr the establishment f new MHICM prgrams in ppulatin areas where n such prgrams exist and the enhancement f existing prgrams that are undersized t meet current needs. These prgrams may be funded using dllars previusly devted t the institutinal supprt f the severely mentally ill. In any case, deplyment f intensive case management shuld nt cme at the expense f ther cmmunity-based and utpatient services fr the seriusly mentally ill." Nte that, accrding t Mueser et. al., Research shws that ACT (Assertive Cmmunity Treatment) is effective at reducing hspitalizatins, stabilizing husing in the cmmunity, reducing symptm severity, imprving quality f life, and lwering verall treatment csts. ACT services have typically been reserved fr cnsumers with severe mental illness and a recent histry f lng-term hspitalizatins r extremely impaired psychscial functining requiring daily assistance t live in the cmmunity. Research indicates that ACT is mst beneficial fr this subgrup f cnsumers and nt the entire ppulatin f cnsumers with severe mental illness. Because n study has assessed the effect f time t enrllment n ACT utcmes and in additin, the VA des nt have explicit standards fr time t enrllment in MHICM, this indicatr will be a descriptive measure f average time t enrllment. This indicatr addresses the fllwing IOM dmains: effectiveness and timeliness. References: Mueser KT, Trrey WC, Lynde D, Singer P and Drake RE. Implementing Evidence Based Practices fr Peple with Severe Mental Illness. Behavir Mdificatin 2003; 27; 387. Numeratr: a) Number f patients subsequently enrlled in MHICM b) Number f days fllwing date f eligibility (per numeratr [a]) until client is enrlled in MHICM Denminatr: Number f patients in a study chrt wh have at least three inpatient discharges r 30 cumulative inpatient days in the study perid and were nt enrlled in MHICM prir t meeting the inpatient utilizatin criteria 106

109 Patient chrts: All patient chrts Definitins: Inpatient discharge: Any psychiatric discharge with a primary psychiatric diagnsis (DXLSF) frm Table 1B f the Key Definitins Dcument using the fllwing bed sectin cdes: 70, 71, 75-79, 89, Inpatient days: Ttal cunt f psychiatric inpatient days frm all inpatient discharges during the study perid with a primary psychiatric diagnsis (DXLSF) frm Table 1B f the Key Definitins Dcument using the fllwing bed sectin cdes: 70, 71, 75-79, 89, Nte: Length f Stay (LS frm the Inpatient Medical SAS Dataset) already subtracts ut bed days n pass and ut f the hspital s n additinal calculatins/exclusins are needed. Hwever, this calculatin is fr ttal length f stay; if a patient were admitted t ne bed sectin and then transferred t a psychiatric bed sectin (r vice versa), this calculatin wuld ver-estimate the length f stay fr the psychiatric bed sectin. There is n pssible methd fr determining when days n pass ccurred (i.e, during the relevant bed sectin days r during ther bed sectin days). Mental Health Intensive Case Management enrllment: Defined as 2+ utpatient encunters with MHICM n separate days. The date f the secnd encunter marks the date f enrllment fr calculating the numeratr. The fllwing stp cdes shuld be used t define MHICM encunters: 546 Mental Health Intensive Case Management Telephne 552 Mental Health Intensive Case Management 568 Mental Health Intensive Case Management Grup Prir Mental Health Intensive Case Management enrllment: Defined as 1+ utpatient encunters with MHICM prir t the cmpletin f at least 3 inpatient discharges r 30 cumulative inpatient days (whichever cmes first). The fllwing stp cdes shuld be used t define MHICM encunters: 546 Mental Health Intensive Case Management Telephne 552 Mental Health Intensive Case Management 568 Mental Health Intensive Case Management Grup Number f days until MHICM enrllment: Cunt f number f days frm the date f the last inpatient discharge r the last f 30 cumulative inpatient days (whichever cmes first) until the date f the secnd MHICM encunter. If the cumulative number f inpatient admissins exceeds three during the study perid, begin cunting number f days until enrllment with the date f discharge fr the third inpatient stay If the cumulative inpatient days fr the year exceed 30 days, begin cunting number f days until enrllment with the date f discharge fr the last f thse inpatient stays Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: We have expanded this indicatr t assess time t MHICM enrllment acrss all ppulatins with the understanding that MHICM is nt an evidence based practice fr all f these ppulatins. We aim t assess the use f MHICM within bth target ppulatins (Biplar I, Schizphrenia, and severe MDD) and nntarget ppulatins 107

110 Nte that there are n VA standards fr timeliness f MHICM enrllment. Updates: We have mdified the denminatr f this indicatr t exclude thse wh were already engaged with MHICM prir t meeting the criteria fr inclusin (e.g., befre they had 3 inpatient discharges r 30 cumulative inpatient days). We have mdified the numeratr t create tw different numeratrs; the first is a simple cunt f thse subsequently enrlled in MHICM and the secnd is a cunt f the number f days frm the qualifying index date frm the denminatr until enrllment in MHICM per ur enrllment definitin We have made explicit that the index date fr cunting days t enrllment is the first f either 3 inpatient discharges r 30 cumulative inpatient days during the study perid. We have added a definitin f prir MHICM enrllment in rder t be clear abut wh we are excluding frm the denminatr f this indicatr. We have made explicit that enrllment in MHICM is defined as tw MHICM encunters (using stated stp cdes) n separate days 108

111 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Supprted Emplyment utilizatin Indicatr number: J Executive Summary: Biplar I, Schizphrenia: Several randmized cntrlled studies have shwn supprted emplyment t be effective amng patients with severe mental illnesses. Bnd et. al. (1997) fund that supprted emplyment prgrams were assciated with higher rates f cmpetitive emplyment, as cmpared t traditinal vcatinal appraches. A study cnducted by Rsenheck et. al. (2007) cncluded that a supprted emplyment prgram within the VA was successful at increasing rates f cmpetitive emplyment, hwever, t less f a degree than thse changes reprted by Bnd et. al. (1997). Rsenheck s study included patients with Substance Use Disrder and PTSD in additin t the severe mental illnesses studied by Bnd et. al. SUD: A quasi-experimental study cnducted by Rsenheck et. al. (2007) cncluded that a supprted emplyment prgram within the VA was successful at increasing rates f cmpetitive emplyment, hwever, t less f a degree than thse changes reprted by Bnd et. al. (1997). Amng thse patients ffered supprted emplyment, thse with diagnses f substance use disrders withut psychiatric cmrbidity experienced substantially greater gains in cmpetitive emplyment than thse with ther psychiatric illnesses. PTSD: There is little evidence supprting the effectiveness f supprted emplyment in these patient ppulatins; Fr this reasn, supprted emplyment utilizatin will be a descriptive indicatr fr the PTSD chrt. Rsenheck et. al. (2007) included patients with PTSD in his quasi-randmized study f supprted emplyment. He fund significant differences in cmpetitive emplyment, hwever, figures fr PTSD alne are nt reprted. Althugh SE is an EBP with rbust evidence f effectiveness fr severely mentally ill adults (typically, peple with schizphrenia, biplar I disrder and severe MDD), there is n rbust evidence linking intensity f utilizatin with utcmes (numeratr b) and in additin, we will nt be able t determine true need amng the peple included in denminatr (a). Fr this reasn, and we will nly use this indicatr descriptively. This indicatr addresses the fllwing IOM dmains: effectiveness. References: Bnd, GR, Drake RE, Mueser KT, Becker DR (1997). An update n supprted emplyment fr peple with severe mental illness. Psychiatric Services, 48, Rsenheck R, Mares A (2007). Implementatin f Supprted Emplyment fr Hmeless Veterans With Psychiatric r Addictin Disrders: Tw-Year Outcmes. Psychiatric Services, March 2007 Vl. 58 N. 3 Numeratr: 1. Patients in the denminatr enrlled in supprted emplyment during the study perid 109

112 2. Amng thse enrlled in supprted emplyment (frm numeratr [1a] and [1b]), number f supprted emplyment visits Denminatr: a) All patients in the study chrts b) Patients in the biplar and schizphrenia chrts OR any patient with tw r mre utpatient visits n separate days r ne inpatient admissin during the study perid with a diagnsis f psychsis Patient chrts: All patient chrts Definitins: Diagnsis f psychsis: patients with tw r mre utpatient encunters n separate days r any inpatient admissins with a primary r secndary diagnsis f psychsis, defined by the fllwing ICD-9 cdes: Paranid state, simple Delusinal disrder Paraphrenia Shared psychtic disrder Other specified paranid states Unspecified paranid state Depressive type psychsis Excitative type psychsis Reactive cnfusin Acute paranid reactin Psychgenic paranid psychsis Other and unspecified reactive psychsis Unspecified psychsis Supprted Emplyment Enrllment: Patients with tw r mre encunters n the same r different days fr the fllwing stp cdes during the study perid: 568: Mental Health Cmpensated Wrk Therapy/Supprted Emplyment Face t Face 569: Mental Health Cmpensated Wrk Therapy/Supprted Emplyment Nn-Face t Face 574: Mental Health Cmpensated Wrk Therapy - Grup Cunt f supprted emplyment encunters: Cunt f supprted emplyment encunters using the same stp cdes prvided abve (multiple encunters n the same day will be cunted separately and nt as a single event) Strength f Evidence: BP, SZ: Grade I SUD: Grade III PTSD: Grade III Feasibility/Data Cllectin Issues: We have expanded this indicatr t assess supprted emplyment utilizatin acrss all ppulatins with the understanding that supprted emplyment is nt an evidence based practice fr all f these ppulatins. We aim t assess the use f supprted emplyment within bth target ppulatins (Biplar I, Schizphrenia, and psychsis) and nn-target ppulatins 110

113 Based n initial evaluatin f the data (5/29/08), it is advisable t present in reprts nly that data fr Denminatr #B (thse with Biplar Disrder, Schizphrenia, and a diagnsis f psychsis). Updates: Fr denminatr (b), we will include thse with tw r mre visits n different days with a primary r secndary diagnsis f psychsis. We have revised the definitin f Supprted Emplyment enrllment t be tw r mre encunters that culd take place n the same r different days. The cunt f Supprted Emplyment encunters will cnsider multiple encunters n a single day as separate events and each will be included in the ttal cunt. We have made explicit that the denminatr fr numeratr (2) are the cunts derived frm numeratrs (1a) and (1b). Althugh this indicatr was riginally identified as having a Grade I strength f evidence fr MDD, that applied nly t severe MDD. We cannt identify the severity f MDD using administrative data and thus have excluded this cnditin frm cnsideratin fr additinal r sub-analyses. We added stp cde 574 (Mental Health Cmpensated Wrk Therapy Grup) t the definitin f Supprted Emplyment 111

114 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Family psycheducatin Indicatr number: K Executive Summary: Biplar I Disrder: This indicatr is based n evidence-based practice recmmendatins. The American Psychiatric Assciatin s (APA) clinical guidelines recmmend family psychtherapy, One adequately sized trial f behaviral family treatment has been cmpleted; the investigatrs fund that behaviral family management (in cncert with adequate pharmactherapy) resulted in a substantial decrease in depressive relapse rates when cmpared with a treatment-as-usual cntrl cnditin. Furthermre, family members' emtinal respnses t a patient's biplar I episdes have a significant impact n hw well the patient recvers frm the episdes, accrding t 4 independent studies in 3 cuntries. Three cntrlled studies have evaluated the effects f family interventins n utcmes f Biplar I Disrder. Miklwitz et al (2000) fund that biplar I patients randmly assigned t family psycheducatin treatment had significantly lwer rates f depressin (but nt mania) after 9 mnths f family psycheducatin treatment, as cmpared t tw family psycheducatin sessins and subsequent crisis management treatment. Schizphrenia: The AHRQ-funded Schizphrenia Patient Outcmes Research Team (PORT) listed family interventin amng the psychscial treatments with demnstrated efficacy (grade ~1) (Lehman et al, 1998, updated 2004). Many randmized clinical trials have shwn that lng-term (greater than six mnths) family psycheducatin has a significant impact n relapse and rehspitalizatin rates fr the patient. Meta-analyses (Pekkala 2002, Pharah 2003) have shwn that fr patients whse families are invlved in a family psycheducatin prgram, relapse rates are reduced by three-quarters in the first year. McFarlane et al (2003) nte that family psycheducatinal interventins fr schizphrenia are sme f the mst substantial and cnsistent empirical effects achieved by any treatment in the mental health field. Majr Depressive Disrder: The Harvard-Pilgrim Health Care Clinical Practice Guidelines fr Majr Depressive Disrder include educatin fr the patient and family/supprt system as a critical step in treating MDD. Several randmized studies have shwn that family psycheducatin, particularly fr the spuse, has been effective in imprving utcmes fr depressin. The APA Clinical Practice Guidelines fr MDD state, Studies f the efficacy f marital r family therapy, either as a primary r adjunctive treatment, have been cnducted amng patients with depressive symptms and nt amng patients with, specifically, majr depressive disrder. Based n data frm 17 clinical trials f marital therapy, tw reviews have cncluded that it is an effective means fr reducing majr depressive disrder symptms and risk f relapse,.citing Hahlweg (1998) and Jacbsn (1976). PTSD: Nelsn and Wright (1996) suggest that effective treatment fr PTSD shuld invlve family psycheducatin, supprt grups fr bth partners and veterans, cncurrent individual treatment, and cuple r family therapy. 112

115 SUD: O Farrell et. al. (2007) fund that brief family treatment interventins were effective in prmting cntinued care amng alchl-dependent and substance-abusing patients in inpatient detxificatin. Nte that in the case f SUD, there is an evidence base fr family psychtherapy, and nt a strng evidence base fr family psycheducatin. Administrative data imperfectly accunts fr family psycheducatin visits (see feasibility nte belw). Fr this reasn, this will be a descriptive indicatr. This indicatr addresses the fllwing IOM dmain: Effectiveness. References: Practice Guideline fr the Treatment f Patients with Biplar I Disrder (2002 Revisin); American Psychiatric Assciatin; Am J Psychiatry 159:4, April 2002 Supplement ; Als, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Assciatin, 2006 Anthny F. Lehman, Dnald M. Steinwachs, and The C-Investigatrs f the PORT Prject, Translating Research Int Practice: The Schizphrenia Patient Outcmes Research Team (PORT): Updated Treatment Recmmendatins 2003, Schizphrenia Bulletin 30: 2 (2004) Hahlweg K, Markman HJ: Effectiveness f behaviral marital therapy: empirical status f behaviral techniques in preventing and alleviating marital distress. J Cnsult Clin Psychl 1988; 56: [F] Jacbsn NS, Martin B: Behaviral marriage therapy: current status. Psychl Bull : [F] Maglian L, Firill A, Malangne C, DeRsa C Maj Ma et al (2006). Patient Functining and Family Burden in a Cntrlled, Real-Wrld Trial f Family Psycheducatin fr Schizphrenia. Psychiatric Services, 57:12, McFarlane WR, Dixn L, Lukens E, et al (2003). Family psycheducatin and schizphrenia: a review f the literature. Jurnal f Marital and Family Therapy, 29: Nelsn, B. S., & Wright, D. W. (1996). Understanding and treating pst-traumatic stress disrder symptms in female partners f veterans with PTSD. Jurnal f Marital and Family Therapy, 22, O'farrell TJ, Murphy M, Alter J, Fals-Stewart W. (2007). Brief family treatment interventin t prmte cntinuing care amng alchl-dependent patients in inpatient detxificatin: A randmized pilt study. J Subst Abuse Treat Jul 3 Numeratr: a) Thse patients included in the denminatr wh have participated in ne r mre family psycheducatin encunters b) Thse individuals receiving family psycheducatin fr at least nine cntinuus mnths Denminatr: All patients in the study chrts Patient chrts: All patient chrts Definitins: Family psycheducatin: Any clinic encunters fr which the fllwing CPT cdes are present: 90846, 90847, Nine cntinuus mnths f family psycheducatin: Defined as ne r mre family psycheducatin encunter in each mnth fr nine cntinuus mnths 113

116 beginning during the study perid; the beginning f the nine mnth perid can be at any pint during the study perid and may cntinue past the end f the study perid Strength f Evidence: Biplar I: Grade I Schizphrenia: Grade I MDD: Grade I PTSD: Grade III SUD: Grade III Feasibility/Data Cllectin Issues: Specified CPT cdes are fr family psychtherapy, which is an imperfect measure f family psycheducatin. We may cnsider evaluating this indicatr separately fr biplar I disrder, schizphrenia and MDD as there is an evidence base fr using this treatment fr these cnditins. We may cnsider lking at frequency (number f mnths, r number f sessins) f family psycheducatin as well. A limitatin t this analysis is that there are veterans wh may nt have family members invlved in their care, we must assume that thse veterans withut families are equally distributed acrss PSAs. Updates: Nne. 114

117 Perfrmance Measure Technical Dcumentatin Mdule: All Indicatr Statement: Prprtin f patients wh have apprpriate labratry screening tests Indicatr number: L Executive Summary: Accrding t the VA Clinical Practice Guidelines, Testing is directed tward detectin f assciated medical cnditins and t rule ut cntraindicatins t medical therapy. Apprpriate labratry studies include: TSH, Cmplete Metablic Panel, Hepatitis, HIV, and HCG (fr females). This recmmendatin is supprted by Williams and Shepherd (2000) in their descriptin f apprpriate treatment f patients presenting in emergency departments with psychiatric symptms. Althugh this indicatr has substantial face validity and it is the standard f care t screen patients fr the reasns stated abve, there is n evidence linking lab screening t utcmes. Fr this reasn, this indicatr will nly be used descriptively. This indicatr addresses the fllwing IOM dmains: Effectiveness and Safety References: Williams ER, Shepherd SM. Medical clearance f psychiatric patients. Emergency Medical Clinician Nrth Am 2000; 18(2):185-98, vii. Numeratr: Thse patients in the denminatr with evidence f the fllwing labratry screening tests at least nce during the study perid: a) TSH b) Liver functin test c) Chemistry panel: a. Sdium b. Creatinine c. Ptassium d) Hepatitis e) HIV Denminatr: Individuals with a study-relevant diagnsis in all patient chrts Patient chrts: All patient chrts Definitins: Labratry screening tests: Defined as ne r mre f the fllwing tests frm the Labratry Natinal Data Extract TSH: TESTNAME cde= 0024 Liver functin tests defined as ne r mre f the fllwing: Aspartate Transaminase AST; Transferase Alanine Amin ALT; Phsphatase Alkaline, Bilirubin, Albumin (TESTNAME cde = 0009, 0045, 0048, 0044, 0049 ) Chemistry Panel (defined by the presence f at least ne f the fllwing tests): Sdium: TESTNAME cde =

118 Creatinine (Defined as either Serum Creatinine r Creatinine Clearance): TESTNAME cde = 0011, 0031 Ptassium: TESTNAME cde = 0002 Hepatitis (defined as ne r mre f the fllwing): TESTNAME cde = 0041, 0042, 0043 HIV (defined as ne r mre f the fllwing): TESTNAME cde = 0038, 0039, 0040 Strength f Evidence: Grade III Feasibility/Data Cllectin Issues: Althugh HCG (fr females) is an imprtant test, this test is nt part f the natinal data extracts and thus cannt be tracked in ur study. Updates: Lab test cdes were reviewed and crrected. 116

119 Part III: Medical Recrds Review Indicatrs 117

120

121 SCHIZOPHRENIA Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: New treatment episde: Assess medicatin side effects (SE) 2-4 mnths after the initiatin f any antipsychtic treatment. Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guidelines fr Management f Psychses. The VA guideline recmmends that clinicians shuld assess patients after 6-8 weeks f pharmaclgy, and that the assessment shuld "cnsider a range f antipsychtic drug side effects in assessing clinical respnse." This recmmendatin has been mdified in the current indicatr; the time perid has been extended t 2-4 mnths after initiatin f psychpharmaclgy t reflect the related VA guideline recmmendatin t reassess side-effects "t determine if treatment may need t be mdified," which has n specific time perid stated in the VA guideline r in the related American Psychiatric Assciatin (APA) guideline (2002 and 2005 update); this was determined by the VA Mental Health Prgram Evaluatin Cnsultatin Grup t be a reasnable and valid time perid fr assessment. The VA guideline recmmends assessing a number f relevant side effects in patients with Schizphrenia diagnses, and prvides the fllwing ratinale: "Antipsychtic medicatins, in particular the secnd generatin antipsychtic medicatins, may be assciated with weight gain and pssible dysregulatin f bld glucse and lipids." After reviewing the VA guideline recmmendatins, the VA Mental Health Prgram Evaluatin Cnsultatin Grup, in cncert with nn-va clinical experts in Schizphrenia, determined that the current indicatr shuld fcus n weight/bmi and akathisia as the tw highest pririty side effects fr the Schizphrenia patient ppulatin, bth in terms f prevalence and f imprtance in prviding safe and effective care. This indicatr addresses the fllwing IOM dmains: Safety, Timeliness, and Effectiveness. Numeratr: Patients frm the denminatr whse medicatin side effects have been assessed in the tw t fur mnths after the start f antipsychtic treatment, including: 1. Weight r BMI 2. Akathisia 3. Any assessment f side effects Denminatr: Patients with schizphrenia diagnsis in a new treatment episde wh have been started n antipsychtic treatment. Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Antipsychtic treatment: Defined as having at least ne prescriptin filled within 30 days f the start f the new treatment episde using the fllwing drug class cdes, 119

122 while excluding patients wh filled a prescriptin within 90 days befre the new treatment episde (t identify patients newly started n the medicatin): CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Side effects (SE): Presence r absence f side effects due t medicatin nted in the recrd 2-4 mnths fllwing the start f a new treatment episde. Weight r BMI: Bdy Mass Index (BMI) is a number calculated frm a persn s weight and height. BMI prvides a reliable indicatr f bdy fat fr mst peple and is used t screen fr weight categries that may lead t health prblems. Akathisia: Akathisia is a cmmn side effect assciated with the use f anti-psychtic medicatins (neurleptics). It is characterized by excessive, usually repetitive, mvements such as pacing, ft tapping and rcking. It is ften described as a 'feeling that yu are ging t cme ut f yur wn skin" if yu dn't mve. Akathisia must be assessed by an authrized prescriber (i.e., MD, DO, NP, r PA). Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm the medical recrd data Measuring weight r BMI withut further ntatin wuld cunt. A flag fr patients n antipsychtics will be given t the abstractrs. 120

123 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Annual assessment f weight/bmi, glycemic cntrl, lipids Indicatr Number: 2 Executive Summary: This indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Psychses. The VA guideline recmmends that patients receive a clinical assessment f weight, lipids, and glycemic cntrl every 6-12 mnths during lng-term therapy. The guideline prvides the fllwing ratinale fr this recmmendatin: Antipsychtic medicatins, in particular the secnd generatin antipsychtic medicatins, may be assciated with weight gain and pssible dysregulatin f bld glucse and lipids. Baseline and peridic mnitring f bld glucse, serum lipids, bld pressure and BMI wuld be prudent particularly in thse persns identified as having diabetes, r wh are at increased risk fr develping diabetes, r thse with ther knwn risk factrs fr cardivascular disease. These measures may help guide initial selectin f antipsychtic medicatins, imprve early detectin f the need fr medical interventin, and enhance nging reevaluatin f the apprpriateness f psychiatric medicatins. (Marder et al., in press) (17). This indicatr addresses the fllwing IOM dmains: Safety and Timeliness. Numeratr: All patients frm the denminatr with an assessment during the study perid f: 1. weight r BMI 2. glycemic cntrl 3. lipids 4. all f the abve 5. at least ne f the abve (a, b, r c) Denminatr: This indicatr will be evaluated fr the fllwing ppulatins: 1. Patients with schizphrenia diagnsis 2. Patients with schizphrenia diagnsis wh are taking antipsychtic medicatin Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade III Definitins: Weight r BMI. Bdy Mass Index (BMI) is a number calculated frm a persn s weight and height. BMI prvides a reliable indicatr f bdy fat fr mst peple and is used t screen fr weight categries that may lead t health prblems. Glycemic cntrl: Defined as a glucse ( 0010, 0057 ) r hemglbin A1C ( 0017 ) labratry test in the DSS Clinical Natinal Data Extracts. Passing this indicatr requires nly ne r the ther test fr glycemic cntrl during the study perid, althugh all tests will be tracked frm administrative data. Lipids: Defined as a LDLC ( 0027 ), HDLC ( 0028 ), ttal chlesterl ( 0029 ), r tryglicerides ( 0030 ) labratry test in the DSS Clinical Natinal Data Extracts. Passing this indicatr requires nly ttal chlesterl r LDL chlesterl during the study perid, but all lab tests will be tracked frm administrative data. 121

124 Feasibility/Data Cllectin Issues: Denminatr frm administrative data Numeratr frm the medical recrd (Weight/BMI) and administrative data (glycemic cntrl and lipids). Measuring weight r BMI withut further ntatin wuld cunt. We need t see that they did the labratry wrk, but dn t need the results. 122

125 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Evidence-Based Practice: Scial Skills Training Indicatr Number: 3 Executive Summary: This indicatr is based n the established and grwing bdy f empirical research literature supprting Scial Skills Training (SST) as an effective psychscial rehabilitatin strategy fr Schizphrenia (Bellack 2004; Mueser et al 1997). The Schizphrenia Patient Outcmes Research Team (PORT) Updated Treatment Recmmendatins (Lehman et al. 2003) prvide the fllwing ratinale t supprt the effectiveness f skills training fr peple with schizphrenia: Individuals with schizphrenia can learn a wide variety f scial and independent living skills when prvided with structured behaviral training; fllwup evaluatins f up t 1 year shw gd retentin f the skills that were taught earlier (Eckman et al. 1992; Wallace et al. 1992; Mueser et al. 1995; Liberman et al. 1998). The results f cntrlled trials indicate the benefit f skills training in imprving patients' scial and independent living skills when such training is ffered in cnjunctin with adequate pharmactherapy (Wallace and Liberman 1985; Eckman et al. 1992; Wirshing et al. 1992; Hayes et al. 1995; Kpelwicz et al. 1998; Liberman et al. 1998; Glynn et al. 2002). Evidence is strngest fr the benefit f skills training in increasing skills assessed by situatinally specific measures (Dilk and Bnd 1996). There are several reprts f cntrlled studies in which scial skills training led t a reductin f symptm severity (Wallace and Liberman 1985; Wirshing et al. 1992; Dbsn et al. 1995; Hayes et al. 1995). Meta-analyses f studies f SST effectiveness have indicated that there is cnsiderable variance amng effect sizes and utcme measures acrss studies, indicating a need fr future research (Dilk and Bnd 1996; Pilling et al. 2002). Despite these reservatins, SST remains a well-supprted and bradly endrsed treatment fr Schizphrenia. Furthermre, SST was specifically mentined in Research Questin 7 (RQ7) f the VA Statement f Wrk (June 2005) fr the current prgram evaluatin as a treatment apprach f specific interest t VA: The specific evidence-based care fr each diagnsis will need t be identified, but fr at least sme f the diagnses will include appraches such as cgnitive behaviral therapy, scial skills training, supprted emplyment with individual assistance, intensive case management (MHICM r ther), and family educatin in VA. This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. References: Bellack AS. Skills training fr peple with severe mental illness. Psychiatr Rehabil J Spring; 27(4): Dilk MN, Bnd GR. Meta-analytic evaluatin f skills training research fr individuals with severe mental illness. J Cnsult Clin Psychl Dec; 64(6): Lehman AF, Kreyenbuhl J, Buchanan RW, Dickersn FB, Dixn LB, Gldberg R, Green-Paden LD, Tenhula WN, Berescu D, Tek C, Sandsn N, Steinwachs DM. The Schizphrenia Patient Outcmes Research Team (PORT): updated treatment recmmendatins Schizphr Bull. 2004; 30(2): Mueser KT, Drake RE, Bnd GR. Recent advances in psychiatric rehabilitatin fr patients with severe mental illness. Harv Rev Psychiatry Sep-Oct; 5(3):

126 Pilling S, Bebbingtn P, Kuipers E, Garety P, Geddes J, Martindale B, Orbach G, Mrgan C. Psychlgical treatments in schizphrenia: II. Meta-analyses f randmized cntrlled trials f scial skills training and cgnitive remediatin. Psychl Med Jul;32(5): Numeratr: All patients receiving during the study perid: (a) any scial skills training visits during the study perid; and (b) hw many scial skills training visits. Denminatr: Patients with Schizphrenia diagnsis receiving any psychscial rehabilitatin during the study perid. Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade I Definitins: Scial Skills Training: Scial skills training visits may include evidence that the prvider assisted with the fllwing: 1. Verbal instructin* 2. Written instructin 3. Mdeling* 4. Behaviral rehearsal* 5. Crrective verbal feedback* 6. Hmewrk 7. Videtape feedback 8. Written feedback 9. Relaxatin training 10. Self-reinfrcement 11. In viv training * Cre Techniques T pass this indicatr, there must be evidence f at least 3 f 4 cre elements (1) verbal instructin, (2) mdeling, (3) behaviral rehearsal, and (4) verbal feedback. Scial cmpetence is based n a set f three cmpnent skills; 1) Scial perceptin r receiving skills invlves theability t accurately read r decde scial inputs. This includes accurate detectin f affect cues, such as facial expressins and nuances f vice, gesture, and bdy psture, as well as verbal cntent (what the interpersnal partner says) and cntextual infrmatin. 2) Scial cgnitin r prcessing skills invlves effective analysis f the scial stimulus, integratin f current infrmatin with histrical infrmatin (e.g., what has the partner dne in previus interactins? What is ne s experience in similar scial situatins?), and planning f an effective respnse. This dmain is als referred t as scial prblem slving. 3) Behaviral respnse r expressive skillsincludes ability t generate effective verbal cntent, t speak with apprpriate paralinguistic characteristics, and t use suitable nnverbal behavirs such as facial expressin, gestures, and psture. Effective scial behavir requires the smth integratin f these three cmpnent prcesses s as t meet the demands f the specific scial situatin. The apprach used by the prvider can be emplyed in ne-t-ne interactins between clinician and client in infrmal, ad hc interactins. Training is characteristically 124

127 cnducted in small grups, which prvides each individual with adequate pprtunity t rehearse. The cntent f training prgrams is rganized int curricula, such as jb interview skills, medicatin management (hw t cmmunicate with health care prviders), dating skills, and safe sex skills. Training duratin can ranges frm 4-8 sessins fr a very circumscribed skill, t 6 mnths t 2 years fr a cmprehensive skills training prgram. Regardless f duratin, training sessins are typically held 2-3 times per week. Training is structured s as t minimize demands n neurcgnitive capacity (Bellack 2007). Psychscial rehabilitatin: Defined as ne r mre utpatient visits where Schizphrenia is the primary r secndary diagnsis using the fllwing stp cdes: Psychscial Rehabilitatin Individual: 532; Psychscial Rehabilitatin Telephne: 537; MHICM Telephne: 546; Intensive Substance Abuse Treatment*: 547; Substance Abuse Grup*: 550; MHICM: 552; Day Treatment Grup: 553; Psychlgy Grup: 558; Psychscial Rehabilitatin Grup: 559; Substance Abuse Grup*: 560 MHICM Grup: 567 Day Treatment Individual: 505 Day Hspital Individual: 506 Substance Abuse Day Hspital*: 548 Day Treatment Grup: 553 Day Hspital Grup: 554 Pst-Traumatic Stress Disrder Day Hspital: 580 Pst-Traumatic Stress Disrder Day Treatment: 581 Psychscial Rehabilitatin Recvery Center Individual: 582 Psychscial Rehabilitatin Recvery Center Grup: 583 * We include substance abuse treatment stp cdes as it may be pssible that peple with dual diagnses f schizphrenia and SUD may receive scial skills training in these clinics. Feasibility/Data Cllectin Issues: Denminatr t cme frm administrative data Numeratr t cme frm medical recrd. 125

128 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Percent f patients with a Glbal Assessment f Functining (GAF) scre less than r equal t 40 and fur r mre visits with a case manager during the study perid Indicatr Number: 4 Executive Summary: This indicatr is based n findings presented by Niv, Chen, Sullivan, and Yung (2007) regarding the "reliability and cnvergent, discriminant, and predictive validity" f the Glbal Assessment f Functining (GAF) scale in a sample f patients with schizphrenia r schizaffective disrder wh received VHA care. Under the advisement f the VA Mental Health Prgram Evaluatin Cnsultatin Grup, this indicatr was develped t identify effective utreach and apprpriate care fr patients with diagnses f Schizphrenia with significant physical and mental impairment by case management prgrams within the VA system. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness, Timeliness, Patient-centeredness, and Efficiency. Numeratr: Fr patients in the denminatr: a) thse wh have fur r mre visits with a case manager fllwing their first eligible GAF scre b) ttal number f visits with a case manager fllwing the first eligible GAF scre within 12 mnths f the first case manager visit. Denminatr: Patients with schizphrenia diagnsis with at least tw Glbal Assessment f Functining (GAF) scres 30 r mre days apart frm each ther with scres f less than r equal t 40 during the study perid. Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade III Definitins: GAF: Glbal assessment f functining, scale f : Superir functining in a wide range f activities, life's prblems never seem t get ut f hand, is sught ut by thers because f his r her many psitive qualities. N symptms 81-90:Absent r minimal symptms ( e.g., mild anxiety befre an exam ), gd functining in all areas, interested and invlved in a wide range f activities, scially effective, generally satisfied with life, n mre than everyday prblems r cncerns ( e.g., an ccasinal argument with family members ) 71-80: If symptms are present, they are transient and expectable reactins t psychscial. stressrs ( e.g., difficulty cncentrating after family argument ); n mre than slight impairment in scial ccupatinal, r schl functining ( e.g., temprarily falling behind in schlwrk) : Sme mild symptms (e.g., depressed md and mild insmnia) OR sme difficulty in scial ccupatinal, r schl functining (e.g., ccasinal truancy r theft within the husehld), but generally functining pretty well, has sme meaningful interpersnal relatinships. 126

129 51-60: Mderate symptms (e.g., flat affect and circumstantial speech, ccasinal panic attacks) OR mderate difficulty in scial, ccupatinal, r schl functining (e.g., few friends, cnflicts with peers r cwrkers) : Severe symptms (e.g., suicidal ideatin, severe bsessinal rituals, frequent shplifting) OR any serius impairment in scial, ccupatinal r schl functining ( e,g., n friends, unable t keep a jb ) : Sme impairment in reality testing r cmmunicatin (e.g., speech is at times illgical, bscure, r irrelevant) OR majr impairment in several areas, such as wrk r schl, family relatins, judgment, thinking, r md (e.g., depressed man avids friends, neglects family, and is unable t wrk; child frequently beats up yunger children, is defiant at hme, and is failing at schl) : Behavir is cnsiderably influenced by delusins r hallucinatins OR serius impairment in cmmunicatin r judgment (e.g., smetimes incherent, acts grssly inapprpriately, suicidal preccupatin) OR inability t functin in almst all areas ( e.g., stays in bed all day, n jb, hme, r friends ) : Sme danger f hurting self r thers (e.g., suicidal attempts withut clear expectatin f death; frequently vilent; manic excitement ) OR ccasinally fails t maintain minimal persnal hygiene ( e.g., smears feces ) OR grss impairment in cmmunicatin ( e.g., largely incherent r mute ). 1-10: Persistent danger f severely hurting self r thers (e.g., recurrent vilence) OR persistent inability t maintain minimal persnal hygiene OR serius suicidal act with clear expectatin f death OR Inadequate infrmatin. Visits with a case manager: Any diagnsis-related visits (primary r secndary diagnsis) with mental health prviders wh d nt have prescribing privileges (e.g., scial wrkers, addictin therapists, psychlgists, RNs, psychiatric technicians, etc.). These will be defined using the prvider cdes (PROV1-PROV10) available in the Medical SAS Outpatient Dataset: Prvider cdes: , , , , , , Feasibility/Data Cllectin Issues: Denminatr will cme frm the medical recrd Numeratr will cme frm administrative data This indicatr will be used fr descriptive purpses. We can present data n case managers fr the patients with a GAF less than r equal t 40, greater than 40, as well as fr thse wh have n recrded GAF during the study perid. 127

130 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Dept Antipsychtic Medicatin fr Schizphrenia Indicatr Number: 5 Executive Summary: This indicatr is based n an indicatr develped by Lehman et al. (1998) as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database, which assigned t it an evidence level f AHRQ Level B ("Fair research evidence & supprting clinical cnsensus/pinin"). The riginal indicatr assessed nly patients with Schizphrenia wh receive dept antipsychtic medicatin. This indicatr has been mdified and expanded under the advisement f the VA Mental Health Evaluatin Cnsultatin Grup t als address patients with dcumentatin that they receive case management, family invlvement, r patientprvider cnversatins abut changing medicatins. Lehman et al. prvide the fllwing ratinale fr measuring dept medicatin fr nncmpliant patients: Nn-cmpliance with antipsychtic medicatin is cmmn and increases the likelihd f relapse and hspitalizatin f patients with schizphrenia. Practice guidelines, including thse frm the Schizphrenia PORT, recmmend that individuals with relapse secndary t nn-cmpliance be treated with dept antipsychtic drugs, lng-acting agents requiring intramuscular administratin 1-2 times per mnth. Research cmparing ral and dept frmulatins shws better cmpliance with dept frmulatins, but n clear advantage in relapse rates. The "family invlvement" cmpnent f this indicatr is based n an indicatr develped by Yung et al. (1998), als dcumented in the CQAIMH database with an evidence level f AHRQ Level C ("Little research evidence, principally based n clinical cnsensus/pinin"). Yung et al. prvide the fllwing ratinale fr assessing recent family invlvement n an annual basis: Randmized cntrlled trials have shwn that interventins directed at family members f individuals with schizphrenia can imprve utcmes fr bth patients and families. These interventins include educating families abut schizphrenia, prviding supprt, and training families in prblem slving and intervening during crisis situatins. Less is knwn abut the assciatin between less-intensive family invlvement in treatment and patient utcmes. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness, Timeliness, Patient-centeredness, and Efficiency. Numeratr: Patients in the denminatr wh are receiving dept antipsychtics during the study year. Denminatr: Patients with schizphrenia diagnsis with episdic treatment using antipsychtic medicatin in the study perid with a previus histry f treatment. Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade I Definitins: Episdic Treatment: Defined as patients wh received at least tw filled prescriptins fr any length but n mre than 180 days (six 30-day prescriptins 128

131 r tw 90-day prescriptins) f an antipsychtic during the study perid using the fllwing drug class cdes: CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Previus Histry f Treatment: Defined as having at least ne utpatient visit in the 12-mnths prir t the study perid where schizphrenia is the primary diagnsis Dept: Injecting patients w/ medicatin fr extended release (e.g., 2wks, 6wks, etc.) Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd A flag will be prvided frm administrative data t identify thse wh meet the definitin f the denminatr fr chart abstractin. 129

132 Perfrmance Measure Technical Dcumentatin Mdule: Schizphrenia Indicatr Statement: Prprtin f patients with schizphrenia wh are in each f the fllwing categries: 1) In cntinuus treatment with antipsychtic medicatin 2) In intermittent treatment with antipsychtic medicatin 3) Nt n antipsychtic medicatin but having mental health prvider visits with a dcumented relapse mnitring plan, 4) Nt n antipsychtic medicatin but having mental health prvider visits withut a dcumented relapse mnitring plan 5) Lst t fllw-up r leave treatment against medical advice Indicatr Number: 6 Executive Summary: This indicatr is based n an indicatr develped by the American Psychiatric Assciatin (APA) as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database, which assigned t it an evidence level f AHRQ Level C ("Little research evidence, principally based n clinical cnsensus/pinin"). The riginal APA indicatr applied t patients with schizphrenia diagnses wh are in the stable phase and have been discntinued frm antipsychtic medicatins during a specified perid; the indicatr assessed thse patients whse medical recrd cntains a written relapse-mnitring plan designed fr use in recgnizing and respnding t early signs f new episdes. Under the advisement f the VA Mental Health Evaluatin Cnsultatin Grup, the denminatr and the numeratr fr this indicatr have bth been mdified and expanded t mre bradly describe the full cmplement f patients with Schizphrenia wh are nt taking medicatin, as well as thse wh are, including thse in cntinuus r intermittent treatment and thse wh are lst t fllw-up r leave treatment against medical advice. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness, Timeliness, and Efficiency. Numeratr: Patients frm the denminatr wh are: 1) In cntinuus treatment with antipsychtic medicatin during the study perid; 2) In intermittent treatment with antipsychtic medicatin during the study perid; 3) Nt n medicatin but having mental health prvider visits with a dcumented relapse mnitring plan during the study perid; 4) Nt n medicatin but having mental health prvider visits withut a dcumented relapse mnitring plan during the study perid; r 5) Lst t fllw-up r leave treatment against medical advice during the study perid. Denminatr: All patients with schizphrenia diagnsis Patient chrts: Patients with schizphrenia diagnsis Strength f Evidence: Grade III Definitins: Cntinuus treatment: Defined as having 300 r mre days supplied f an antipsychtic during the study perid CN700, Antipsychtics 130

133 CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Intermittent treatment: Defined as having less than 300 days but mre than 60 days supplied f an antipsychtic during the study perid and have at least 2 prescriptins (e.g., ne 90-day prescriptin desn t cunt). CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Nt n medicatin: Defined as having less than 60 days supplied f an antipsychtic during the study perid CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Relapse mnitring plan: Evidence f a plan designed fr use in recgnizing and respnding t incipient signs f decmpensatin and/r new episdes and educating the patient n what t d if they were t emerge. This might be in the frm f a list f prdrmal symptms r early warning signs and a list f strategies available t the patient t deal with them (e.g., taking prn medicatins r instructins t call fr help r reprt t the ER if symptms persist). This wuld need t be dcumented quarterly. Lst t fllw-up: Mre than 3 mnths withut a visit fr peple nt n medicatin (NOTE: This will cme frm admin data) Leave treatment against medical advice: A nte in the medical recrd dcumenting that the patient was leaving treatment against medical advice. Fr inpatient, a nte in the chart r standard frm. Feasibility/Data Cllectin Issues: Denminatr frm administrative data Numeratr frm administrative data and medical recrd. Numeratr categries are mutually exclusive Numeratrs #3 and #4 are cllapsed int a single numeratr due t medical recrd abstractin issues. 131

134 BIPOLAR DISORDER Perfrmance Measure Technical Dcumentatin Mdule: Biplar Disrder Indicatr Statement: Percent f patients with biplar disrder diagnsis with evidence f an initial assessment that includes appraisal fr alchl and chemical substance use in a new treatment episde Indicatr Number: 1 Executive Summary: This indicatr is based directly n Measure 4 f the evidencebased measures develped by the STABLE Prject (Specificatins fr Biplar Disrder Perfrmance Measures, updated Nvember 2006) t specifically assess quality f care fr patients with Biplar diagnses. The fllwing research-supprted statements and related references cnstitute STABLE's clinical ratinale fr this indicatr: Between 40-70% f peple with biplar disrder have a histry f substance use disrder A current r past cmrbid substance use disrder may lead t wrse utcmes fr biplar disrders, including mre symptms, mre suicide attempts, lnger episdes and lwer quality f life Substance abuse may bscure r exacerbate md swings that have n ther apparent external cause Substance abuse may als precipitate md episdes r be used by patients t self-treat in an attempt t imprve the symptms f episdes This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness and Timeliness. References: Ostacher, MJ; Sachs, GS, Update n Biplar Disrder and Substance Abuse: Recent Findings and Treatment Strategies, J Clin Psychiatry 2006; 67[9]:e10 Regier DA, Farmer ME, Rae DS, et al. Cmrbidity f mental disrders with alchl and ther drug abuse: results frm the Epidemilgic Catchment Area (ECA) Study, JAMA 1990; 264: American Psychiatric Assciatin, Practice Guideline fr the Treatment f Patients with Biplar Disrder, Am J Psychiatry 159: 4, April 2002 Supplement Numeratr: Patients frm the denminatr wh receive an initial assessment fr biplar disrder that includes assessment f alchl and chemical substance use within 30 days after the start f a new treatment episde. Denminatr: Patients with biplar disrder in a new treatment episde Patient chrts: Patients with biplar disrder Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins Dcument Initial assessment that includes appraisal fr alchl and chemical substance use: Dcumented assessment t include at least ne f the fllwing: 132

135 Clinician dcumentatin regarding presence r absence f alchl and chemical substance use Patient cmpleted histry/assessment frm that addresses alchl and chemical substance use that is dcumented as being nted/acknwledged by clinician perfrming the assessment Use f screening tls that address alchl and chemical substance use including AUDIT-C and CAGE-AID Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data 133

136 Perfrmance Measure Technical Dcumentatin Mdule: Biplar Disrder Indicatr Statement: Annual assessment f weight r BMI, glycemic cntrl, and lipids Indicatr Number: 2 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guidelines fr Management f Psychses. The VA guideline recmmends that patients receive a clinical assessment every 6-12 mnths during lng-term therapy that includes assessment f weight, lipids, and glycemic cntrl. The guideline prvides the fllwing ratinale fr this recmmendatin: Antipsychtic medicatins, in particular the secnd generatin antipsychtic medicatins, may be assciated with weight gain and pssible dysregulatin f bld glucse and lipids. Baseline and peridic mnitring f bld glucse, serum lipids, bld pressure and BMI wuld be prudent particularly in thse persns identified as having diabetes, r wh are at increased risk fr develping diabetes, r thse with ther knwn risk factrs fr cardivascular disease. These measures may help guide initial selectin f antipsychtic medicatins, imprve early detectin f the need fr medical interventin, and enhance nging reevaluatin f the apprpriateness f psychiatric medicatins. This indicatr is supprted by a number f related evidence-based measures specific t patients with biplar disrder develped by the STABLE (STAndards fr BipLar Excellence) Prject (Specificatins fr Biplar Disrder Perfrmance Measures, updated Nvember 2006), A.M. Kilburne et al. (Jurnal f Affective Disrders, 2007), and by Marcus et al. (1999) as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database. A shrt list f these related measures fllws: STABLE (Endrsed by Natinal Quality Frum (NQF)): Percentage f patients with biplar diagnsis with evidence f screening fr hyperglycemia within 16 weeks / 6 mnths after initiating treatment with an atypical antipsychtic agent. STABLE (Future NQF submissin): Percentage f patients with biplar diagnsis with evidence f assessment fr hyperlipidemia within 16 weeks after initiating treatment with an atypical antipsychtic agent. Marcus et al: Bld level mnitring with md stabilizers fr biplar disrder AM Kilburne et al: Percent f patients with biplar diagnsis receiving lipid tests n r within 6 mnths after receiving atypical antipsychtic medicatin (Cardivascular disease risk mnitring) AM Kilburne et al: Percent f patients with biplar diagnsis receiving serum glucse level test n r within 6 mnths after receiving atypical antipsychtic medicatin (Cardivascular disease risk mnitring) This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and Timeliness. Numeratr: Patients frm denminatr wh have had an assessment f weight/bmi, glycemic cntrl, and lipids during the study perid Denminatr: This indicatr will be evaluated fr the fllwing ppulatins: 1. Patients with biplar disrder 2. Patient with biplar disrder wh are taking a md stabilizer r antipsychtic 134

137 Patient chrts: Patients with biplar disrder Strength f Evidence: Grade II Definitins: Weight/BMI: Bdy Mass Index (BMI) is a number calculated frm a persn s weight and height. BMI prvides a reliable indicatr f bdy fatness fr mst peple and is used t screen fr weight categries that may lead t health prblems. Glycemic cntrl: Defined as a glucse ( 0010, 0057 ) r hemglbin A1C ( 0017 ) labratry test in the DSS Clinical Natinal Data Extracts. Passing this indicatr requires nly ne r the ther test fr glycemic cntrl during the study perid althugh all tests will be tracked frm administrative data. Lipids: Defined as a LDLC ( 0027 ), HDLC ( 0028 ), ttal chlesterl ( 0029 ), r tryglicerides ( 0030 ) labratry test in the DSS Clinical Natinal Data Extracts. Passing this indicatr requires nly ttal chlesterl r LDL chlesterl during the study perid but all lab tests will be tracked frm administrative data. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm administrative data (lipids and glycemic cntrl) and medical recrd data (weight/bmi) 135

138 Perfrmance Measure Technical Dcumentatin Mdule: Biplar Disrder Indicatr Statement: Assess medicatin side effects between the secnd and furth mnth after the initiatin f an antipsychtic r md stabilizer Indicatr Number: 3 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guidelines fr Management f Psychses. The VA guideline recmmends that clinicians shuld assess patients after 6-8 weeks f pharmaclgy, and that the assessment shuld "cnsider a range f antipsychtic drug side effects in assessing clinical respnse." The VA guideline recmmendatin has been mdified in the current indicatr insfar as the time perid has been extended t 2-4 mnths after initiatin f psychpharmaclgy t encmpass the related VA guideline recmmendatin t reassess side-effects "t determine if treatment may need t be mdified," which has n specific time perid stated in the VA guideline r in the related American Psychiatric Assciatin (APA) guideline (2002 and 2005 update); this was determined by the VA Mental Health Prgram Evaluatin Cnsultatin Grup t be a reasnable and valid time perid fr assessment. The VA guideline recmmends assessing a number f relevant side effects in patients with biplar diagnses, and prvides the fllwing ratinale: Antipsychtic medicatins, in particular the secnd generatin antipsychtic medicatins, may be assciated with weight gain and pssible dysregulatin f bld glucse and lipids. Bth sedatin and weight gain are listed elsewhere in the same VA guideline as "Side Effects f Cnventinal and Secnd Generatin Antipsychtics." After reviewing the VA guideline recmmendatins, the VA Mental Health Prgram Evaluatin Cnsultatin Grup, in cncert with nn-va clinical experts in biplar disrder, determined that the current indicatr shuld fcus n weight/bmi and excessive sedatin as the tw highest pririty side effects fr the biplar patient ppulatin, bth in terms f prevalence and f imprtance in prviding safe and effective care. Still, we will evaluate assessment f ther side effects, if nted. This indicatr addresses the fllwing IOM dmains: Effectiveness, Patient-centeredness, Timeliness, and Safety. Numeratr: Patients frm the denminatr whse medicatin side effects (SE) have been assessed in the tw t fur mnths after the initiatin f an antipsychtic r md stabilizer, including: 1) Excessive Sedatin 2) Other side effects Denminatr: Patients with biplar disrder diagnsis in a new treatment episde wh have been started n an antipsychtic r md stabilizer Patient chrts: Patients with biplar disrder diagnsis Strength f Evidence: Grade II 136

139 Definitins: New Treatment Episde: See the Key Definitins Dcument Antipsychtic r Md Stabilizer treatment: Defined as having at least ne prescriptin filled within 30 days f the index visit fllwing the start f a new treatment episde using the fllwing drug class cdes, while excluding patients wh filled a prescriptin within 90 days befre the new treatment episde (t identify patients newly started n the medicatin): CN400, Anticnvulsants CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other CN750, Lithium Salts Excessive Sedatin: Patient lks r reprts being sleepy, tired, drwsy, takes t many naps, can t stay awake, lethargic, etc Other side effects: This may include akathisia, tremr, acne, nausea, diarrhea, plyuria (increased urine prductin), plydipsia (increased thirst), hypthyridism, plycystic vary syndrme (PCOS), drying/thinning f hair, skin rash, headache, cgnitive dulling Nte: If dcumentatin ntes n side effects, this is als acceptable. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Weight/BMI cllected frm the first date when it is recrded in the study perid rather than 2 t 4 mnths after the initiatin f a md stabilizer r antipsychtic medicatin. 137

140 Perfrmance Measure Technical Dcumentatin Mdule: Biplar Disrder Indicatr Statement: Percent f patients with a Glbal Assessment f Functining (GAF) scre less than r equal t 40 and 4 r mre visits with a case manager during a year Indicatr Number: 4 Executive Summary: This indicatr is based n an indicatr develped by Yung et al. (1998), as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database, which assigned t it an evidence level f AHRQ Level C ( Little research evidence, principally based n clinical cnsensus/pinin). The indicatr is supprted by findings presented by Niv, Chen, Sullivan, and Yung (2007) regarding the "reliability and cnvergent, discriminant, and predictive validity" f the Glbal Assessment f Functining (GAF) scale in a sample f patients with schizphrenia r schizaffective disrder wh received VHA care. Yung et al. prvide the fllwing ratinale: Case management services may be prvided t individuals with schizphrenia t assist in crdinating mental health care, medical care, and cmmunity-based services such as husing benefits and rehabilitative care. Three recent, cmprehensive reviews have been cnducted n the effectiveness f case management. One examined case management mdels cllectively, including intensive prgrams such as Assertive Cmmunity Treatment (ACT), and fund strng evidence fr effectiveness. The ther tw reviews lked separately at case management prgrams ther than ACT, finding a lack f cnclusive evidence supprting effectiveness fr these prgrams. The majrity f this evidence was generated fr peple with severe mental illness, a term that althugh variably defined, is interpreted here (as elsewhere) as inclusive f severely impaired peple with schizphrenia r biplar diagnses. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness, Efficiency, Timeliness, and Safety. Numeratr: Fr patients in the denminatr: c) thse wh have fur r mre visits with a case manager fllwing their first eligible GAF scre d) ttal number f visits with a case manager fllwing the first eligible GAF scre fr 12 mnths fllwing the first visit with a case manager. Denminatr: Patients with biplar diagnsis with at least tw Glbal Assessment f Functining (GAF) scres 30 r mre days apart frm each ther with scres f less than r equal t 40 during the study perid. Patient chrts: Patients with biplar disrder Strength f Evidence: Grade III Definitins: Glbal Assessment f Functining (GAF): (scale f 0-100) : Superir functining in a wide range f activities, life's prblems never seem t get ut f hand, is sught ut by thers because f his r her many psitive qualities. N symptms 138

141 81-90:Absent r minimal symptms (e.g., mild anxiety befre an exam), gd functining in all areas, interested and invlved in a wide range f activities, scially effective, generally satisfied with life, n mre than everyday prblems r cncerns (e.g., an ccasinal argument with family members) 71-80: If symptms are present, they are transient and expectable reactins t psychscial. stressrs (e.g., difficulty cncentrating after family argument); n mre than slight impairment in scial ccupatinal, r schl functining (e.g., temprarily falling behind in schlwrk) : Sme mild symptms (e.g., depressed md and mild insmnia) OR sme difficulty in scial ccupatinal, r schl functining (e.g., ccasinal truancy r theft within the husehld), but generally functining pretty well, has sme meaningful interpersnal relatinships : Mderate symptms (e.g., flat affect and circumstantial speech, ccasinal panic attacks) OR mderate difficulty in scial, ccupatinal, r schl functining (e.g., few friends, cnflicts with peers r cwrkers) : Severe symptms (e.g., suicidal ideatin, severe bsessinal rituals, frequent shplifting) OR any serius impairment in scial, ccupatinal r schl functining (e.g., n friends, unable t keep a jb) : Sme impairment in reality testing r cmmunicatin (e.g., speech is at times illgical, bscure, r irrelevant) OR majr impairment in several areas, such as wrk r schl, family relatins, judgment, thinking, r md (e.g., depressed man avids friends, neglects family, and is unable t wrk; child frequently beats up yunger children, is defiant at hme, and is failing at schl) : Behavir is cnsiderably influenced by delusins r hallucinatins OR serius impairment in cmmunicatin r judgment (e.g., smetimes incherent, acts grssly inapprpriately, suicidal preccupatin) OR inability t functin in almst all areas (e.g., stays in bed all day, n jb, hme, r friends) : Sme danger f hurting self r thers (e.g., suicidal attempts withut clear expectatin f death; frequently vilent; manic excitement) OR ccasinally fails t maintain minimal persnal hygiene (e.g., smears feces) OR grss impairment in cmmunicatin (e.g., largely incherent r mute). 1-10: Persistent danger f severely hurting self r thers (e.g., recurrent vilence) OR persistent inability t maintain minimal persnal hygiene OR serius suicidal act with clear expectatin f death OR Inadequate infrmatin. Visits with a case manager: Any diagnsis-related visits (primary r secndary diagnsis) with mental health prviders wh d nt have prescribing privileges (e.g., scial wrkers, addictin therapists, psychlgists, RNs, psychiatric technicians, etc.). These will be defined using the prvider cdes (PROV1-PROV10) available in the Medical SAS Outpatient Dataset: Prvider cdes: , , , , , , Feasibility/Data Cllectin Issues: Denminatr will cme frm medical recrd data Numeratr will cme frm administrative data 139

142 We can evaluate this indicatr fr thse wh have a GAF f 40 r less, fr thse with a GAF greater than 40, and fr thse with n GAF r where the GAF is dcumented but a scre is nt recrded. 140

143 Perfrmance Measure Technical Dcumentatin Mdule: Biplar Disrder Indicatr Statement: Prprtin f patients with biplar disrder wh are in each f the fllwing categries during the study perid: 6) In cntinuus treatment with md stabilizer medicatin 7) In intermittent treatment with md stabilizer medicatin 8) Nt n md stabilizer medicatin but having mental health prvider visits with a dcumented relapse mnitring plan, 9) Nt n md stabilizer medicatin but having mental health prvider visits withut a dcumented relapse mnitring plan 10) Lst t fllw-up r leave treatment against medical advice Indicatr Number: 5 Executive Summary: This indicatr is based n tw separate indicatrs develped by the British Medical Assciatin's (BMA) Quality and Outcmes Framewrk (QOF; February 2006) and the American Psychiatric Assciatin (APA) as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database. The riginal BMA measure assessed "the percentage f patients with schizphrenia, biplar affective disrder and ther psychses wh d nt attend the practice fr their annual review wh are identified and fllwed up by the practice team within 14 days f nn-attendance." BMA prvided the fllwing ratinale: Fr many patients with mental health prblems, the mst imprtant indicatrs relate t the inter-persnal skills f the dctr, the time given in cnsultatins and the pprtunity t discuss a range f management ptins. Within the 'patient experience' sectin f the quality framewrk (see the riginal measure dcumentatin), there exists the pprtunity t fcus patient surveys n particular grups f patients. This wuld be ne way in which a practice culd lk in mre detail at the quality f care experienced by peple with mental health prblems.... Pr cmpliance with medicatin is well recgnised [sic], and it is estimated that arund 50% f peple with schizphrenia d nt always take their medicatin regularly. This may lead t relapse, hspitalizatin and prer utcme (Csernansky and Schuchart, 2002). There is als evidence t suggest that nn-attendance at appintments may be interpreted by sme practices as "irratinality," as part f having a serius mental illness, rather than recgnising that nt turning up fr an appintment may be a sign f relapse (Lester et al., 2005). The VA Mental Health Prgram Evaluatin Cnsultatin Grup determined that the bject f the BMA measure might be mre effectively achieved by mdifying a similar APA indicatr fr patients with schizphrenia diagnses. The riginal APA indicatr assessed thse patients whse medical recrd cntains a written relapse-mnitring plan designed fr use in recgnizing and respnding t early signs f new episdes. Under the advisement f the VA Mental Health Prgram Evaluatin Cnsultatin Grup, the denminatr and the numeratr fr the APA indicatr were mdified and expanded t mre bradly describe the cmplement f patients with wh are nt taking medicatin, as well as thse wh are. On the strength f the riginal BMA measure, the VA Mental Health Prgram Evaluatin Cnsultatin Grup als determined that this indicatr culd reasnably apply t patients with biplar diagnses. This indicatr addresses the 141

144 fllwing Institute f Medicine (IOM) dmains: Effectiveness, Efficiency, Timeliness, and Safety. Numeratr: Patients frm the denminatr wh are: 6) In cntinuus treatment with md stabilizer medicatin during the study perid; 7) In intermittent treatment with md stabilizer medicatin during the study perid; 8) Nt n medicatin but having mental health prvider visits with a dcumented relapse mnitring plan during the study perid; 9) Nt n medicatin but having mental health prvider visits withut a dcumented relapse mnitring plan during the study perid; r 10) Lst t fllw-up r leave treatment against medical advice during the study perid. Denminatr: Patients with biplar disrder Patient chrts: Patients with biplar disrder Strength f Evidence: Grade I Definitins: Cntinuus treatment: Defined as having 300 r mre days supplied f a md stabilizer during the study perid CN400, Anticnvulsants; CN750, Lithium Salts; CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Intermittent treatment: Defined as having less than 300 days but mre than 60 days supplied f md stabilizer during the study perid and have at least 2 prescriptins (e.g., ne 90-day prescriptin desn t cunt). CN400, Anticnvulsants; CN750, Lithium Salts; CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Nt n medicatin: Defined as having less than 60 days supplied f a md stabilizer during the study perid CN400, Anticnvulsants; CN750, Lithium Salts; CN700, Antipsychtics CN701, Phenthiazine/Related Antipsychtics CN709, Antipsychtics, Other Relapse mnitring plan: Evidence f a plan designed fr use in recgnizing and respnding t incipient signs f decmpensatin and/r new episdes and educating the patient n what t d if they were t emerge. This might be in the frm f a list f prdrmal symptms r early warning signs and a list f strategies available t the patient t deal with them (e.g., taking prn medicatins r instructins t call fr help r reprt t the ER if symptms persist). This wuld need t be dcumented quarterly. Lst t fllw-up: Mre than 3 mnths withut a visit fr peple nt n medicatin (this infrmatin will cme frm the administrative data). 142

145 Leave treatment against medical advice: A nte in the medical recrd dcumenting that the patient was leaving treatment against medical advice. Fr inpatient, a nte in the chart r standard frm. Licensed mental health prvider: See the Key Definitins Dcument Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm administrative data and medical recrd data Numeratr categries are mutually exclusive 143

146 POST TRAUMATIC STRESS DISORDER (PTSD) Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Assess PTSD symptms with a standardized measure/instrument Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress and n the findings f Greenberg, Rsenheck, & Fntana (2003), which have shwn that the assessment f PTSD Symptms (using the Shrt Frm f Mississippi Scale fr Cmbat-related PTSD & NEPEC PTSD scale) is related t utcmes f primary interest in PTSD treatment. Elsewhere, Fntana and Rsenheck (1994) addressed the imprtance f using standardized instruments t assess PTSD symptms acrss multiple dmains f functining, while at the same time minimizing the verall length f the data cllectin prtcls. The VA Mental Health Prgram Evaluatin Cnsultatin Grup endrsed this finding, and recmmended that the use f standardized PTSD symptm assessment instruments be used mre frequently and cnsistently acrss all VHA care services fr patients with PTSD diagnses. The VA clinical guideline fr PTSD des recmmend and prvide evidence supprting a thrugh assessment f PTSD symptms fr patients in bth primary and mental health specialty care settings (Lagmasin et al., 1999; Williams & Shepherd, 2000), but des nt specifically recmmend that standardized assessment instrument be used in all cases. The VA Mental Health Prgram Evaluatin Cnsultatin Grup has fund that the current use f standardized instruments is generally cnfined t frmal PTSD prgrams and that medical recrd chart data is unreliable fr tracking PTSD symptms and utcmes, and therefre recmmended that this indicatr be develped and implemented t address this issue. This indicatr addresses the fllwing IOM dmains: Effectiveness and patient-centeredness. References: Greenberg GA, Rsenheck RA, Fntana A. Cntinuity f care and clinical effectiveness: treatment f psttraumatic stress disrder in the Department f Veterans Affairs. J Behav Health Serv Res Apr-Jun;30(2): Fntana A, Rsenheck R. A shrt frm f the Mississippi Scale fr measuring change in cmbat-related PTSD. J Trauma Stress Jul;7(3): Lagmasin I, Daly R, Studemire A. Medical assessment f patients presenting with psychiatric symptms in the emergency setting. Psychiatr Clin Nrth Am Dec;22(4):819-50, viii-ix Williams ER, Shepherd SM. Medical clearance f psychiatric patients. Emerg Med Clin Nrth Am May;18(2):185-98, vii Numeratr: Patients in the denminatr wh have an assessment f PTSD symptms within the first 30 days f a new treatment episde. Denminatr: a) PTSD patients with a new treatment episde 144

147 b) PTSD patients with a new treatment episde that begins in specialty mental health care. Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Specialty mental health: See the Key Definitins dcument; defined as ne r mre visits t eligible specialty mental health prviders within the first 30 days fllwing the start f a new treatment episde. Assessment f PTSD symptms: This may be dne by standardized measure/instrument r by interview. Mst cmmnly used assessment instruments may be the PCL and CAPS. Adult PTSD Self Reprts: Psttraumatic Diagnstic Scale (PDS) PTSD Checklist (PCL) Revised Civilian Mississippi Scale fr PTSD (R-CMS) Screen fr Psttraumatic Stress Symptms (SPTSS) Trauma Symptm Checklist 40 (TSC-40) Trauma Symptm Inventry (TSI) Purdue PTSD Scale Revised (PPTSD-R) Davidsn Trauma Scale (DTS) Distressing Events Questinnaire (DEQ) Impact f Events Scale Revised (IES-R) Ls Angeles Symptm Checklist (LASC) Mississippi Scale fr Cmbat-Related PTSD (M-PTSD, M-PTSD-DS) Mdified PTSD Symptm Scale (MPSS-SR) Penn Inventry fr Psttraumatic Stress Disrder (Penn Inventry) Adult PTSD Interviews: PTSD Symptm Scale Interview (PSS-I) Structured Clinical Interview fr the DSM-IV Axis I Disrders (SCID PTSD Mdule) Structured Interview fr PTSD (SI-PTSD) Clinician-Administered PTSD Scale (CAPS) Assessment f PTSD symptms by interview; includes an assessment f presence r absence f each the fllwing: Re-experiencing f event Intrusive thughts, nightmares, flashbacks, intense psychlgical distress r physilgical reactivity at internal r external cues, etc. Avidance/scial disengagement Effrts t avid related thughts, places, r peple, diminished interest in significant activities, feeling f detachment r estrangement frm thers, restricted range f affect, sense f freshrtened future, etc. Symptms f increased arusal Difficulty falling r staying asleep, irritability r utbursts f anger, difficulty cncentrating, hypervigilance, exaggerated startle respnse, etc. 145

148 This indicatr is NOT satisfied with use f a standardized PTSD screening instrument [e.g., Primary Care PTSD (PC-PTSD), Trauma Screening Questinnaire (TSQ)] r a trauma expsure measure [Ptential Stressful Events Interview (PSEI), Evaluatin f Lifetime Stressrs (ELS)]. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data We will cllect data abut the specific tls used and the scres n thse tls. We will dcument whether assessment was dne by standardized assessment measure/instrument r by interview. In analysis, we will evaluate whether thse in specialty mental health received a standardized assessment measure/instrument. Fr thse in a new treatment episde withut qualificatin (denminatr a), we will evaluate whether they received any assessment as well as whether assessment was frm interview r a standardized assessment. 146

149 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Cmplicated PTSD with a new treatment episde f PTSD with n care by a licensed mental health prvider Indicatr Number: 2 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress. This indicatr will be used fr descriptive purpses. The VA Clinical Practice Guideline fr PTSD recmmends the fllwing: 1. Primary care patients with cmplex PTSD shuld be referred t mental health specialty care fr treatment. 2. Primary care patients with severe PTSD shuld be ffered initiatin f therapy r referred t mental health specialty care fr treatment. 3. Primary care patients with PTSD with functinal impairment because f acute physilgical symptms (e.g. arusal) shuld be ffered initiatin f therapy r referred t mental health specialty care fr treatment. This indicatr was develped t assess the extent t which these recmmendatins are implemented in VHA primary care settings. In ding s, the definitin f applicable patients was mdified insfar as patients with "cmplex" r "severe" PTSD, r with "functinal impairment because f acute physilgical symptms has been peratinally defined as "PTSD patients with SUD r mental health cmrbidity," under the advisement f the VA Mental Health Prgram Evaluatin Cnsultatin Grup. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. References: Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Numeratr: Patients in the denminatr with n care by a licensed mental health prvider within 30 days f the start f the new treatment episde Denminatr: PTSD patients with a new treatment episde wh als have any mental health cmrbidity (MDD, SUD, Biplar Disrder, r Schizphrenia) r risk behavirs MDD SUD Biplar disrder Schizphrenia (includes ther psychtic disrders, as per table 1B) Active suicidal ideatin/suicidal behavir (Suicide mdule) Recent assaultive behavir (e.g., last week) Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument 147

150 Licensed mental heath prvider: See the Key Definitins dcument, defined as any diagnsis-related visit (primary r secndary diagnsis using Table 1B frm the Key Definitins Dcument) with a licensed mental health prvider Any ntatin f patient refusal fr a referral cnstitutes a pass n this indicatr Denminatr is ppulated with thse veterans wh have ne r mre f the bulleted characteristics as defined belw: Mental health cmrbidity: Defined as tw r mre diagnsis-related encunters fr MDD, biplar disrder, schizphrenia, r SUD (primary r secndary diagnsis using Table 1B f the Key Definitins Dcument) in the six mnths prir t the start f the new treatment episde Risk Behavirs: Defined as dcumentatin f psitive assessment within 14 days f the start f the new treatment episde Recent assaultive behavir: Ntatin in the chart within 14 days f the start f the new treatment episde n whether the patient exhibited recent assaultive behavir Active Suicidal Ideatin r suicidal behavir: Ntatin in the chart n whether the patient is actively cnsidering r fantasizing abut taking his wn life. This may range frm vague urges t detailed plans abut the act. Only thse wh exhibit these behavirs within 30 days f the NTE shuld be included. [NOTE: This cmes frm the Suicide Mdule and reflects the first instance in the study perid, and is nt indexed t the NTE] Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative and medical recrd data Numeratr will cme frm medical recrd (refusal, referral) and administrative data (mental health prvider visit) Refusals: Data will be cllected separately abut patient refusals f specialty mental health care referrals. Nt cmpleted referrals: Data will be cllected separately abut referrals t mental health specialty care that were made but nt cmpleted during the study perid. Denminatr data can be cllected with suicide mdule, but as the first time it is seen in the study perid; if the patient had mre than ne episde f suicidal ideatin r suicidal behavir, we will nly knw abut the first instance in the study perid. 148

151 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Prprtin f all patients with a new PTSD episde wh are assessed fr depressin Indicatr Number: 3 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress. The VA Clinical Practice Guideline fr PTSD recmmends that all patients with ASD/PTSD be assessed fr "histrical patterns f risk fr psychiatric cmrbidities" and prvides evidence t supprt this recmmendatin (Davidsn et al., 1991 Farrell et al., 1995 Weisberg et al., 2002) (B-5,B-7). The guideline further recmmends that prviders "recgnize that mental disrders, and psychscial prblems cmmnly cexist with PTSD and shuld screen fr them during the evaluatin treatment f PTSD" and that primary care prviders in particular shuld "cnsider the existence f cmrbid cnditins when deciding whether t treat patients in the primary care setting r refer them fr specialty mental health care." Accrding t the guideline; Cmrbid psychiatric cnditins are imprtant t recgnize, because they can mdify clinical determinatins f prgnsis, patient r prvider treatment pririties, and setting where PTSD care will be prvided.... Prviders shuld als expect that 50 t 80 percent f patients with PTSD have ne r mre cexisting mental disrders. Sme cmrbid medical r psychiatric cnditins may require early specialist cnsultatin, in rder t assist in determining treatment pririties. In sme cases, these disrders may require stabilizatin befre (r in cncert with) initiating PTSD treatment. Specifically regarding depressin, the guideline further states that, "while many mild t mderate illnesses may nt necessarily present situatins mandating immediate attentin, the presence f severe depressive symptms may represent a medical emergency, even in the absence f suicidal ideatin." Althugh the guideline des recmmend assessing a range f psychiatric cmrbidities, this indicatr has been develped t address nly depressin because it is the mst prevalent psychiatric cmrbidity fund in ppulatins with diagnses f PTSD, and because standardized instruments fr assessing depressin are available t facilitate reliable and valid assessments. This indicatr addresses the fllwing IOM dmain: Effectiveness. References: Davidsn JR, Fa EB. Diagnstic issues in psttraumatic stress disrder: cnsideratins fr the DSM-IV. J Abnrm Psychl Aug;100(3): Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L, Keller MB. Nnpsychiatric illness amng primary care patients with trauma histries and psttraumatic stress disrder. Psychiatr Serv Jul;53(7): Numeratr: Patients in the denminatr wh are assessed fr presence r absence f cmrbid depressin within 30 days after the start f the new treatment episde 149

152 Denminatr: PTSD patients with a new treatment episde Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Assessed fr depressin: Any dcumentatin f the presence r absence f depressin, r any assessment f md, either by frmal assessment (standardized tl) r by interview. Standardized tls fr screening and/r assessment include: PRIME-MD: 2-questin screen PHQ-2: 2-questin Patient Health Questinnaire PHQ-9: 9-questin Patient Health Questinnaire BDI: Beck Depressin Inventry BDI-S: (13-item versin) CEB-D: 5-item brief versin develped fr patients 60 years ld CES-D: Center fr Epidemilgic Studies-Depressin Scale (5, 10, r 20- item versin) MOS Depressin Questinnaire: Medical Outcmes Study Depressin Questinnaire IDS-SR 30 : Inventry f Depressive Symptmatlgy 30 item screener QIDS-SR 16 : Quick Inventry f Depressive Symptmatlgy 16 item screener HRSD 17 : Hamiltn Rating Scale fr Depressin 17 item screener HRSD 21 : Hamiltn Rating Scale fr Depressin 21 item screener HRSD 24 : Hamiltn Rating Scale fr Depressin 24 item screener MADRS: Mntgmery Asberg Depressin Rating Scale Structured Clinical Interview fr the DSM-IV Axis I Disrders (SCID MDD Mdule) SSDS-PC SIGECAPS mnemnic may als be used. This cllects the symptms f depressin frm the DSMIV. S: sleep disturbance I: Interest/pleasure reductin G: Guilt feelings r thughts f wrthlessness E: Energy changes/fatigue C: Cncentratin/attentin impairment A: Appetite/weight changes P: Psychmtr disturbances S: Suicidal thughts Infrmal assessment includes dcumentatin f the presence r absence f depressive symptms (e.g., sad md, suicidal thughts, hpelessness, etc.). Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd 150

153 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Cgnitive Behaviral Therapy (CBT) fr PTSD Indicatr Number: 4 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress and n the strng evidence base supprting the use f Cgnitive Behaviral Therapy (CBT) as an effective evidence-based therapy fr PTSD. This indicatr addresses the fllwing IOM dmain: Effectiveness. The 2004 VA Clinical Practice Guideline fr PTSD identifies Cgnitive Therapy as a psychtherapy interventin that is f "significant benefit" in the pursuit f reducing symptms severity and imprving the glbal functining f patients with PTSD (I-17). The guideline advises that Cgnitive Therapy is "strngly recmmended fr treatment f PTSD in military & nn-military ppulatins" (I-18). The guideline prvides substantial evidence in supprt f the claim that "Randmized cntrlled trials (RCTs) have shwn that CT is an effective interventin fr patients with PTSD" (I-20). CBT cmbines elements f cgnitive and behaviral appraches, emphasizing bth behaviral changes and changes in negatively biased patterns f cgnitin. CBT is structured and time-limited and is typically at least 12 sessins in duratin, but can be as shrt as 9 sessins fr certain manualized treatment appraches (e.g., CBT fr PTSD, Fa & Rthbaum, 1998) and significantly lnger when treating persnality disrders (e.g., Cgnitive-Behaviral Treatment f Brderline persnality disrder, Linehan, 1993). CBT has instructinal cmpnents and makes use f hmewrk assignments. Cgnitive behaviral therapy is based n the cncept that thughts, feelings, and behavirs, are interrelated and each influences the ther. CBT is a cllabrative effrt between the therapist and the client. Cgnitive behaviral therapists try t understand the functinal relatinship between thughts, feelings, and behavirs. They als encurage their clients t treat thughts as hyptheses abut the wrld, questin their negative thinking, and develp mre helpful thinking patterns. Cgnitive behaviral therapists have a specific agenda fr each sessin. Specific techniques / cncepts are taught during each sessin. CBT fcuses n helping the client achieve the gals they have set and training skills that can help t prevent recurrence f prblems in the future. References: Fa, E. B., & Rthbaum, B. O. (1998). Treating the trauma f rape: Cgnitivebehaviral therapy fr PTSD. New Yrk: Guilfrd. Linehan, M. M. (1993). Cgnitive-behaviral treatment f brderline persnality disrder. New Yrk: Guilfrd. Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Numeratr: Patients in the denminatr wh receive: a) Any Cgnitive Behaviral Therapy (CBT) visits (including behaviral therapy and cgnitive therapy) in the study perid, and 151

154 b) The number f CBT visits received in the year after the first CBT visit frm the same CBT prvider Denminatr: Patients with PTSD diagnsis wh are receiving psychtherapy Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade I Definitins: Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Cgnitive Behaviral Therapy: Fr PTSD, techniques used in CBT include: Discussin f thughts related t the traumatic event(s) and cgnitive restructuring (e.g., discussing the cnnectin between thughts and feelings, treating thughts as hyptheses abut the wrld, evaluating the evidence supprting r disprving a certain thught, finding cgnitive distrtins in thughts, creating ratinal/helpful alternative thughts fr a negative thught, Scratic questining). Educatin abut PTSD symptms and diagnsis (e.g., discussin f cmmn reactins t traumatic events, discussin f the rle f avidance in maintaining PTSD symptms, discussin f the rle f thughts in maintaining PTSD symptms, discussin f relatinship between trauma and patient s specific symptms). Anxiety management techniques (e.g., relaxatin training, breathing training). Cnducted expsure t reduce anxiety related t trauma reminders (e.g., in viv, imaginal, flding, prlnged, directed, interceptive, EMDR) during the sessin r discussin f expsure cnducted as hmewrk. Emtin regulatin (e.g., acceptance f negative emtins, tlerating the present mment, develping a nn-judgmental stance). Cllabratively determined hmewrk fr veteran t practice skills learned in sessin Help with activity mnitring and scheduling (e.g., having patient mnitr his/her activities fr a specific perid f time, discussing the cnnectin between rewarding activities and md, determining activities patient finds pleasurable and/r prvide him/her with sense f mastery, scheduling these activities as hmewrk). Training in cping skills, such as assertiveness and prblem slving Relapse preventin (e.g., discussin abut hw t deal with symptm recurrence, anniversaries f the trauma, traumas that may ccur in the future). Educatin abut CBT fr PTSD (e.g., prviding patient with a ratinale fr treatment, i.e., why a certain CBT technique wrks t reduce PTSD symptms). Discussin f hmewrk assigned during previus sessin and prblemslving regarding hmewrk nn-cmpliance. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm the medical recrd 152

155 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Prprtin f patients with PTSD diagnsis wh are mnitred regarding symptm severity Indicatr Number: 5 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress. The VA guideline recmmends "regular fllw-up with mnitring and dcumentatin f symptm status" in the treatment f PTSD in bth primary care and specialty mental health settings. In discussing the regularity f mnitring, the guideline recmmends that patients be assessed every three mnths after initiating treatment fr PTSD, in rder t mnitr changes in clinical status and revise the interventin plan accrdingly. The interval f three mnths is suggested because many cntrlled trials f first line therapies fr PTSD recmmended in this guideline demnstrate clinically significant changes during this time frame." This indicatr reflects these recmmendatins as applied t PTSD-diagnsed patients in a new treatment episde. The VA Clinical Practice guideline recmmendatins were mdified slightly under the advisement f the VA Mental Health Prgram Evaluatin Cnsultatin Grup. Althugh the VA Cnsultatin Grup was dubtful that standardized measures/ instruments t mnitr PTSD symptms are used bradly acrss VA settings, they nevertheless endrsed the imprtance f recmmending the widespread VA implementatin f such tls in the future. Currently, VA Clinical Experts believe that such standardized PTSD measures/instruments are used nly in PTSD-specific treatment settings. The 2004 VA Clinical Practice Guideline fr PTSD supprts this by recmmending that "The use f a pencil-paper measure f PTSD symptm severity such as the PTSD Checklist shuld be cnsidered. Scres n the PCL may be serially ver time t create a lngitudinal recrd f symptm severity and may be helpful fr recgnizing envirnmental r seasnal precipitants f PTSD symptms. This indicatr addresses the fllwing IOM dmains: Safety, Timeliness, and Effectiveness. References: Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Numeratr: Patients in the denminatr wh have an assessment f PTSD symptm severity by standardized instrument a) New Treatment Episde: At least every 3 mnths fr the first year, and Denminatr: a) PTSD patients with a new treatment episde b) All PTSD patients Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade III 153

156 Definitins: New Treatment Episde: See the Key Definitins dcument Assess PTSD symptm severity: Must use a standardized tl. The mst cmmnly used instruments may be the PCL and CAPS. Standardized tls fr assessing PTSD symptms include: Adult PTSD Self Reprts: Psttraumatic Diagnstic Scale (PDS) PTSD Checklist (PCL) Revised Civilian Mississippi Scale fr PTSD (R-CMS) Screen fr Psttraumatic Stress Symptms (SPTSS) Trauma Symptm Checklist 40 (TSC-40) Trauma Symptm Inventry (TSI) Purdue PTSD Scale Revised (PPTSD-R) Davidsn Trauma Scale (DTS) Distressing Events Questinnaire (DEQ) Impact f Events Scale Revised (IES-R) Ls Angeles Symptm Checklist (LASC) Mississippi Scale fr Cmbat-Related PTSD (M-PTSD, M-PTSD- DS) Mdified PTSD Symptm Scale (MPSS-SR) Penn Inventry fr Psttraumatic Stress Disrder (Penn Inventry) Adult PTSD Interviews: PTSD Symptm Scale Interview (PSS-I) Structured Clinical Interview fr the DSM-IV Axis I Disrders (SCID PTSD Mdule) Structured Interview fr PTSD (SI-PTSD) Clinician-Administered PTSD Scale (CAPS) This indicatr is NOT satisfied with use f a standardized PTSD screening instrument [e.g., Primary Care PTSD (PC-PTSD), Trauma Screening Questinnaire (TSQ)] r a trauma expsure measure [Ptential Stressful Events Interview (PSEI), Evaluatin f Lifetime Stressrs (ELS)]. This indicatr is NOT satisfied by nn-standardized assessment. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data In analysis, we will separate ut by: a. All PTSD patients, and b. Thse PTSD patients in specialty mental health Medical recrd abstractrs will cllect the dates f the first 5 assessments after the PTSD new treatment episde. 154

157 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Prprtin f patients with PTSD diagnsis wh receive an adequate trial f selective sertnin reuptake inhibitrs (SSRIs) Indicatr Number: 6 Executive Summary: This indicatr is based n recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress. The guideline "strngly recmmend[s] selective sertnin reuptake inhibitrs (SSRIs)" as mntherapy fr the treatment f PTSD, and assigns this recmmendatin an "A" grade, defined as "a strng recmmendatin that the interventin is always indicated and acceptable" based n "high grade evidence directly linked t health utcme" and "mre than a small relative impact n a frequent cnditin with a substantial burden f suffering; r a large impact n an infrequent cnditin with a significant impact n the individual patient level" (AA-3, AA-4). The guideline prvides extensive ratinale and evidence supprting the use f SSRIs, including but nt limited t the fllwing excerpt: Antidepressants, particularly sertnergic reuptake inhibitrs have prved effective in treating PTSD, and have been recmmended as first-line agents in treatment guidelines (Davidsn et al., 2001; Brady et al., 2000; Fa et al., 2000; Fa et al., 1999). Sertraline is the best-studied f the SSRIs, with fur studies f ver 100 participants each shwing a significant respnse t the drug (Brady et al., 2000;). This indicatr addresses the fllwing IOM dmains: Effectiveness, Efficiency, and Timeliness. References Brady K, Pearlstein T, Asnis GM et al. Efficacy and safety f sertraline treatment f psttraumatic stress disrder: a randmized cntrlled trial. Jama 2000; 283 (14): Davidsn JR, Rthbaum BO, van der Klk B A et al. Multicenter, duble-blind cmparisn f sertraline and placeb in the treatment f psttraumatic stress disrder. Arch Gen Psychiatry 2001; 58 (5): Davidsn JR, Rthbaum BO, van der Klk B A et al. Multicenter, duble-blind cmparisn f sertraline and placeb in the treatment f psttraumatic stress disrder. Arch Gen Psychiatry 2001b; 58 (5): Fa EB, Davidsn JRT, Frances A. The Expert Cnsensus Guideline Series: Treatment f Psttraumatic Stress Disrder. J Clin Psychiatry 1999; 60 (Suppl 16). Fa EB, Keane TM, Friedman MJ. Effective Treatments fr PTSD: Practice Guidelines frm the Internatinal Sciety fr Traumatic Stress Studies. New Yrk, NY: Guilfrd. Lndbrg PD, Hegel MT, Gldstein S et al. Sertraline treatment f psttraumatic stress disrder: results f 24 weeks f pen-label cntinuatin treatment. J Clin Psychiatry 2001; 62 (5): Management f Pst-Traumatic Stress. Washingtn, DC: VA/DD Clinical Practice Guideline Wrking Grup, Veterans Health Administratin, Department f Veterans Affairs and Health Affairs, Department f Defense, December Office f Quality and Perfrmance publicatin 10Q-CPG/PTSD-04. Rapaprt MH, Endictt J, Clary CM. Psttraumatic stress disrder and quality f life: results acrss 64 weeks f sertraline treatment. J Clin Psychiatry 2002; 63 (1): Numeratr: Patients in the denminatr wh receive a trial f SSRIs fr 60 days r have a dcumented reasn fr discntinuing SSRI treatment in < 60 days f the start f 155

158 the SSRI trial (patient refusal, discntinued fr medical reasns, nt an apprpriate candidate). Denminatr: Patients with PTSD with a new treatment episde wh are in: a. Specialty mental health care and wh are nt receiving psychtherapy b. Any type f care and wh are nt receiving psychtherapy c. Any care Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade I Definitins: New Treatment Episde: See the Key Definitins dcument Specialty mental health: See the Key Definitins dcument tw r mre visits within 90 days f the start f the new treatment episde. Patients wh are nt receiving psychtherapy: Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Patients with fewer than 4 diagnsis-related psychtherapy visits within 60 days f the start f the SSRI trial defines a patient nt receiving psychtherapy SSRI trial: Tw r mre cnsecutive 30-day prescriptins r ne 90-day prescriptin fr an SSRI/SNRI (assciated NDC cdes can be fund in the Key Definitins Dcument): SSRIs: Citalpram Escitalpram Fluxetine Fluvxamine Parxetine Sertraline SNRIs: Dulxetine Venlafaxine Date f start f SSRI trial: Defined as the date f the first prescriptin filled fr an SSRI as defined abve Refusals: Cllect data separately abut any patient refusals f SSRI treatment. Feasibility/Data Cllectin Issues: Numeratr will cme frm administrative (SSRI treatment) and medical recrd data (Initial SSRI refusal, reasn fr early SSRI discntinuatin side effects, ntatin that patient is nt a candidate fr SSRI treatment rule ut biplar r cncerns abut sertnin syndrme). Cllect each type separately. Denminatr will cme frm administrative data (new treatment episde, n psychtherapy). SSRI fr 6 cnsecutive weeks within a calendar year will be cunted fr the numeratr In analysis, cmpare PTSD chrt with chrt that has PTSD and MDD. Dsage f SSRI cnsidered nt as imprtant as the duratin f treatment. 156

159 Perfrmance Measure Technical Dcumentatin Mdule: Pst Traumatic Stress Disrder (PTSD) Indicatr Statement: Reductin in target symptms during the new treatment episde Indicatr Number: 7 Executive Summary: This indicatr is based n an indicatr prpsed by VA in the PTSD Appendix A t supprt PTSD Prgram Outcme #5 ("VA patients shuld attain reductin r remissin f target symptms"), and has been mdified and develped with the VA Mental Health Prgram Evaluatin Cnsultatin Grup (February - August 2007). In the PTSD Appendix A, VA prpsed measuring "reductin in target symptms, e.g., hyper-arusal, trauma re-experiencing, avidance f assciated stimuli, reductin in suicide risk, dcumented GAF scres, side effects " with the fllwing data surces: "medical recrd, GAF scres, SF-36 data, SHEP." There d nt appear t be any previusly develped perfrmance indicatrs that supprt the use f these measurements in evaluating quality f care. Hwever, clinical experts in PTSD and in general mental health care, bth internal and external t VA, endrsed the currently develped indicatr as being high-pririty, relevant, useful, and meaningful within the VA system. There are, hwever, caveats assciated with utilizing this indicatr. It is likely that this indicatr can nly be reliably and validly recrded if a standardized instrument is used, yet it is unlikely that such standardized instruments are currently in use in mst applicable VA care settings fr patients with PTSD diagnses. This indicatr addresses the fllwing IOM dmains: Effectiveness, Timeliness, and Efficiency. Numeratr: Patients in the denminatr wh within the 3-mnths fllwing a new treatment episde have a dcumented reductin in scre frm a standardized measure/instrument Denminatr: PTSD patients with a new treatment episde and at least tw standardized assessments using the same tl within 90 days f the start f the new treatment episde Patient chrts: Patients with PTSD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Standardized measure/instrument: Cllect all fr 90 days after start f new treatment episde (up t a maximum f 5 per NTE). The mst cmmnly used instruments may be the PCL and CAPS. Standardized tls fr assessing PTSD symptms include: Adult PTSD Self Reprts: Psttraumatic Diagnstic Scale (PDS) Ttal severity scre: 0-51 (may be dcumented as scres in each f 4 parts f the scale which will ttal n mre than 51) Can als be scred with an algrithm as PTSD =yes/n PTSD Checklist (PCL) Ttal scre: 17-85, based n a 17-item instrument. (NOTE: If sme f the 17 items are nt answered, scre will be <17) 157

160 Can als be scred with the DSM-IV criteria, r a cmbinatin f DSM-IV and ttal scre Separate scres can als be btained fr Criteria B, C, and D Revised Civilian Mississippi Scale fr PTSD (R-CMS) Ttal scre: , based n a 30-item instrument (see nte fr PCL). Screen fr Psttraumatic Stress Symptms (SPTSS) Scre: 0-10, based n average f 17 items rated frm 0-10 Trauma Symptm Checklist 40 (TSC-40) Ttal scre: Trauma Symptm Inventry (TSI) Uses a prprietary scring algrithm, nt based n a ttal scre. Assessment with this instrument shuld include a scre reprt. Recmmend cding this as PTSD diagnsis = Yes/N, r scre reprt = present/absent fr simplicity. Purdue PTSD Scale Revised (PPTSD-R) Ttal scre: (see nte fr PCL) Can als be scred with an algrithm as PTSD =yes/n Davidsn Trauma Scale (DTS) Frequency scre: 0-68 Severity scre: 0-68 Ttal scre: Distressing Events Questinnaire (DEQ) Renamed the PTSD Screening and Diagnstic Scale (PSDS) accrding t a 2000 study Ttal scre: 0-68 Can als be scred with DSM-IV symptm criteria and dcumented as PTSD =yes/n Impact f Events Scale Revised (IES-R) Ttal scre: 0-88 Ls Angeles Symptm Checklist (LASC) Ttal scre: Can als be scred with an algrithm as PTSD =yes/n Mississippi Scale fr Cmbat-Related PTSD (M-PTSD, M-PTSD-DS) Ttal scre: Mdified PTSD Symptm Scale (MPSS-SR) Ttal scre: 0-51, r severity: A-D Penn Inventry fr Psttraumatic Stress Disrder (Penn Inventry) Ttal scre: 0-78 Adult PTSD Interviews: PTSD Symptm Scale Interview (PSS-I) Ttal scre: 0-51 Can als be scred with an algrithm as PTSD =yes/n Structured Clinical Interview fr the DSM-IV Axis I Disrders (SCID PTSD Mdule) N ttal scre, diagnsis is made using an algrithm; see cmments fr TSI. Assessment with this instrument shuld include a scre reprt. Structured Interview fr PTSD (SI-PTSD) Ttal scre:

161 Can als be scred with an algrithm as PTSD =yes/n Clinician-Administered PTSD Scale (CAPS) Several scring methds are in use, including a ttal scre and an algrithm. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data (standardized tl scres) In analysis, decisin will have t be made n what reductin in scre will cunt. Fr analysis, we may want t lk at this by specialty care vs. all care. 159

162 MAJOR DEPRESSIVE DISORDER (MDD) Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Percentage f patients whse severity f MDD was classified during the initial assessment perid using a reasnable instrument Indicatr Number: 1 Executive Summary: The fllwing indicatr cmes frm the Physician Cnsrtium fr Perfrmance Imprvement Majr Depressive Disrder Physician Perfrmance Measurement Set, released by American Medical Assciatin n behalf f the Physician Cnsrtium fr Perfrmance Imprvement in Octber 2003 and revised August The riginal specificatins d nt prvided any descriptin f the instruments r ther means thrugh which patient severity f MDD disrder shuld be assessed. Therefre, this indicatr has been revised t include specific mentin f reasnable instruments fr this purpse. The Physician Cnsrtium fr Perfrmance Imprvement prvides primarily general ratinale fr this indicatr, but des indicate that Despite ptential risks and established clinical guidelines, recent data suggest that sme patients are nt being managed ptimally fr this disease. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: Patients frm the denminatr whse severity f majr depressive disrder was classified within 30 days f a new treatment episde using a reasnable instrument Denminatr: Patients with MDD diagnsis in a new treatment episde Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Classificatin: The fllwing instruments wuld cunt fr classificatin: PHQ-9: 9 questin Patient Health Questinnaire BDI: Beck Depressin Inventry CES-D: Center fr Epidemilgic Studies-Depressin Scale MOS Depressin Questinnaire: Medical Outcmes Study Depressin Questinnaire IDS-SR 30 : Inventry f Depressive Symptmlgy 30 item screener QIDS-SR 16 : Quick Inventry f Depressive Symptmlgy 16 item screener HRSD 17 : Hamiltn Rating Scale fr Depressin 17 item screener HRSD 21 : Hamiltn Rating Scale fr Depressin 21 item screener HRSD 24 : Hamiltn Rating Scale fr Depressin 24 item screener MADRS: Mntgmery Asberg Depressin Rating Scale SCID: Structural Clinical Interview fr DSM IV (MDD mdule) In additin, ntatin in the recrd as t degree f severity (i.e., mderate severity, severe depressin ) wuld cunt 160

163 SIGECAPS mnemnic may als be used. This cllects the symptms f depressin frm the DSMIV. S: Sleep disturbance I: Interest/pleasure reductin G: Guilt feelings r thughts f wrthlessness E: Energy changes/fatigue C: Cncentratin/attentin impairment A: Appetite/weight changes P: Psychmtr disturbances S: Suicidal thughts. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Fr data cllectin, we will cllect the type f screener used as well as whether degree f severity cmes frm a nte in the recrd withut an instrument. This will allw us t see if there are differences when an instrument is used We will represent the numeratr tw ways: 1) Patients frm the denminatr with a quantitative symptm assessment and 2) Patients frm the denminatr with a qualitative symptm assessment. 161

164 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Prprtin f MDD patients with a new treatment episde wh have an initial and fllw-up quantitative symptm assessment. Indicatr Number: 2 Executive Summary: The fllwing indicatr cmes frm the 2005 Health Resurces and Services Administratin (HRSA) Health Disparities Cllabrative (HDC) Depressin Cllabrative Measures set. This measure is ne f 8 additinal recmmended measures in the HRSA Health Disparities Cllabrative fr Depressin, and is based n AHRQ guidelines, which suggest that if there is n respnse at 6 weeks treatment needs t be changed r augmented. HRSA HDC prvides the fllwing ratinale: Depressin care in the United States is even mre fragmented than care f ther chrnic illnesses, creating a majr gap between the recmmended guidelines fr care and actual care. It is estimated that nly 19 percent--fewer than 1 in 5--f peple with depressin wh see their primary care prvider receive apprpriate, guideline-based care. Imprving depressin care is nt nly a matter f meeting the typical challenges f prviding gd chrnic illness care--fllwing peple ver time rather than respnding t acute episdes, prviding systematic fllw-up t ensure that patients adhere t treatment plans, and s n. In additin, depressin care brings its wn cmplex set f challenges, ranging frm underdiagnsis t financial disincentives fr prviders t special treatment requirements because the underlying nature f the illness frequently undercuts patients' ability t be effective managers f their wn care. The title f the riginal HRSA HDC indicatr was: Depressin: percent f clinically significant depressin patients wh have a dcumented Current Patient Health Questinnaire (PHQ) reassessment between 4 t 8 weeks after their last New Episde PHQ. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: Patients frm the denminatr with a dcumented quantitative symptm assessment: 1) Initial: Within 30 days fllwing the start f the new treatment episde; AND 2) At fllw-up: Between the secnd and furth mnth after new episde assessment Denminatr: Patients with MDD diagnsis in a new treatment episde Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See Key Definitins dcument Quantitative symptm assessment may include: PHQ: Patient Health Questinnaire BDI: Beck Depressin Inventry CES-D: Center fr Epidemilgic Studies-Depressin Scale MOS Depressin Questinnaire: Medical Outcmes Study Depressin Questinnaire IDS-SR30: Inventry f Depressive Symptmlgy 30 item screener 162

165 QIDS-SR16: Quick Inventry f Depressive Symptmlgy 16 item screener HRSD17: Hamiltn Rating Scale fr Depressin 17 item screener HRSD21: Hamiltn Rating Scale fr Depressin 21 item screener HRSD24: Hamiltn Rating Scale fr Depressin 24 item screener MADRS: Mntgmery Asberg Depressin Rating Scale SIGECAPS mnemnic may als be used. This cllects the symptms f depressin frm the DSMIV. S: Sleep disturbance I: Interest/pleasure reductin G: Guilt feelings r thughts f wrthlessness E: Energy changes/fatigue C: Cncentratin/attentin impairment A: Appetite/weight changes P: Psychmtr disturbances S: Suicidal thughts. Feasibility/Data Cllectin Issues: The denminatr will cme frm administrative data The numeratr will cme frm medical recrd data Realistically, nurses will see nly the PHQ, BDI and CES-D, s we will give them cpies f these three. Hwever, all wuld cunt twards the indicatr if seen. SIGECAPS is nt a quantitative assessment. This will be gruped with ther qualitative ntatins. 163

166 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: If a new diagnsis f depressin is made, specific cmrbidities shuld be elicited and dcumented in the recrd, including presence r absence f: a) Alchl r ther drug use; b) Medicatin use; and c) Histry f biplar symptms Indicatr Number: 3 Executive Summary: The primary surce fr this indicatr is Kerr & Clarke 1997 #2 (Depressin Guideline Panel, 1993a & 1993b). This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Kerr & Clarke's ratinale fr the riginal indicatr is as fllws: Practitiners need t cnsider the presence f ther c-mrbidities prir t making a diagnsis f majr depressin. Other factrs that may cntribute t the patient's mental health and which the clinician may want t treat first include: substance abuse, medicatins that cause depressin, general medical disrder, causal, nnmd psychiatric disrder and/r grief reactin (AHCPR, 1993a). The clinician shuld als cnsider alternative diagnses by eliciting a prper patient histry. Examples f alternative diagnses include: biplar disrder (if the patient manifests prir manic episdes) (4). The riginal Kerr & Clarke indicatr has been mdified by the additin f 2 cmrbities identified by the 2002 VA/DD Clinical Practice Guideline fr the Management f Majr Depressive Disrder as imprtant. The guideline recmmends that initial patient assessments "differentiate uniplar frm biplar depressin" because "A past histry f mania r hypmania excludes a patient frm a diagnsis f MDD. These patients may require referral t a mental health prfessinal. These patients ften need specialist s treatment and fllw-up, since initiating r titrating rutine antidepressant medicatin can precipitate a manic episde" (36). Similarly, the guideline als recmmends that initial assessments identify patients wh may be experiencing depressed symptms as a result f an underlying medical cnditin such as trauma, fr the fllwing reasns: "Simultaneus treatment is ften required fr bth the medical prblem and psychiatric symptms. Additinally, there is ften a strng assciatin between the level f disability frm the medical cnditin and the depressive symptm requiring treatment" (51). Numeratr: Patients frm the denminatr wh are assessed fr presence r absence f the fllwing cmrbidities: a) Alchl r ther drug use-within 30 days fllwing the start f either the MDDNTE r SUDNTE, whichever happens secnd; b) Medicatin use within 30 days n r after the MDD NTE; and c) Histry f biplar symptms within 30 days befre f after the MDD NTE. Denminatr: Patients with MDD diagnsis in a new treatment episde Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III 164

167 Definitins: New Treatment Episde: See the Key Definitins dcument Alchl and drug use: Dcumentatin f n recent alchl and n recent drug use OR infrmatin abut recent alchl and drug use including type, quantity, and frequency fr all substances used. (COLLECTED IN CROSS CUTTING MODULE IN ABSTRACTION) Type: Specifically ask abut alchl, marijuana, ccaine, herin/narctics, methamphetamine/stimulants, intravenus drug use; r nte abut denying all ther drug use Quantity (nly needed fr alchl): May include nte in chart n any f the fllwing: Number f drinks per day, number f drinks per week, any nte abut binge drinking (>5 drinks per day), any evidence f quantity Frequency: Nte abut daily, mnthly, weekly, r ccasinal use Medicatin use: List f medicatin that the patient is currently taking. Ntatin in the recrd that the patient is nt n any medicatins wuld cunt Biplar symptms: Presence r absence f signs f mania and depressin. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Fr medicatin use, we may want t cnsider validating any ntes that say there is nt medicatin use with pharmacy data. We are making the assumptin that the treating prvider read all related ntes within the 30 day windw. Therefre, we are allwing a lk back perid f 30 days prir t the NTE fr thse questins pertaining t histrical infrmatin. 165

168 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Past psychiatric histry f MDD Indicatr Number: 4 Executive Summary: The fllwing indicatr cmes frm Wells et al., 1993, as catalged in the Natinal Inventry f Mental Health Quality Measures develped by the Center fr Quality Assessment & Imprvement in Mental Health. Wells et al., 1993 prvided the fllwing ratinale fr this indicatr: A psychiatric histry is an imprtant part f an inpatient admissin assessment, with implicatins fr diagnsis, treatment, and discharge planning. Clinical practice guidelines recmmend that this assessment include previus episdes f psychiatric illness (including symptms, functining and duratin) and previus treatment (including dse, duratin & respnse). The title f the riginal indicatr was Assessment f Psychiatric Histry in Treating Depressin, and was restricted t inpatients ages 65 years and lder. The riginal indicatr has been mdified t include assessment f family psychiatric histry and has been extended t all new patients with a diagnsis f majr depressin, regardless f age. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: Patients frm the denminatr wh received assessment f lifetime psychiatric histry f MDD within 30 days f the new treatment episde (befre, after r n). Denminatr: Patients with MDD diagnsis in a new treatment episde Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Assessment f psychiatric histry f MDD: nly includes persnal histry f MDD (indicatin f recurrence and treatment respnse histry); shuld be fund in the prgress ntes; nly seeing histry f ther psychiatric cmrbidities withut ntes n MDD histry wuld nt cunt. Shuld als think abut ways t capture treatment histry, especially t see if there is an adequate medicatin histry in the chart. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data The dcumentatin f past histry must be included in the new assessment t cunt. 166

169 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Prprtin f patients with MDD diagnsis that received Cgnitive Behaviral Therapy (CBT) Indicatr Number: 5 Executive Summary: This indicatr has been develped based n the strength f the evidence bases supprting Cgnitive Behaviral Therapy (CBT) and Interpersnal Psychtherapy as effective therapies fr majr depressin. CBT cmbines elements f cgnitive and behaviral appraches, emphasizing bth behaviral activatin and changes in negatively biased patterns f cgnitin. This apprach has the mst research supprting its effectiveness fr immediate gains during current episde and lng term benefit in preventing future episdes f illness. CBT is structured and time-limited, and is at least 12 sessins in duratin. The evidence base fr CBT is strngest fr majr depressin but rbust evidence als exists fr schizphrenia. Interpersnal Psychtherapy fcuses n clarificatin and reslutin f difficulties in relatinships, explring lsses, rle disputes and transitins, and scial skills deficits. Supprting dcumentatin and ratinale fr these tw therapies is cited in the 2002 VA/DD Clinical Practice Guideline fr the Management f Majr Depressive Disrder, as well as in a number f ther surces, including but nt limited t the fllwing: Butler, Andrew C.; Chapman, Jasn E.; Frman, Evan M., and thers. The empirical status f cgnitive-behaviral therapy: A review f meta-analyses. Clinical Psychlgy Review {Netherlands : Elsevier Science}Vl 26(1) (Jan 2006): American Psychiatric Assciatin (APA) Guideline Watch: Practice Guideline fr the Treatment f Patients with Majr Depressive Disrder, 2 nd ed. Editrs Fchtmann LJ and Gelenberg AJ. American Psychiatric Assciatin (APA), Keller MB, McCullugh JP, Klein DN, Arnw B, Dunner DL, Gelenberg AJ, Markwitz JC, Nemerff CB, Russell JM, Thase ME, Trivedi MH, Zajecka J: A cmparisn f nefazdne, the cgnitive behaviral-analysis system f psychtherapy, and their cmbinatin fr the treatment f chrnic depressin. N Engl J Med 2000; 342: This indicatr addresses the fllwing IOM dmains: Effectiveness. Numeratr: Patients frm the denminatr: a) Receiving any Cgnitive Behaviral Therapy (CBT) visits (including Behaviral Therapy and Cgnitive Therapy) in the study perid, and b) The number f CBT visits received Denminatr: Patients with MDD diagnsis receiving any psychtherapy Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade I - Althugh there is substantial rbust evidence that CBT is effective fr MDD, we must als remain aware that evidence is still unclear regarding the ptimal dse/duratin f this treatment. Definitins: Any Psychtherapy Visits (fr defining the denminatr ppulatin): See the Key Definitins Dcument 167

170 Cgnitive Behaviral Therapy (CBT): CBT fr Majr Depressive Disrder (MDD) is typically at least 12 sessins in duratin Discussin f thughts and feelings that may cntribute t depressin Discussin f behavirs that may cntribute t depressin Discussin f cgnitive mdel f depressin Teach skills t manage depressin, such as reattributin, increasing participatin in enjyable activities Educatin abut diagnsis f depressin Cllabratively determine hmewrk fr veteran t practice skills learned in sessin. Helped veteran with activity mnitring and scheduling (e.g., cmpleting an activity mnitring chart, recrding activity pleasure ratings, develping an activity schedule) Asked veteran t d things that he/she enjyed ding between sessins Practice skills learned in sessin, write dwn daily activities, write dwn thughts, behaviral experiments, behaviral activatin, etc. Assist veteran in questining negative thughts and develping new mre adaptive thughts; help veteran create statements that he/she culd use t respnd t negative thughts (e.g., practicing ratinal respnses using reattributin r alternative reasning) Help veteran understand the beliefs r assumptins behind his/her thinking (e.g., cre beliefs, cgnitive schemas, patterns in thinking). CBT cmbines elements f cgnitive and behaviral appraches, emphasizing bth behaviral activatin and changes in negatively biased patterns f cgnitin. CBT is structured and time-limited and is typically at least 12 sessins in duratin. CBT has instructinal cmpnents and makes use f hmewrk assignments. Cgnitive behaviral therapy is based n the cncept that thughts, feelings, and behavirs, are interrelated and each influences the ther. CBT is a cllabrative effrt between the therapist and the client. Cgnitive behaviral therapists want t gain a very gd understanding f their clients' cncerns, and they typically ask questins t btain understanding f the client s experience and perspectives. They als encurage their clients t ask questins f themselves. Cgnitive behaviral therapists have a specific agenda fr each sessin. Specific techniques / cncepts are taught during each sessin. CBT fcuses n helping the client achieve the gals they have set and training skills that can help t prevent recurrence f prblems in the future. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data The definitin f CBT abve is prvided t help abstractrs identify the dates f CBT sessins. Fr data cllectin, we will nt require that all cmpnents f the descriptin be present. This is a descriptive measure abut the number f CBT visits. While CBT is typically 12 visits, the indicatr des nt require that there be exactly 12 visits identified. In analysis, we will stratify primary care and mental health t lk at the number f visits in each. Thse patients with NTE will have these questins re-abstracted using revised study perid dates. We will rely n administrative data t pick up number f visits fr CBT by the same prvider, lking backward and frward ne year. 168

171 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Assessment f degree f respnse/remissin, side effects and adherence/cmpliance f medicatin Indicatr Number: 6 Executive Summary: The primary surce fr this indicatr is Kerr and Clarke 1997 #13 (Depressin Guideline Panel, 1993a & 1993b). Kerr and Clarke's justificatin includes the fllwing: The Depressin Guideline Panel recmmended fllw-up visits at 12-week intervals, but did nt have any evidence abut ptimal timing. At each visit during which depressin is discussed, the degree f respnse/remissin and side effects f medicatin shuld be assessed and dcumented during the first year f treatment (AHCPR, 1993a). Kerr and Clarke further cmmented that "Even effectively treated patients may relapse r develp txicities t medicatins. While mst persns will be ff f medicatins after ne year, the ptimal time t remve medicatins is still nt well established. The benefits assciated with this indicatr were described as: "Alleviate symptms f depressin. Reduce txicities f medicatin. Reduce remissin." The riginal indicatr title, as fllws, was wrded almst identically t the title as it currently stands: At each visit during which depressin is discussed, degree f respnse/remissin and side effects f medicatin shuld be assessed and dcumented during the first year f treatment. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: Patients frm the denminatr fr which there is dcumentatin describing assessment f degree f respnse/remissin, side effects f and adherence/cmpliance t medicatin in the perid tw t fur mnths fllwing the start f the new treatment episde Denminatr: Patients with MDD in a new treatment episde n medicatin Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: Depressin diagnsis: See Table 1B in the Key Definitins Dcument New Treatment Episde: See the Key Definitins dcument Patients n Medicatin: Defined as patients with ne r mre 30-day prescriptins filled fr an antidepressant in the three mnths after the start f the new treatment episde using the fllwing VA Drug Class Cdes: CN600, Antidepressants CN601, Tricyclic Antidepressants CN602, Mnamine Oxidase Inhibitr Antidepressants CN609, Antidepressants, Other CN750, Lithium Salts. 169

172 Degree f respnse/remissin and adherence/cmpliance: Prgress nte that indicates patient is ding better r feels kay r is nt ding better r desn t feel kay. Side effects f medicatin: presence r absence f side effects nted in the recrd. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data A list f side effects fr the abstractrs will be develped in case prviders name them withut calling them side effects Abstractrs are cllecting additinal infrmatin; first date f each mnth, allwing up t 12 dates. We will analyze the additinal infrmatin descriptively. 170

173 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Dcumentatin that the fllw-up visit between the secnd and furth mnth includes assessment f respnse Indicatr Number: 7 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2002 VA/DD Clinical Practice Guideline fr the Management f Majr Depressive Disrder. The VA guideline fr recmmends frequent assessments f side effects/adherence every 1-2 weeks; this indicatr reflects a less stringent timeframe f 2-4 mnths. This indicatr addresses the fllwing IOM dmains: Safety, Timeliness, and Effectiveness. Numeratr: Patients frm the denminatr with a licensed mental health prvider at which MDD is the primary r secndary diagnsis and during which there was assessment and dcumentatin f respnse t utpatient grup and/r individual MDD psychtherapy in the perid tw t fur mnths fllwing the start f the new treatment episde Denminatr: Patients with MDD in new treatment episde wh are in psychtherapy Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Licensed Mental Health Prvider: See the Key Definitins dcument Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument in the tw mnths fllwing the start f the new treatment episde Respnse: Nte in the chart abut effectiveness r lack theref f medicatin r treatment. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Abstractrs are cllecting additinal infrmatin; first date f each mnth, allwing up t 12 dates. We will analyze the additinal infrmatin descriptively Fr analysis, lk at: Whether persn had 12-week fllw up (can happen between 8-20 weeks) Whether there was assessment and dcumentatin f respnse, side effects, and adherence. 171

174 Perfrmance Measure Technical Dcumentatin Mdule: Majr Depressive Disrder (MDD) Indicatr Statement: Rates f Inapprpriate Level f Care: Cmplicated MDD with n care by a licensed mental health prvider Indicatr Number: 8 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2002 VA/DD Clinical Practice Guideline fr the Management f Majr Depressive Disrder. The VA guideline recmmends that patients in Primary Health Care shuld be referred t and treated by a mental health prvider if there is any evidence f psychsis, histry f mania, active suicidal ideatin, suicidal behavir, r psychiatric cmrbidity. The VA guideline prvides extensive guidance t supprt this recmmendatin. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: a) Patients frm the denminatr with n care by a licensed mental health prvider within 3 mnths f the start f the new treatment episde b) Patients frm the denminatr with n care by a licensed mental health prvider within 30 days f the ntatin f psitive suicidal ideatin r suicidal behavir Denminatr: a) Patients with MDD diagnsis in a new treatment episde fr whm there is evidence f any f these categries in the thirty days n, after, r befre the start f the new treatment episde: Psychsis Mania b) Patients with MDD wh have psitive suicidal ideatin r suicidal behavir Patient chrts: Patients with MDD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Licensed mental health prvider: See the Key Definitins dcument Psychsis: Ntatin in the recrd f psychsis/psychtic symptms, hallucinatins, delusins, r parania Mania: Ntatin abut histry f mania r current mania, including extremely elevated md, energy and unusual thught patterns Active Suicidal Ideatin r suicidal behavir: Ntatin in the chart n whether the patient is actively cnsidering r fantasizing abut taking his wn life. This may range frm vague urges t detailed plans abut the act. (This infrmatin is abstracted frm the medical recrds in the suicide mdule fr the first instance f suicidal behavir r ideatin recrded within the study perid). Feasibility/Data Cllectin Issues: Numeratr cmes frm administrative data Denminatr cmes frm the medical recrd and administrative data. 172

175 SUBSTANCE USE DISORDER (SUD) Perfrmance Measure Technical Dcumentatin Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Cmprehensive SUD Assessment: Recvery envirnment Indicatr Number: 1 Executive Summary: The fllwing indicatr cmes frm the 2001 VA/DD Clinical Practice Guidelines fr SUD. The VA Clinical Practice Guideline recmmends that a cmprehensive SUD Assessment and an assessment f gals shuld address each f the fllwing 10 general categries fr patients beginning a new treatment episde (ASAM, 1996; Senay, 1997; Strauss, 1995): 1. Patient's demgraphics and identifying infrmatin, including husing, legal, and ccupatinal status 2. Patient's chief cmplaint and histry f the presenting cmplaint 3. Recent substance use and severity f substance-related prblems 4. Lifetime and family histry f substance use 5. C-mrbid psychiatric cnditins and psychiatric histry 6. Scial and family cntext 7. Develpmental and military histry 8. Current medical status and medical histry, including risk fr HIV r hepatitis C 9. Mental status and physical examinatins 10. Patient s perspective n current prblems and treatment gals r preferences This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness and patient-centeredness. References: American Sciety f Addictin Medicine (ASAM) (1996). Patient Placement Criteria fr the Treatment f Substance-Related Disrders (2 nd ed.). Washingtn, D.C.: ASAM, Inc. Senay, E. C. (1997). Diagnstic interview and mental status examinatin. In J. H. Lwinsn, P. Ruiz, R. B. Millman, & J. G. Langrd, (Eds.), Substance Abuse, A Cmprehensive Textbk, (3 rd ed.), (pp ). Baltimre, MD: Williams & Wilkins. Strauss, G. D. (1995). The psychiatric interview, histry, and mental status examinatin. In H. I. Kaplan & B. J. Sadck (Eds.), Cmprehensive Textbk f Psychiatry (6 th ed.), Vl. 1, (pp ). Baltimre, MD: Williams & Wilkins. Numeratr: Patients frm the denminatr wh have their recvery envirnment assessed within 30 days f the start f the new treatment episde Denminatr: Patients with SUD diagnsis with a new treatment episde in specialty mental health care Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III 173

176 Definitins: New Treatment Episde: See the Key Definitins dcument Specialty mental health: Defined as ne r mre diagnsis-related visits within 30 days f the start f the new treatment episde (see the Key Definitins dcument fr the prvider cdes assciated with specialty mental health) Assessment f recvery envirnment includes assessing 1) wh lives with the patient r prvides scial supprt 2) Whether r nt their scial supprts/peple they live with are alchl r drug users 3) Whether these peple supprt their recvery (if they are nted t be users themselves, this wuld cunt as assessment) If the prvider dcuments that the patient is/is nt mtivated, this des NOT qualify. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Chart abstractrs will lk frward 30 days int the recrd frm the start f the new treatment episde fr relevant infrmatin Limiting sample t thse in specialty mental health care will be dne during the analysis phase The date f the first diagnsis-related visit (primary r secndary diagnsis) at the start f each new treatment episde will be prvided frm administrative data fr chart abstractin. 174

177 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Assessment fr PTSD in specialty care Indicatr Number: 2 Executive Summary: The fllwing indicatr is based n recmmendatins regarding cmprehensive SUD assessment in the 2001 VA/DD Clinical Practice Guidelines fr SUD. These recmmendatins have been expanded here t include a specific screening fr PTSD as part f the cmprehensive SUD assessment. The ratinale fr screening fr PTSD is due t the high cmrbidity f bth disrders amng a veteran ppulatin. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness and patient-centeredness. Numeratr: Patients frm the denminatr wh have assessment fr PTSD within 30 days f the start f the new treatment episde Denminatr: Patients with SUD diagnsis with a new treatment episde in specialty mental health Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Specialty mental health: Defined as ne r mre diagnsis-related visits within 30 days f the start f the new treatment episde (see the Key Definitins dcument fr the prvider cdes assciated with specialty mental health) Assessment fr PTSD symptms: A. Includes assessment f presence r absence f each the fllwing (This des nt require a standardized measure/instrument.): Re-experiencing f event Intrusive thughts, nightmares, flashbacks, intense psychlgical distress r physilgical reactivity at internal r external cues, etc. Avidance/scial disengagement Effrts t avid related thughts, places, r peple, diminished interest in significant activities, feeling f detachment r estrangement frm thers, restricted range f affect, sense f freshrtened future, etc. Symptms f increased arusal Difficulty falling r staying asleep, irritability r utbursts f anger, difficulty cncentrating, hypervigilance, exaggerated startle respnse, etc. *OR* B. Screen fr symptms cnsistent with PTSD using a standardized screen such as the PCL/PC-PTSD Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data PC-PTSD recently implemented in the VA as f Octber

178 Chart abstractrs will lk frward 30 days int the recrd frm the start f the new treatment episde fr relevant infrmatin Limiting sample t thse in specialty mental health care will be dne during the analysis phase Chart abstractrs are instructed t cnsider dcumentatin f n histry f trauma r traumatic event as evidence that the patient was evaluated fr PTSD. 176

179 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Cnduct brief interventin at initial visits fr patients with alchl abuse r dependence Indicatr Number: 3 Executive Summary: The fllwing indicatr is based n recmmendatins in the 2001 VA/DD Clinical Practice Guidelines fr SUD. The Clinical Practice Guideline recmmends the use f brief interventins t "prmte reduced hazardus use f alchl and ther drugs and prevent future cmplicatins r dependence" and cites multiple surces f evidence t supprt this recmmendatin (e.g., Kaner, 2007). The guideline prvides the fllwing ratinale: Multiple randmized clinical trials have demnstrated the efficacy f brief interventins by physicians in primary care settings. Training in brief prvider interventin has been demnstrated t increase rates f alchl cunseling in primary care when accmpanied by real-time cues fr screening and facilitative clinic supprt services (Adams et al., 1998; Buchsbaum et al., 1993). The guideline qualifies this recmmendatin in specialty care by acknwledging the fllwing: Cnsiderable evidence shws that even brief interventins (i.e., ne t fur brief sessins) can be effective fr many patients with alchl dependence, particularly as early interventins fr thse with mild t mderate dependence severity (Finney & Ms, 1998 Wilk et al., 1997). Cmparable findings have nt been reprted fr brief interventin with ther substance dependence (e.g., piid and ccaine dependence), which typically require intensive treatment early in recvery (Crits- Cristph & Siqueland, 1996). This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. References: Kaner EFS, Beyer F, Dickinsn HO, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B. Effectiveness f brief alchl interventins in primary care ppulatins. Cchrane Database f Systematic Reviews 2007, Issue 2. Art. N.: CD DOI: / CD pub3. Adams, A., Ockene, J. K., Wheeler, E. V., et al. (1998). Alchl cunseling, physicians will d it. Jurnal f General Internal Medicine, 13, Buchsbaum, D., Buchanan, R., Lawtn, M., et al. (1993). A prgram f screening and prmpting imprves shrt-term physician cunseling f dependent and nndependent harmful drinkers. Archives f Internal Medicine, 153, Finney, J. W., & Ms, R. H. (1998). Psychscial treatments fr alchl use disrders. In P. E. Nathan & J. M. Grman (Eds.), A Guide t Treatments That Wrk (pp ). New Yrk: Oxfrd University Press. Crits-Cristph, P., & Siqueland, L. (1996). Psychscial treatment fr drug abuse: selected review and recmmendatins fr natinal health care. Archives f General Psychiatry, 53, Numeratr fr 1: Prprtin f patients that have medical recrds dcumenting: (a) Prvider advice t drink less r abstain frm alchl and feedback was prvided abut risks f alchl use t health cnditin r t general health during the study perid. OR 177

180 (b) Cmpleted referral t specialty mental health during the study perid. OR (c) Already in specialty care OR (d) All ther patients Numeratr fr 2: Prprtin f patients that have medical recrds dcumenting: (e) Within 30 days f the new treatment episde; prvider advice t drink less r abstain frm alchl and feedback was prvided abut risks f alchl use t health cnditin r t general health OR (f) Within 30 days f the new treatment episde; cmpleted referral t specialty mental health OR (g) Started the new treatment episde in specialty care OR (h) All ther patients Denminatr: This indicatr is evaluated fr the fllwing ppulatins: 1. All SUD patients with alchl abuse r dependence within the study perid; 2. All SUD patients with alchl abuse r dependence in a new treatment episde Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade I Definitins: Alchl Dependence and Alchl Abuse: Defined as ne r mre encunters where relevant diagnses (ICD-9 cdes fr and ) are the primary r secndary diagnsis Cmpleted referral t specialty mental health: A diagnsis-related visit with a specialty mental health prvider within 60 days f the first diagnsis-related visit (primary r secndary) during the study perid Already in specialty mental health (Numeratr 1): Defined as tw r mre utpatient encunters with a specialty mental health prvider (see the Key Definitins Dcument fr definitin) in 90 days prir t the first diagnsis-related visit (primary r secndary diagnsis f r ) f any kind in the study perid Prvider advice t drink less r abstain frm alchl: Nte in medical recrd that states that the prvider and patient discussed the prs and cns f drinking less r abstaining, r nte frm prvider stating that s/he recmmended t the patient t drink less r abstain (e.g., recmmendatin may be dcumented in the treatment planning nte), r referral t specialty SUD care r t the cmmunity (e.g., 12 step) Feedback was prvided abut risks f alchl use t health cnditin r t general health: Nte in medical recrd that states that the prvider and patient discussed the risks assciated with alchl and the patient s current medical cnditin and/r the prvider referred the patient t primary care r a specialty medical clinic fr health risks assciated with alchl use 178

181 Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data. Numeratr will cme frm medical recrd fr part (a), administrative data fr parts (b), (c), and (d). Fr peple wh had a new treatment episde in the last thirty days f the study perid and wh were abstracted befre WVMI changed their abstractin methd t fllw them ut a full year, the data are censred. Numeratr 1a will be abstracted by medical recrd abstractrs using an r, rather than an and, meaning that a pass is cded if the prvider gives advice abut drinking r prvides feedback abut risks. 179

182 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Pharmactherapy fr alchl dependence (a) ffered, (b) filled, (c) refused, r (d) cntraindicated Indicatr Number: 4 Executive Summary: The fllwing indicatr is based n recmmendatins in the 2001 VA/DD Clinical Practice Guidelines fr SUD. The Clinical Practice Guideline recmmends identifying patients with alchl dependence wh shuld be cnsidered fr addictin-fcused pharmactherapy. The guideline states that there "are tw medicatins currently apprved fr the treatment f alchl dependence: naltrexne and disulfiram," and prvisinally endrses acamprsate, which has since received mre substantial empirical supprt and apprval. In discussing this recmmendatin, the guideline prvides the fllwing backgrund and ratinale: There are several factrs t cnsider regarding what, if any, pharmactherapy t use fr alchl dependence. First, there must be sme mtivatin n the part f the patient t achieve and maintain abstinence. Pharmactherapy is unlikely t wrk if patients are nt willing t make a cmmitment t recvery. Secnd, patients shuld generally be in sme kind f cunseling r psychtherapy. There are exceptins t this, fr example, a patient wh has been abstinent fr sme time and is invlved in self-help grups, but requires pharmactherapy t help maintain abstinence. Third, cmpliance-enhancing prcedures must be integrated int the treatment plan (Vlpicelli et al., 1997; Pettinati et al., 2000). Of the tw medicatins currently available, naltrexne has strnger evidence f efficacy, especially in the first three mnths f abstinence. It shuld be rutinely cnsidered fr patients beginning alchlism treatment. Naltrexne shuld als be cnsidered whenever a patient is able t maintain sme abstinence, but is having difficulty with slips r cravings. Disulfiram shuld be cnsidered mre selectively. Mnitred administratin significantly imprves cmpliance. Disulfiram shuld be cnsidered whenever a patient requests it r when sme frm f mnitring is available. In clinical practice, it is smetimes used t prvide additinal supprt during perids f high risk f relapse. Evidence fr its efficacy in cmbined ccaine and alchl dependence is relatively strng (Carrll et al., 1998; McCance-Katz et al., 1998; Gerge et al., 2000; Petrakis et al., 2000). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and effectiveness. References: Vlpicelli, J. R., Rhines, K. C., Rhines, J. S., et al. (1997). Naltrexne and alchl dependence: rle f subject cmpliance. Archives f General Psychiatry, 54, Pettinati, H. M., Vlpicelli, J. R., Pierce, J. D., et al. (2000). Imprving naltrexne respnse: an interventin fr medical practitiners t enhance medicatin cmpliance in alchl dependent patients. Jurnal f Addictive Diseases, 19, 1, Carrll, K. M., Nich, C., Ball, S. A., et al. (1998). Treatment f ccaine and alchl dependence with psychtherapy and disulfiram. Addictin, 93, 5, McCance-Katz, E. F., Ksten, T. R., & Jatlw, P. (1998). Chrnic disulfiram treatment effects n intranasal ccaine administratin: initial results. Bilgical Psychiatry, 43, 7, Gerge, T. P., Chawarski, M. C., Pakes, J., et al. (2000). Disulfiram versus placeb fr ccaine dependence in buprenrphine-maintained subjects: a preliminary trial. Bilgical Psychiatry, 47 (12),

183 Petrakis, I. L., Carrll, K. M., Nich, C., et al. (2000). Disulfiram treatment fr ccaine dependence in methadne-maintained piid addicts. Addictin, 95, 2, Numeratr: Patients frm the denminatr wh were: a) ffered a prescriptin fr naltrexne, Antabuse (disulfiram) r acamprsate but did nt fill within 30 days n r after the start f the new treatment episde OR b) ffered a prescriptin and filled within 30 days f the start f the new treatment episde OR c) ffered a prescriptin fr naltrexne, Antabuse (disulfiram) r acamprsate but refused medicatin within 30 days n r after the start f the new treatment episde OR d) fund t have dcumentatin that prescriptin is cntraindicated within 30 days n r after start f new treatment episde OR e) fund t have n dcumentatin f ffer r refusal and n recrd f prescriptin being filled Denminatr: Patients with: a) alchl dependence with a new treatment episde b) alchl dependence in a new treatment episde and a cmrbid mental health diagnsis (MDD, BP, Schiz, PTSD) Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade I Definitins: Alchl Dependence: Defined as the primary diagnsis (ICD-9 cde: ) n the first utpatient visit fllwing the start f the new treatment episde New Treatment Episde: See the Key Definitins dcument Cmrbid mental health diagnsis: Use c-ccurring disrder definitin frm Key Definitins Dcument Pharmactherapy: Naltrexne r Antabuse (Disulfiram) r acamprsate (See Appendix A in Key Definitins Dcument fr assciated NDC cdes) Filled prescriptin: One r mre prescriptins filled within 30 days f start f new treatment episde Cntraindicatins t naltrexne (ReVia): Currently receiving piid analgesics, currently dependent n piids including maintenance n piate agnists (e.g., methadne); patient has failed the nalxne challenge test r has a psitive urine screen fr piids; acute hepatitis r liver failure; histry f sensitivity t naltrexne r its cmpnents; dcumentatin that patient is nt a candidate fr this drug Cntraindicatins t Antabuse (disulfiram): Severe mycardial disease r crnary cclusin; psychses, hypersensitivity t disulfiram r its derivatives; patients receiving r have recently received metrnidazle, paraldehyde, alchl, r alchlcntaining preparatins (e.g., cugh syrup); dcumentatin that patient is nt a candidate fr this drug Cntraindicatins t acamprsate (Campral): Previusly demnstrated hypersensitivity t acamprsate r it is cmpunds; severe renal impairment (Creatinine clearance 30 ml/min); dcumentatin that patient is nt a candidate fr this drug Offered: Prescriptin written r ntatin in the chart that prvider discussed using the medicatin with the patient 181

184 Refused: Ntatin in the chart that the patient refused medicatin Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Filled prescriptins frm the numeratr will cme frm administrative data; ffered r refused prescriptins will cme frm medical recrd data. We will cllect refusals separately in rder t assess the number f peple ffered treatment wh did nt accept it. A flag fr patients with alchl dependence (ICD-9 cde: ) as primary r secndary diagnsis will be prvided frm administrative data fr chart abstractin. Remve thse with alchl abuse (ALAB) and nly scre this fr thse with alchl dependence (ALDEP). 182

185 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Maintenance pharmactherapy fr piate dependence at empirically based dsages (a) ffered, (b) filled, (c) refused medicatin, r (d) cntraindicated Indicatr Number: 5 Executive Summary: The fllwing indicatr is based n a recmmendatin in the 2001 VA/DD Clinical Practice Guidelines fr SUD t cnduct pharmactherapy management with patients with piid dependence. Further, it differentiates the rates f ffered medicatin and actual utilizatin. Infrmatin n empirically-based dsages and cntraindicatins t Methadne are detailed in the Clinical Practice Guidelines; Prviders shuld adjust piid agnist dses t maintain a therapeutic range between signs/symptms f vermedicatin (e.g., smnlence, misis, itching, hyptensin, and flushing) and piid withdrawal (e.g., drug craving, anxiety, dysphria, and irritability). One anticipated sensitivity f this indicatr is that a large number f piid dependence diagnses may be made inapprpriately by primary care due t physical dependence as a functin f pain management. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and effectiveness. Numeratr: Patients frm the denminatr wh were: a) ffered Methadne r a prescriptin fr buprenrphine at the empirically based dse but did nt fill within 30 days n r after the start f the new treatment episde OR b) ffered Methadne r a prescriptin fr buprenrphine at the empirically based dse and filled within 30 days n r after the start f the new treatment episde OR c) ffered Methadne r a prescriptin fr buprenrphine at the empirically based dse but refused medicatin within 30 days n r after the start f the new treatment episde OR d) fund t have dcumentatin that prescriptin is cntraindicated within 30 days n r after start f new treatment episde OR e) fund t have n dcumentatin f ffer r refusal and n recrd f prescriptin being filled Denminatr: Patients with SUD diagnsis with piate dependence with a new treatment episde Patient chrts: Patients with SUD diagnsis with piate dependence Strength f Evidence: Grade I Definitins: Opiate Dependence: Defined as the primary diagnsis (ICD-9 cde: , 304.7) n the first utpatient visit fllwing the start f the new treatment episde New Treatment Episde: See the Key Definitins dcument Pharmactherapy: Methadne r buprenrphine (including buprenrphine/ nalxene) Methadne: Defined by ne r mre stp cdes fr piid substitutin (stp cde: 523) within 90 days f the start f the new treatment episde 183

186 Buprenrphine: SUBOXONE (CIII) is (buprenrphine HCl and nalxne HCl dihydrate sublingual tablets). SUBUTEX (CIII) is (buprenrphine HCl sublingual tablets). Buprenrphine is generic name and Subetex and Subxne are trade names. Refer t Appendix A in the Key Definitins Dcument fr the NDC cdes assciated with Buprenrphine. Filled prescriptin: One r mre prescriptins filled within 30 days f start f new treatment episde Patient preference: Fr (c) abve indicatin that patient preferred an alternative t lng-term maintenance pharmactherapy and was ffered naltrexne as an piid antagnist Cntraindicatins t Methadne (frm VA SUD CPGs): Allergy t agent, cncurrent enrllment in anther OAT, significant liver failure, and/r use f piid antagnists (e.g., nalxne, nalmefene, r naltrexne) OR a nte in chart that patient is nt a candidate fr this treatment Cntraindicatins t Buprenrphine: SUBOXONE and SUBUTEX shuld nt be administered t patients wh have been shwn t be hypersensitive t buprenrphine, and SUBOXONE shuld nt be administered t patients wh have been shwn t be hypersensitive t nalxne. Als accept wrding in the chart that patient is nt a candidate fr this treatment Empirically based dse: Buprenrphine: Dse shuld reach 12 mg within first week OR chart shuld dcument justificatin fr lwer dse OR reasn fr discntinuatin f buprenrphine Methadne: Dse shuld reach 60 mg within the first mnth OR chart shuld dcument justificatin fr lwer dse (n evidence f relapse by urinalysis r self-reprt) OR reasn fr discntinuatin f methadne Refused: Ntatin in the chart that the patient refused medicatin: Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data. Numeratr: Filled prescriptins frm the numeratr will cme frm administrative data fr buprenrphine; ffered r refused prescriptins will cme frm the medical recrd. Methadne dsage and ffered r refused r justificatin fr lwer dse, and discntinuatin will all cme frm the medical recrd. We will cllect refusals separately in rder t assess the number f peple ffered treatment wh did nt accept it. A flag fr patients where piate dependence (ICD-9 cde: , ) as the primary r secndary diagnsis frm administrative data fr chart abstractin. 184

187 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Opiate Agnist Therapy (OAT) as first line f defense fr at least 90 days f treatment at beginning f a new treatment episde Indicatr Number: 6 Executive Summary: The fllwing indicatr cmes frm 2001 VA/DD Clinical Practice Guidelines fr SUD. The Clinical Practice Guideline recmmends determining if "Opiid Agnist Therapy (OAT) is apprpriate fr and acceptable t the patient" with the bjective f "careful cnsideratin f OAT as the first line treatment fr piid dependence." The guideline prvides the fllwing discussin fr this recmmendatin: OAT is inaccurately cnsidered by sme prviders t be a treatment f last recurse; hwever, evidence cnsistently shws that patients have better utcmes when maintained with an agnist than a placeb (Newman and Whitehall, 1979; Strain et al., 1993a; Strain et al., 1993b) r than when prvided lng-term detxificatin (Sees et al., 2000). Discharge frm OAT prgrams is generally fllwed by relapse and ther adverse utcmes (Gerstein et al., 1994). Unless there are legal r ther extenuating circumstances (such as active duty in DD), OAT shuld be cnsidered fr any patient with a diagnsis f piid dependence. Fr patients wh previusly relapsed, re-treatment shuld be a cnsideratin. As part f the decisin prcess, it is imprtant t determine if apprpriate agnist dsing was utilized and whether there were psychscial barriers that culd be better addressed upn re-attempting OAT. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and effectiveness. References: Newman, R. G. & Whitehall, W. B. (1979). Duble-blind cmparisn f methadne and placeb-maintenance treatments f narctic addicts in Hng Kng. Lancet, 2, (8141), Strain, E. C., Stitzer, M. I., Liebsn, I. A., et al. (1993a). Dse-respnse effects f methadne in the treatment f piid dependence. Annals f Internal Medicine, 119, Strain, E. C., Stitzer, M. I., Liebsn, I. A., et al. (1993b). Methadne dse and treatment utcme. Drug and Alchl Dependence, 33, Sees, K. L., Delucchi, K. L., Massn, C., et al. (2000). Methadne maintenance versus 180-day psychscially enriched detxificatin fr treatment f piid dependence: a randmized cntrlled trial. Jurnal f the American Medical Assciatin, 283 (10), Gerstein, D. R., Jhnsn, R. A., Harwd, H. J., et al. (1994). Evaluating Recvery Services: The Califrnia Drug and Alchl Treatment Assessment (CALDATA) general reprt. Califrnia Department f Drug and Alchl Prgrams, Sacrament. 185

188 Numeratr: Patients frm denminatr receiving 90 dses f OAT in the 90 days fllwing the first dse Denminatr: Patients with piate dependence wh are initiating OAT within 30 days n r after the start f a new treatment episde Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade I Definitins: New Treatment Episde: See the Key Definitins dcument Opiate Dependence: Defined as the primary diagnsis (ICD-9 cde: , ) n the first utpatient visit fllwing the start f the new treatment episde Opiate Agnist Therapy (OAT): Methadne, Buprenrphine; maintenance/duratin f treatment shuld be indicated n the riginal rder in the medical recrd; exclude peple wh are receiving piate assisted detxificatin r shrt-term taper. Initiating OAT: One r mre methadne stp cdes r 1+ prescriptins fr buprenrphine within 30 days f start f a new treatment episde Methadne treatment defined by stp cde: 523 Buprenrphine: See Appendix A fr related NDC cdes Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr can cme frm medical recrd data r administrative data (we will pilt this indicatr) Cunt number f Methadne visits in a 90 day perid fr data cllectin A flag fr patients with piate dependence (ICD-9 cde: , ) will be prvided frm administrative data fr chart abstractin. 186

189 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Prprtin f patients in SUD that have a cntinuus SUD treatment invlvement fr at least: 1) Three mnths, 2) Six mnths, r 3) One year r lnger at time f discharge And rates f: 4) Prgram cmpletin Indicatr Number: 7 Executive Summary: The fllwing indicatr cmes frm the Office f Quality Perfrmance fr 90-day treatment retentin and has been revised t include multiple days in treatment. The Office f Quality Perfrmance prvides the fllwing ratinale: Research has shwn unequivcally that gd addictin treatment utcmes are cntingent n adequate lengths f treatment. There is n predetermined length f addictin treatment that assures success, but duratin f treatment is the factr mst cnsistently assciated with successful addictin treatment utcme. Many patients drp ut during the initial 90 days f treatment with limited clinical benefit and high rates f relapse. While tw cntacts per mnth fr three mnths wuld rarely be sufficient, mst patients require nging treatment fr at least this duratin t establish early remissin. The initial intensity f treatment shuld be cnsidered primarily as a means t prmte treatment retentin, e.g., severely dependent patients typically may require multiple treatment cntacts per week in rder t stabilize early remissin. Hwever, fr many patients fllwing initial stabilizatin, it may be apprpriate t prvide a lwer intensity f addictin-fcused treatment extending ver a lnger duratin with superir remissin rates fr thse wh remain engaged in treatment fr 6-12 mnths. Many individuals cntinue t benefit frm treatment (e.g., methadne maintenance) ver a perid f years. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effective and efficiency. Numeratr: Number f patients in the denminatr wh EITHER cmpleted the prgram OR had a cntinuus length-f-stay in the SUD specialty care f ne visit beynd each time perid: 1) Three mnths, 2) Six mnths, r 3) One year And rates f: 4) Prgram cmpletin Denminatr: Patients with SUD diagnsis in a new treatment episde in SUD specialty care Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade II 187

190 Definitins: New Treatment Episde: See the Key Definitins dcument Specialty SUD care: Defined as a visit within 30 days f the start f the new treatment episde where SUD is the primary diagnsis (Table 1B) and care takes place in ne f the fllwing utpatient r inpatient settings: Any specialty SUD care utpatient clinic visits as dcumented in the Key Definitins Dcument (with primary r secndary SUD diagnsis): Any inpatient/residential treatment admissin with the fllwing bed sectin cdes (with primary r secndary SUD diagnsis): 27 Substance Abuse Residence Rehabilitatin 29 Substance Abuse Cmpensated Wrk Therapy/Transitin 72 Alchl Dependence High Intensity 73 Drug Dependence High Intensity 74 Substance Abuse High Intensity 84 Psychiatric Substance Abuse (Intermediate Care) 86 Dmiciliary Substance Abuse 90 Substance Abuse STAR I, II, and III Length f Stay: Three mnths 7+ SUD specialty visits r SUD-related inpatient admissins with a cmbined LOS f 7+ days Six mnths 13+ SUD specialty visits r SUD-related inpatient admissins with a cmbined LOS f 13+ days (1+ visits per quarter) One year 25+ SUD specialty visits (2+ visits per quarter) r SUD-related inpatient admissins with a cmbined LOS f 25+ days Cmpleted the prgram: Nte in the chart stating that patient cmpleted prgram, including discharge summary r ntatin f graduatin ceremny Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data and administrative data Prgram cmpletin: Discharge r interim nte (e.g., a nte fr patients transferring frm inpatient t utpatient). Minimum frequency f visits is 2 times per mnth. Includes phne sessins. Date f prgram cmpletin shuld fllw start f new treatment episde. Any dates f cmpletin that ccur befre the start f the new treatment episde will be ignred. 188

191 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Prprtin f patients with SUD diagnsis that received evidencebased cgnitive behaviral Relapse Preventin Therapy (RPT) by the first prvider f RPT. Indicatr Number: 8 Executive Summary: This indicatr is based n the American Psychiatric Assciatin (APA) Practice Guideline fr the Treatment f Patients with Substance Use Disrders, which identifies cgnitive behaviral relapse preventin therapy as an evidence-based psychscial treatment fr treatment f patients with SUD and prvides descriptive evidence supprting its efficacy. Accrding t the APA guideline, psychscial treatments are essential cmpnents f a cmprehensive treatment prgram (5). The guideline prvides evidence supprting the efficacy f cgnitive behaviral Relapse Preventin Therapy, including the fllwing: Relapse preventin is a treatment apprach in which CBT techniques are used t help patients develp greater self-cntrl t avid relapse (Marlatt & Grdn, 1985; Annis & Davis, 1989). Specific relapse preventin strategies include discussing the patient s ambivalence abut the substance use disrder, identifying emtinal and envirnmental triggers f craving and substance use, develping and reviewing specific cping strategies t deal with internal r external stressrs, explring the decisin chain leading t reinitiatin f substance use, learning frm brief episdes f relapse (slips) abut triggers leading t relapse, and develping effective techniques fr early interventin ([Marlatt & Grdn, 1985], [Annis, 1986]). In mre recent clinical trials ([Prject MATCH, 1997], [O Malley et al., 1992]), techniques drawn frm cgnitive therapy and relapse preventin have been cmbined with the aims f initiating abstinence and preventing relapse. This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. References: American Psychiatric Assciatin (APA) Practice Guideline fr the Treatment f Patients with Substance Use Disrders, 2 nd ed. American Jurnal f Psychiatry. April 2007, 164(4). Marlatt GA, Grdn JR (eds): Relapse Preventin: Maintenance Strategies in the Treatment f Addictive Behavirs. New Yrk, Guilfrd, 1985 Annis HM, Davis CS: Relapse preventin, in Handbk f Alchlism Treatment Appraches. Edited by Hester RK, Miller WR. New Yrk, Pergamn, 1989, Annis HM: A relapse preventin mdel fr treatment f alchlics, in Treating Addictive Behavirs: Prcesses f Change. Ed. Miller WR, Heather N. New Yrk, Plenum, 1986, O Malley SS, Jaffe AJ, Chang G, Schttenfeld RS, Meyer RE, Runsaville B: Naltrexne and cping skills therapy fr alchl dependence: a cntrlled study. Arch GenPsychiatry 1992; 49: Prject MATCH Research Grup: Matching alchlism treatments t client hetergeneity: Prject MATCH pst-treatment drinking utcmes. J Stud Alchl 1997; 58:7 29 Numeratr: Patients frm the denminatr wh received: 189

192 a) Any evidence-based cgnitive behaviral Relapse Preventin Therapy (RPT) in the study perid b) The number f RPT visits received in the year fllwing the first RPT encunter by the same prvider in (a) Denminatr: Patients with SUD diagnsis wh have at least ne psychtherapy visit in the study perid Strength f Evidence: Grade I Patient chrts: Patients with SUD diagnsis Definitins: Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Relapse Preventin Therapy (RPT): Discussin f the fllwing tpics: 1. Assessment f envirnmental and/r emtinal characteristics that may be assciated with relapse (help veteran identify triggers [emtins, thughts] fr use) 2. Identify and discuss high risk situatins that veteran encuntered in past; explre actins he/she tk t avid r cpe with this situatin 3. Cping skills training t prevent relapse (discuss, teach, shw, r rehearse hw t cpe with difficult situatins withut using alchl r drugs) a. Help veteran prepare fr pssible triggers r situatins that might lead t use b. Encurage veteran t anticipate future high risk situatins and t frmulate apprpriate ways t manage these situatins c. Rle play different situatins that veteran may encunter 4. Lifestyle mdificatin strategies: discussin abut alternative activities t learn t cpe, such as meditatin, exercise, spiritual practices ****************************************************************************************** RPT interventin strategies can be gruped int three categries: cping skills training, cgnitive therapy, and lifestyle mdificatin. Cping skills training strategies include bth behaviral and cgnitive techniques. Cgnitive therapy prcedures are designed t prvide clients with ways t reframe the habit change prcess as a learning experience, with errrs and setbacks expected as mastery develps. Finally, lifestyle mdificatin strategies such as meditatin, exercise, and spiritual practices are designed t strengthen a client's verall cping capacity. In clinical practice, cping skills training frms the crnerstne f RPT, teaching clients strategies t: Understand relapse as a prcess Identify and cpe effectively with high-risk situatins Cpe with urges and cravings Implement damage cntrl prcedures during a lapse t minimize its negative cnsequences Stay engaged in treatment even after a relapse, and Learn hw t create a mre balanced lifestyle ****************************************************************************************** 190

193 Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data First date f psychtherapy frm administrative data will be prvided fr chart review. Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Fr peple wh had a new treatment episde in the last thirty days f the study perid and wh were abstracted befre WVMI changed their abstractin methd t fllw them ut a full year, additinal data will cme frm the administrative data files. 191

194 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Prprtin f patients with SUD diagnsis that received evidencebased Cntingency Management (CM) r Cntingency Cntracting Indicatr Number: 9 Executive Summary: This indicatr is based n the American Psychiatric Assciatin (APA) Practice Guideline fr the Treatment f Patients with Substance Use Disrders, which identifies cntingency management as an evidence-based psychscial treatment fr treatment f patients with SUD. Accrding t the APA guideline, psychscial treatments are essential cmpnents f a cmprehensive treatment prgram (5). The guideline prvides evidence supprting the efficacy f cntingency management therapy, including the fllwing: As an adjunctive treatment, cntingency management has been used with a variety f substances f abuse, including ccaine (Higgins et al., 2000, Silverman et al., 2004), piates (Stitzer et al., 1992, Silverman et al., 1996), and marijuana (Budney et al., 2000). Althugh mst studies have centered n abstinence frm substance use, cntingency management prcedures are ptentially applicable t a wide range f target behavirs and prblems (27). This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. References: American Psychiatric Assciatin (APA) Practice Guideline fr the Treatment f Patients with Substance Use Disrders, 2 nd ed. American Jurnal f Psychiatry. April 2007, 164(4). Higgins ST, Wng CJ, Badger GJ, Ogden DE, Dantna RL: Cntingent reinfrcement increases ccaine abstinence during utpatient treatment and 1 year f fllwup. J Cnsult Clin Psychl 2000; 68:64 72 Silverman K, Rbles E, Mudric T, Bigelw GE, Stitzer ML: A randmized trial f lngterm reinfrcement f ccaine abstinence in methadne-maintained patients wh inject drugs. J Cnsult Clin Psychl 2004; 72: Stitzer ML, Iguchi MY, Felch LJ: Cntingent take-hme incentive: effects n drug use f methadne maintenance patients. J Cnsult Clin Psychl 1992; 60: Silverman K, Wng CJ, Higgins ST, Brner RK, Mntya ID, Cntreggi C, Umbricht- Schneiter A, Schuster CR, Prestn KL: Increasing piate abstinence thrugh vucherbased reinfrcement therapy. Drug Alchl Depend 1996; 41: Budney AJ, Higgins ST, Radnvich KJ, Nvy PL: Adding vucher-based incentives t cping skills and mtivatinal enhancement imprves utcmes during treatment fr marijuana dependence. J Cnsult Clin Psychl 2000; 68: Numeratr: Patients frm the denminatr wh received: a) Any evidence-based Cntingency Management (CM) r Cntingency Cntracting in the study perid b) The number f Cntingency Management (CM) r Cntingency Cntracting visits received in the study perid by the same prvider in (a). Denminatr: Patients with SUD diagnsis wh have at least ne psychtherapy visit in the study perid 192

195 Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade I Definitins: Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Cntingency Management (CM) and Cntingency Cntracting: 1. Cntract fr behavir change that indicates the rewards fr achieving specific treatment gals such as appintment attendance r abstinence based n urine drug screen mnitring 2. Vuchers and/r ther psitive reinfrcement fr meeting treatment gals a. Use a pre-planned system t prvide increasingly mre valuable rewards fr increasingly lnger perids f uninterrupted abstinence 3. Withdrawal f vuchers r ther negative reinfrcement fr nt meeting treatment gals (e.g., nn cmpliance with therapy r medicatin regimen) **************************************************************************************** CM is a strategy used in alchl and ther substance abuse treatment t encurage psitive behavir change (e.g., abstinence, attending therapy sessins) by prviding reinfrcing cnsequences when patients meet treatment gals and by withhlding thse cnsequences r prviding punitive measures when patients engage in the undesired behavir (e.g., drinking, failure t adhere t clinic rules). Fr example, psitive cnsequences fr abstinence may include receipt f vuchers that are exchanged fr retail gds, whereas negative cnsequences fr drinking may include withhlding f vuchers. The reinfrcing r punishing cnsequences may be cntingent n bjective evidence f recent alchl and/r drug use r n anther behavir imprtant in the treatment prcess, such as cmpliance with a medicatin regimen r regular clinic attendance. Often CM prcedures may invlve cntingency cntracting, which is tailred fr each patient and may be implemented thrugh explicit written cntracts that detail the desired behavir change, duratin f interventin, frequency f mnitring, and ptential cnsequences f a patient's success r failure. ****************************************************************************************** Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Dates fr psychtherapy visits frm administrative data will be prvided fr chart review. Dates fr all visits (up t 50 visits) that meet the definitin belw (different frm the definitin used t define the denminatr) will be prvided fr chart abstractin. Psychtherapy: Defined as ne r mre diagnsis-related psychtherapy encunter (primary r secndary frm Table 1B in the Key Definitins Dcument) with ne f the CPT cdes listed in the relevant sectin f the Key Definitins Dcument Fr peple wh had a new treatment episde in the last thirty days f the study perid and wh were abstracted befre WVMI changed their abstractin methd t fllw them ut a full year, additinal data will cme frm the administrative data files. 193

196 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Prprtin f patients abstinent frm drugs OR alchl in the 30 days prir t their last visit fr utpatient specialty care treatment Indicatr Number: 10 Executive Summary: This indicatr cmes frm the Substance Abuse and Mental Health Services Administratin (SAMHSA) s Natinal Outcmes Measures (NOMs). It has been revised t include cllateral supprt fr abstinence including prvider and family reprt. NOMs defines abstinence as an imprtant utcme, The first and fremst dmain is abstinence frm drug use and alchl abuse r decreased symptms f mental illness with imprved functining. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effective and efficiency. Numeratr: Patients frm the denminatr wh were abstinent frm drugs OR alchl in the 30 days prir t their last visit fr utpatient specialty care treatment during the study perid Denminatr: Patients with SUD diagnsis in specialty mental health care Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade III Definitins: Specialty mental health: Denminatr defined as ne r mre specialty mental health visits in the 30 days befre the last specialty mental health visit f the study perid. See the Key Definitins dcument fr the definitin f specialty mental health. Abstinent frm drugs: Absence f drugs frm urinalysis (UA); prvider, family r self reprt f being abstinent un-cntradicted by ther surce. Any evidence f drug use wuld indicate that the patient was nt abstinent. Als make nte if n infrmatin prvided n abstinence Abstinent frm alchl: Breathalyzer indicating n alchl n breath; prvider, family r self reprt f being abstinent un-cntradicted by ther surce. Als make nte if n infrmatin prvided n abstinence. Last fllw up visit: Last dcumented visit fr specialty care. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Drugs include any drug, nt just drug f dependence In data cllectin, if n infrmatin prvided n abstinence make nte f it T make this cnsistent with results frm SAMHSA NOMS, assessment f abstinence frm alchl is based n all relevant infrmatin in the chart. Fr peple wh were abstracted befre WVMI changed their abstractin methd t fllw them ut a full year, additinal data will be censred. 194

197 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Patients diagnsed with SUD in primary care were given a referral t specialty SUD care Indicatr Number: 11 Executive Summary: This indicatr cmes frm 2001 VA/DD Clinical Practice Guidelines fr SUD. The Clinical Practice Guideline states that "When acceptable t the patient, a specialty care rehabilitatin plan is generally indicated" and prvides evidence (Gerstein & Harwd, 1990, Institute f Medicine, 1990) fr this recmmendatin (A-11, A-12). The guideline prvides the fllwing discussin and ratinale: Substance use disrders ften fllw a chrnic, relapsing curse, making individualized treatment mre cmplicated (McLellan et al., 1996; O Brien & McLellan, 1996). Treatment has nt yet been well-cnceptualized fr many patients wh either have respnded with minimal imprvement t repeated rehabilitative treatments r are unable r unwilling t engage in rehabilitatin effrts, but wh desire ther services. Even when patients are unable and/r unwilling t participate in rehabilitatin r shw minimal benefit, there are pprtunities t address SUDs in ther care settings. Care management appraches fr SUDs are similar t management f ther severe and persistent disrders fr which n cure has been identified, such as biplar disrder r diabetes mellitus (McLellan et al., 2000). Recent evidence suggests that appraches emphasizing engagement with the patient ver lng perids f time, case management, and integratin f substance abuse treatment interventins with treatment fr the cexisting cnditins result in reduced substance use and assciated cmplicatins (Drake & Mueser, 2000; Osher & Drake, 1996; U.S. DHHS, 1994; Willenbring et al., 1995; Willenbring et al., 1999). In the absence f serius c-mrbidity r with apprpriate specialist cnsultatin, care management can be prvided within sme addictin treatment clinics. Even when patients refuse referral r are unable t participate in specialized addictin treatment, many are accepting f general medical r psychiatric care. Clinicians in multiple settings can deliver care management fr patients with SUDs. The chrnic illness apprach is cnsistent with management appraches fr many ther disrders treated in medical and psychiatric settings (Drake & Mueser, 2000; McLellan et al., 2000; Willenbring et al., 1999). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness and patient-centeredness. References: Gerstein, D., & Harwd, H. (Eds.) (1990). Treating Drug Prblems (Vl. 1). Washingtn, DC: Natinal Academy Press. Institute f Medicine (IOM) (1990). Bradening the Base f Treatment fr Alchl Prblems. Washingtn, DC: Natinal Academy Press. McLellan, A. T., Wdy, G. E., Metzger, D., et al (1996). Evaluating the effectiveness f treatments fr substance use disrders: reasnable expectatins, apprpriate cmparisns. Milbank Quarterly, 74, O'Brien, C. P., & McLellan, A. T. (1996). Myths abut the treatment f addictin. Lancet, 347,

198 McLellan, A. T., Lewis, D. C., O Brien, C. P., et al. (2000). Drug dependence, a chrnic medical illness: implicatins fr treatment, insurance, and utcmes evaluatin. Jurnal f the American Medical Assciatin, 284, Drake, R. E., & Mueser, K. T. (2000). Psychscial appraches t dual diagnsis. Schizphrenia Bulletin, 26, Osher, F. C., & Drake, R. E. (1996). Reversing a histry f unmet needs: appraches t care fr persns with c-ccurring addictive and mental disrders. American Jurnal f Orthpsychiatry, 66, U. S. Department f Health and Human Services (1994, reprinted 1995). Assessment and Treatment f Patients with Cexisting Mental Illness and Alchl and Other Drug Abuse (DHHS Publicatin N. (SMA) ). Rckville, MD: Department f Health and Human Services. Willenbring, M. L., Olsn, D. H., & Bielinski, J. B. (1995). Integrated utpatient treatment fr medically ill alchlic men: results frm a quasi-experimental study. Jurnal f Studies n Alchl, 56, Willenbring, M. L., Olsn, D. H., & Bielinski, J. B. (1999). A randmized trial f integrated utpatient treatment fr medically ill alchlic men. Archives f Internal Medicine, 159, Numeratr: (1) Patients frm the denminatr wh were already in Specialty SUD care OR (2) Patients frm the denminatr nt already in Specialty SUD care wh were ffered a referral t Specialty SUD care and wh a) Refused referral t Specialty SUD care; b) Did nt cmplete a referral t Specialty SUD care r c) Cmpleted at least ne visit t Specialty SUD care Denminatr: Patients with SUD diagnsis Patient chrts: Patients with SUD diagnsis Strength f Evidence: Grade II Definitins: Patients already in specialty SUD care (numeratr 1): Patients are cnsidered already in specialty SUD care if their first diagnsis-related (primary r secndary) visit f the study perid is in specialty SUD care (based n definitin in Key Definitins Dcument) Patients with referral (numeratr 2): Patients nt already in specialty SUD care wh receive a referral t specialty SUD care within 30 days either befre r after the first diagnsis-related (primary r secndary) visit f the study perid. Cmpleted referral: Making and shwing up t an appintment within 30 days f the referral Nt cmpleting a referral: Nte in the chart that patient was referred and did nt fllw up with the specialty SUD prvider Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm bth administrative and medical recrd data Time frames fr cmpleting referral will be made later n in analysis 196

199 We will cllect refusals separately in rder t assess the number f peple ffered treatment wh did nt accept it. In analysis, stratify t lk at results fr everyne and fr thse specifically diagnsed with dependence. Fr peple wh were abstracted befre WVMI changed their abstractin methd t fllw them ut a full year, additinal data will be censred. 197

200 Perfrmance Measure Technical Dcumentatin Mdule: Substance Use Disrder (SUD) Indicatr Statement: Assess fr current psychiatric symptms and/r psychiatric histry fr patients with SUD in specialty mental health Indicatr Number: 12 Executive Summary: The fllwing indicatr is based n the 2001 VA/DD Clinical Practice Guidelines fr Management f SUD stating that assessment f c-mrbid psychiatric cnditins and psychiatric histry is imprtant in a SUD cmprehensive bipsychscial assessment. This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. Numeratr: Patients frm the denminatr wh, within 30 days n, after r befre the start f the new treatment episde, had their current c-mrbid psychiatric symptms and/r past psychiatric histry assessed. Denminatr: Patients with a new treatment episde f SUD in specialty mental health Patient chrts: Patients with SUD Strength f Evidence: Grade III Definitins: SUD new treatment episde: See the Key Definitins dcument Specialty mental health: See the Key Definitins dcument; ne r mre diagnsisrelated visits (SUD primary diagnsis nly, Table 1B) in the 30 days fllwing the start f the new treatment episde. Assessment fr c-mrbid psychiatric symptms (numeratr) which includes dcumentatin f: Current signs, symptms r patient cmplaints f psychsis (includes hallucinatins, delusins, and bizarre behavir), depressin (includes depressed md, truble getting ut f bed, change in appetite, lsing interest in activities, and suicidal thughts) r mania (includes expansive r irritable md, inflated sense f self imprtance, decreased need fr sleep, increased talkativeness, and racing thughts) Ntatin f n current mental health symptms is satisfactry. Past psychiatric histry: Includes past histry f biplar disrder, majr depressin r psychsis/schizphrenia, culd include a nte abut previus hspitalizatins r treatments fr ne f these cnditins Ntatin f n past psychiatric histry is satisfactry. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data This indicatr is identical t C-Occurring Disrders Indicatr #1. Chart abstractrs are instructed t lk fr dcumentatin f an assessment and fr dcumentatin f the presence r absence f at least ne symptm fr ne disrder r tw disrders. Dcumentatin that the patient has n previus treatment fr his all f his diagnses is accepted as evidence f a psychiatric treatment histry assessment. 198

201 199

202 CO-OCCURRING DISORDERS Perfrmance Measure Technical Dcumentatin Mdule: C-Occurring Disrders Indicatr Statement: Assess fr current symptms and histry fr patients with COD in specialty mental health Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n the 2001 VA/DD Clinical Practice Guidelines fr Management f SUD stating that assessment f c-mrbid psychiatric cnditins and psychiatric histry is imprtant in a SUD cmprehensive bipsychscial assessment. This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. Numeratr: Patients frm the denminatr wh: a) Within 30 days after the start f a c-ccurring disrder new treatment episde had their symptms f cmrbid mental health diagnsis assessed by a licensed mental health prvider; and b) Within 30 days befre, n, r after the start f a c-ccurring disrder new treatment episde had their psychiatric histry assessed (X-Cutting mdule) Denminatr: Patients with a new treatment episde fr a c-ccurring disrder in specialty mental health care Patient chrts: Patients with SUD and a cmrbid diagnsis f MDD, BP, SZ, r PTSD Strength f Evidence: Grade III Definitins: Cmrbid MDD, BP, SZ, r PTSD diagnsis (denminatr): See the Key Definitins Dcument fr definitin f cmrbid cnditin.c-occurring Disrder Index Visit: See the Key Definitins Dcument Specialty mental health: See the Key Definitins Dcument; ne r mre diagnsisrelated visits (where mental health cnditin r SUD is primary diagnsis, Table 1B in the Key Definitins Dcument) in the 30 days fllwing the start f the new treatment episde. Assessment fr psychiatric symptms fr the c-mrbid mental health cnditin (numeratr) which includes dcumentatin f: Current signs, symptms r patient cmplaints f psychsis (includes hallucinatins, delusins, and bizarre behavir), depressin (includes depressed md, truble getting ut f bed, change in appetite, lsing interest in activities, and suicidal thughts), mania (includes expansive r irritable md, inflated sense f self imprtance, decreased need fr sleep, increased talkativeness, and racing thughts) r PTSD (expsure t a traumatic event with recurrent and intrusive recllectins) Ntatin f n current mental health symptms is satisfactry. 200

203 Past psychiatric histry: Includes past histry f biplar disrder, majr depressin, psychsis/schizphrenia r PTSD culd include a nte abut previus hspitalizatins r treatments fr ne f these cnditins Ntatin f n past psychiatric histry is satisfactry. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data This indicatr is als present in the SUD technical manual. Numeratr b is cllected in SUD mdule in WVMI abstractin. Fr c-ccurring disrders, the new treatment episde date is the secnd validated new treatment episde date. If there is n secnd validated new treatment episde, the first will be used. Psychiatric histry cmes frm the Crss-Cutting mdule. 201

204 Perfrmance Measure Technical Dcumentatin Mdule: C-Occurring Disrders Indicatr Statement: All patients diagnsed with COD wh are in a new treatment episde fr COD shuld receive apprpriate treatment fr bth their substance use disrder and mental health disrder Indicatr Number: 2 Executive Summary: The fllwing indicatr is based n the VA/DD Clinical Practice Guidelines fr Management f SUD (2001) and PTSD (2000) and applies acrss all diagnses relevant t this evaluatin. Fr example, the guidelines fr SUD state that: Patients apprpriate fr care management may have a range f medical and psychiatric c-mrbid cnditins that require integrated care, with cncurrent attentin t their substance dependence r abuse. These patients may require substantial emergency care and stabilizatin and may repeatedly present in crisis, but are unwilling t return fr utpatient visits r engage in alchl and/r drug treatment. Patients wh are willing t engage in nging medical r psychiatric care have nt refused all help. Such patients may als receive integrated care management frm addictin treatment prviders in sme settings (e.g., Opiid Agnist Therapy [OAT], dual disrders prgrams, r prgrams fr chrnic SUDs) (Willenbring et al., 1995). This indicatr is als based n empirical supprt fr integrating mental health and substance abuse treatments int a cmbined service (Drake, Mueser, Brunette, & McHug, 2004) and was created based n elements f the Integrated Treatment fr Dual Disrders (IDDT; Mueser, Nrdsky, Drake, & Fx, 2003). Accrding t SAMHSA (2006): Integrated treatment crdinates substance abuse and mental health interventins t treat the whle persn mre effectively; the term refers bradly t any mechanism by which treatment interventins fr COD are cmbined within a primary treatment relatinship r service setting. As such, integrated treatment reflects the lngstanding cncern within substance abuse treatment prgrams fr treating the whle persn, and recgnizes the imprtance f ensuring that entry int any ne system can prvide access t all needed systems. Treatment fr peple with c-ccurring disrders must address bth their mental health and substance abuse needs (Center fr Substance Abuse Treatment, 2005; Mee-Lee et al. 2001; Burnam & Watkins, 2006), regardless f the level f severity f each prblem. This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. References: COSIG Prgram, 2006 (SAMHSA Actin Plan); Center fr Substance Abuse Treatment. Substance abuse treatment fr persns with c-ccurring disrders. Rckville (MD): Substance Abuse and Mental Health Services Administratin (SAMHSA); (Treatment imprvement prtcl [TIP]; n. 42). Center fr Substance Abuse Treatment. TIP 42: Substance abuse treatment fr persns with c-ccurring disrders. U.S. Department f Health and Human Services, Public Health Service, Substance Abuse and Mental Health Treatment Administratin (SAMHSA) Mee-Lee, D., Shulman, G.D., Fishman, M. et al. Patient Placement Criteria fr the Treatment f Substance Related Disrders, Secnd Editin-Revised (ASAM PPC- 2R).Chevy Chase, MD: American Sciety f Addictin Medicine,

205 Burnam, M.A., Watkins, K.E. (2006). C-ccurring Substance Abuse and Mental Disrders: Specialized Public Systems and Integrated Care, Health Affairs 25 (3), Numeratr: Patients frm the denminatr wh had (1) any visits within three mnths f the start f the c-ccurring disrder new treatment episde r (2) 2 visits every mnth fr the first three mnths fllwing the start f the c-ccurring disrder new treatment episde that: a) Addressed SUD b) Addressed mental illness by a qualified prvider c) Addressed BOTH d) Addressed NEITHER Denminatr: Patients with a new treatment episde fr a c-ccurring disrder Patient chrts: Patients with a chrt diagnsis f SUD and cmrbid MDD, BP, SZ, r PTSD Strength f Evidence: Grade II Definitins: C-Occurring Disrder Index Visit: See the Key Definitins Dcument Cmrbid MDD, BP, SZ, r PTSD diagnsis (denminatr): See the Key Definitins Dcument fr definitin f cmrbid cnditin. Addressed SUD: Dcumentatin in the medical recrd f grup r individual r family treatment fr SUD; medicatin fr SUD; a nte by the prvider that says the persn desn t need SUD treatment r a nte frm prvider that says the persn is in sustained remissin/has been sber fr > 1 year. Addressed mental health: Dcumentatin in the medical recrd f grup r individual (includes psychtherapy) r family treatment; medicatin fr mental health; r a nte by the prvider that says the persn desn t need mental health treatment Qualified prvider: Licensed independent prvider (includes MD, DO, physician s assistant, nurse practitiner/clinical nurse specialist, licensed clinical scial wrker, psychlgist r a trainee with a c-signature) Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm the medical recrd data Patients can pass by either (1) r (2) in the numeratr Fr sme individuals, the apprpriate treatment may be n treatment at all if cmrbid cnditin is nt active. This shuld still be nted in the chart. 203

206 Perfrmance Measure Technical Dcumentatin Mdule: C-Occurring Disrders Indicatr Statement: Prprtin f patients with COD and severe functinal impairment that receive integrated substance abuse and mental health treatment Indicatr Number: 3 Executive Summary: The fllwing indicatr is based n the VA/DD Clinical Practice Guidelines fr Management f SUD (2001) and PTSD (2000) and applies acrss all diagnses relevant t this evaluatin. Fr example, the guidelines fr SUD state that: Patients apprpriate fr care management may have a range f medical and psychiatric c-mrbid cnditins that require integrated care, with cncurrent attentin t their substance dependence r abuse. These patients may require substantial emergency care and stabilizatin and may repeatedly present in crisis, but are unwilling t return fr utpatient visits r engage in alchl and/r drug treatment. Patients wh are willing t engage in nging medical r psychiatric care have nt refused all help. Such patients may als receive integrated care management frm addictin treatment prviders in sme settings (e.g., Opiid Agnist Therapy [OAT], dual disrders prgrams, r prgrams fr chrnic SUDs) (Willenbring et al., 1995). The fllwing indicatr is based n empirical supprt fr integrating mental health and substance abuse treatments int a cmbined service (Drake, Mueser, Brunette, & McHug, 2004) and was created based n elements f the Integrated Treatment fr Dual Disrders (IDDT; Mueser, Nrdsky, Drake, & Fx, 2003). Accrding t SAMHSA (2006): Integrated treatment crdinates substance abuse and mental health interventins t treat the whle persn mre effectively; the term refers bradly t any mechanism by which treatment interventins fr COD are cmbined within a primary treatment relatinship r service setting. As such, integrated treatment reflects the lngstanding cncern within substance abuse treatment prgrams fr treating the whle persn, and recgnizes the imprtance f ensuring that entry int any ne system can prvide access t all needed systems. In additin, integrated treatment is recmmended fr patients with severe and persistent mental illness (Drake et al., 2004). This indicatr addresses the fllwing Institute f Medicine (IOM) dmain: Effectiveness. Reference: COSIG Prgram, 2006 (SAMHSA Actin Plan); Center fr Substance Abuse Treatment. Substance abuse treatment fr persns with c-ccurring disrders. Rckville (MD): Substance Abuse and Mental Health Services Administratin (SAMHSA); (Treatment imprvement prtcl [TIP]; n. 42). Numeratr: Patients frm the denminatr wh received treatment fr bth their mental health and substance use disrder during the study perid frm: 204

207 (a) (b) (c) (d) One clinic team r clinician crss-trained in bth mental health and SUD issues (e.g., IDDT); r Separate clinic teams that are well crdinated (e.g., ntes indicated active cmmunicatin r knwledge that separate clinics were wrking with patient); r Separate clinic teams nt well crdinated (e.g., n cmmunicatin between the tw clinic teams r nly a referral); r Only received treatment fr ne cnditin Denminatr: a) Patients, with a c-ccurring disrder and wh have GAF scre 40, wh had at least tw diagnsis-related visits during the study perid b) Patients, with a c-ccurring disrder and wh have GAF scre >40, wh had at least tw diagnsis-related visits during the study perid c) Patients, with a c-ccurring disrder and wh have n reprted GAF, wh had at least tw diagnsis-related visits during the study perid Patient chrts: Patients with chrt diagnsis f SUD and MDD, BP, SZ, r PTSD Strength f Evidence: Grade I Definitins: Cmrbid MDD, BP, SZ, r PTSD diagnsis: See the Key Definitins Dcument Glbal Assessment f Functining (GAF): Scale f Qualifying GAF scre may be at any time during the study perid. Cllect first date n which a GAF 40 is nted in the recrd. Diagnsis-related visits: Defined as any encunters n separate days where either SUD r the patient s mental health cnditin (Table 1B, Key Definitins Dcument) is the primary diagnsis. T qualify fr the denminatr, yu may have tw encunters fr SUD r tw encunters fr a mental health cnditin, r ne f each. One clinic team r crss-trained clinician: Ntatin in the chart that the patient is participating in dual diagnsis/integrated treatment grups specifically designed t address bth mental health and substance abuse prblems; grups culd be family, persuasin, dual recvery, etc (IDDT). Separate clinic teams nt well crdinated: Ntatin in the chart that tw different teams are treating the tw cnditins, but n evidence that they are cmmunicating with each ther regarding the intersectin f the treatment. Separate clinic teams that are well crdinated: Ntatin in the chart that tw different teams are treating the tw cnditins, but there is evidence that they are cmmunicating with each ther regarding the intersectin f the treatment. Treatment fr nly ne cnditin: NO evidence in the chart that bth cnditins were treated and NO nte that treatment f ne f the cnditins is nt necessary because the cnditin is under cntrl. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data and medical recrd data Numeratr will cme frm medical recrd data Numeratr may be difficult t peratinalize and define well. 205

208 Fr data cllectin purpses, nurse abstractrs will assess the whle study perid and will determine which categry best describes the care that was prvided. We will nt be cllecting infrmatin n a visit-by-visit basis. Data fr the numeratr will be cllected n everyne. We will be able t evaluate this indicatr fr thse with GAF scres 40, >40, and with n GAF reprted. Denminatrs (b) and (c) will be used descriptively. 206

209 Perfrmance Measure Technical Dcumentatin Mdule: C-Occurring Disrders Indicatr Statement: Prprtin f patients with COD in a new treatment episde fr COD with an administrative discharge Indicatr Number: 4 Executive Summary: A review f the addictin treatment literature dne by WL White, et. al. reveals a number f key findings related t current administrative discharge practices. Definitinal Prblems: Discharge categries and their definitins differ acrss prgrams, but there is evidence that discharge rates by type f discharge vary acrss cmmunity-based and prisn-based treatment prgrams (Pelissier, et al., 2003) and vary frm therapist t therapist within the same treatment prgram (Najavits & Weiss, 1994). Discharge Status and Clinical Outcmes: In adult ppulatins, addictin treatment retentin and cmpletin are predictive f psitive utcmes, and failure t cmplete treatment (including thse administratively discharged) is predictive f wrse utcmes (Price, 1997; Grella, et al., 1999; Wallace & Weeks, 2004). Administrative Discharge Prfiles: Adult and adlescent nncmpleters are mre likely t have clinical prfiles marked by yunger age, greater prblem severity (althugh sme studies reprt a psitive link between severity and retentin) psychiatric impairment (i.e., depressin, cnduct disrder, antiscial persnality disrder, schizphrenia), histry f perpetratin f vilence, less mtivatin fr recvery, and less recvery supprts in their family and scial netwrk (Gdley, et al., 2001; Hser, et al., 1998; DeLen & Jainchill, 1986; Agsti, et al.,1996; DeLen, et al., 2000; Pelissier, et al., 2003). Administrative Discharge Prevalence and Level f Care Patterns: At the present time, 18 percent (288,000 thusand) f the 1.6 millin peple admitted t publicly funded addictin treatment in the United States are administratively discharged (cmpared t 49 percent wh cmplete treatment, 24 percent wh leave against staff advice; and 9 percent wh are transferred) (Substance Abuse and Mental Health Services Administratin, 2002). Rates f AD are nt unifrm acrss levels f care. The highest t lwest rates f AD are fund in methadne maintenance (30.7 percent), lng-term residential (24.8 percent), utpatient (23.7 percent), intensive utpatient (19.8 percent), detxificatin (9.4 percent), shrt-term residential (9 percent), and inpatient hspital treatment (4.6 percent) (SAMHSA, 2002). Cmmn bjectives fr treatment prgrams t use AD include: T prtect the integrity f the treatment milieu. T assure the best utilizatin f limited treatment resurce. T prtect the reputatin f the treatment prgram. T prevent the treatment rganizatin and its staff frm enabling clients. T fulfill the ethical bligatin f terminating and (at least nminally) referring clients wh fail t respnd t prgram services. Reference: White, W.L., Sctt, C.K., Dennis, M.L., and Byle, M.G. (2005) It s Time t Stp Kicking Peple Out f Addictin Treatment, Cunselr 6 (2),

210 Numeratr: a) Prprtin f patients with an administrative discharge n r after the start f the new treatment episde b) Patients with an administrative discharge within 90 days f the start f a new treatment episde c) Patients with an administrative discharge mre than 90 days f the start f a new treatment episde d) Patients with n dcumentatin f an administrative discharge e) Fr descriptive purpses, nte reasns fr discharge Denminatr: Patients with a new treatment episde fr a c-ccurring disrder Patient chrts: Patients with chrt diagnsis f SUD and MDD, BP, SZ, r PTSD Strength f Evidence: Grade III Definitins: C-Occurring Disrder Index Visit: See the Key Definitins Dcument Cmrbid MDD, BP, SZ, r PTSD diagnsis: See the Key Definitins Dcument fr a definitin f a cmrbid cnditin. Administrative discharge: the adversarial terminatin f services due t a client s failure t cmply with prgram rules and expectatins, als referred t as disciplinary discharge, discharge fr cause, r discharge upn staff request. The reasns fr AD vary by mdality but generally include: Failing t participate in service activities, e.g., missing cunseling sessins. Threatening, r appearing t threaten, the physical r psychlgical safety f thers. Breaking rules regarding relatinship bundaries, e.g., having phne r face-t-face cntact with family members r friends during a blackut perid, verbal abuse (prfanity, racial slurs), r fraternizatin (sexual r ther inapprpriate activity with anther client). Refusing t live within rules established fr cmmunal living (e.g., hygiene, assigned chres, disruptiveness, quiet hurs, and punctuality fr treatment activities). Failing t pay service fees. Pssessing cntraband in the treatment facility (e.g., illicit drugs, cigarettes, prhibited fd items). Using alchl r unprescribed drugs. Failing t secure medicatin fr a psychiatric cnditin. The AD status is distinct frm successful treatment cmpletin (smetimes referred t as planned discharge r graduatin ), client terminatin f service participatin against staff advice (als referred t as against medical advice, absent withut leave r drp-uts ), r referrals t anther treatment resurce (als referred t as transfers ). Or, unable t determine why administrative discharge. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data 208

211 The team will pilt this indicatr t see if discharge is apprpriate. It is pssible that patient was referred t anther prgram t get the level f care they need and therefre administrative discharge wuld be apprpriate and gd care. It is pssible t have mre than ne reasn fr discharge. We will evaluate the reasns fr discharge based n gd and pr quality separately. Fr example, thse wh receive an administrative discharge and are referred t anther prgram wuld be cnsidered having gd care. Thse wh receive anther type f administrative discharge wuld be categrized as having pr care. We can present the indicatr as any administrative discharge as well as presenting it with its three cmpnents: any within 90 days, any after 90 days in the study perid, and thse with n administrative discharge. 209

212

213 CROSS-CUTTING: PSYCHOSOCIAL NEEDS INDICATORS Perfrmance Measure Technical Dcumentatin Mdule: Psychscial Indicatrs Indicatr Statement: Patients receive Mental Status Exam (MSE) including assessment f: - Appearance (Persnal hygiene/apprpriate dress [Schiz]) - General Behavir (Schiz, Biplar, MDD, SUD & PTSD) Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management f Pst- Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. Fr example, the VA guideline fr majr depressive disrder directs prviders t "Perfrm Mental Status Examinatin (MSE)" in primary care, utpatient mental health specialty and inpatient mental health care settings in rder t "develp an apprpriate clinical understanding f the patient that will infrm subsequent prvider decisins" (7-8). Assessing Axes IV and V f DSM-IV is part f the mental status examinatin cnducted in psychiatry and has been recmmended as part f standard practice (APA, 2006). Furthermre, the VA guideline fr psychses recmmends that clinicians assess patients' "Functinality and Psychscial Supprt System," defined as fllws: This assessment has t d with immediate needs fr husing, transprtatin and access, life skills, wrk and/r emplyment, educatin, financial, scial skills, health awareness, family, legal, cultural and/r spiritual help. Essentially this is a full evaluatin f the issues relevant t Axes IV and V f DSM-IV After reviewing a cmprehensive list f issues relevant t Axis V f DSM-IV, the VA Mental Health Prgram Evaluatin Cnsultatin Grup identified "Persnal hygiene/apprpriate dress" and "Apprpriate behavir" as being the mst relevant assessment dmains t patients with Schizphrenia (bth dmains) and Biplar, MDD, SUD, r PTSD (secnd dmain nly). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Efficiency, Effectiveness, and Timeliness. Reference: American Psychiatric Assciatin: Practice Guideline fr the Psychiatric Evaluatin f Adults, Secnd Editin. Washingtn, DC: American Psychiatric Assciatin (APA); 2006 Numeratr: Patients wh received a Mental Status Exam (MSE) including assessment f: - Appearance (Persnal hygiene/apprpriate dress [Schiz]) AND - General Behavir (Schiz, Biplar; MDD, SUD & PTSD) a) Baseline assessment fr all patients with a new treatment episde: within 30 days after the start f the new treatment episde b) Annual assessment fr all patients: within study year Denminatr: a) All patients with a new treatment episde 211

214 b) All patients Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Mental Health r SUD Diagnses: See Table 1A in the Key Definitins dcument Persnal hygiene/apprpriate dress (Schiz) MSE cre element 1b: Basic grming and hygiene, dress and whether it was apprpriate attire fr the ccasin (e.g. like a heavy cat in ht summer weather) and persnal hygiene (e.g. ful dr, being unkempt, dirty clthes, evidence f nt bathing) Apprpriate behavir (All diagnses in specialty care): MSE cre element 2: The patient s general behavir which may include: Level f distress, degree f eye cntact, attitude tward the interviewer (e.g., aggressive, hstile, discnnected, r uncperative during the sessin). Feasibility/Data Cllectin Issues: Numeratr will cme frm medical recrd data (same data gathered fr Crss- Cutting Indicatr #6). Denminatr will cme frm administrative data Analyses f apprpriate behavir fr thse in specialty care will be cnducted pst hc. Specialty care will be defined per the Key Definitins Dcument as ne r mre specialty care encunters in the 30 days fllwing the start f the new treatment episde. Numeratr is cllected in the crss-cutting mdule in WVMI abstractin. 212

215 Perfrmance Measure Technical Dcumentatin Mdule: Psychscial Indicatrs Indicatr Statement: Patients with a new treatment episde in specialty care receive baseline assessment f Psychscial Needs r Deficits (Axis IV) acrss the fllwing dmains: -Husing -Scial supprts -Emplyment Indicatr Number: 2 Executive Summary: This indicatr is based n an indicatr develped by the American Psychiatric Assciatin (APA), as dcumented in the Center fr Quality Assessment and Imprvement in Mental Health (CQAIMH) database, which assigned t it an evidence level f AHRQ Level C ("Little research evidence, principally based n clinical cnsensus/pinin.") The riginal indicatr was entitled "Assessment fr Psychscial Issues f Psychiatric Patients" and assessed the number f patients wh underg a psychiatric evaluatin during a specified perid whse medical recrd dcuments an evaluatin f the patient's psychscial deficits. The APA prvided the fllwing ratinale in supprt f this indicatr: Clinical practice guidelines recmmend that a psychiatric evaluatin f a newly presenting patient include an assessment f the individual's psychscial and develpmental histry. Such an assessment typically includes infrmatin abut develpmental milestnes, family and scial relatinships, educatinal and wrk histry, and majr life events including a histry f trauma. This assessment can infrm diagnsis and treatment as well as prvide infrmatin abut patient strengths, vulnerabilities, and ptential surces f supprt. This indicatr is als supprted by the 2004 VA/DD Clinical Practice Guidelines fr Management f Psychses, which recmmends that clinicians assess patients' "Functinality and Psychscial Supprt System," defined as fllws: This assessment has t d with immediate needs fr husing, transprtatin and access, life skills, wrk and/r emplyment, educatin, financial, scial skills, health awareness, family, legal, cultural and/r spiritual help. Essentially this is a full evaluatin f the issues relevant t Axes IV and V f DSM-IV. After reviewing a cmprehensive list f issues relevant t Axis IV f DSM-IV, the VA Mental Health Prgram Evaluatin Cnsultatin Grup identified the three dmains f Husing, Scial Supprts, and Emplyment as the mst relevant fr patients with the diagnses included in this prgram evaluatin, the mst measurable using VA data, and the mst actinable using VA services. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Efficiency, Effectiveness, Timeliness, and Patient- Centeredness. Numeratr: Patients frm the denminatr wh receive a baseline assessment f the presence r absence f psychscial needs r deficits (Axis IV) acrss the fllwing dmains within: ne mnth f the start f the new treatment episde -Husing -Scial supprts -Emplyment status (wrk r ther meaningful daily activity) Denminatr: All patients with a new treatment episde 213

216 Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Mental Health r SUD Diagnses: See Table 1A in the Key Definitins dcument Assessment f the presence r absence f psychscial needs r deficits acrss each dmain. Any dcumentatin that indicates the prvider assessed fr the presence r absence f psychscial need/deficits acrss each dmain. This culd be revealed by subjective statements frm the patient r bjective bservatins dcumented by the prvider. Fr example: Husing- Assessment f physical shelter. Dcumenting the patient lives alne wuld nt be sufficient unless the type f shelter was assessed. Acceptable dcumentatin culd include statements such as: Patient has safe and secure living situatin Currently hmeless, needs immediate husing Wife recently kicked patient ut f the huse, desn t have a place t stay lined up yet. Cmpleted patient prfile r needs assessment that allws the patient t describe their shelter/husing. Scial Supprts- Dcumenting the patient is married wuld nt be sufficient unless the element f need/deficit was addressed. Acceptable dcumentatin culd include statements such as: Patient is lnely Cmplains abut having n friends States husband is nn-supprtive Cmpleted patient prfile r needs assessment that addresses scial supprts need/deficit Patient feels she can t stp drinking until her stressful living situatin changes. Emplyment status-purpseful daily activity. This culd include anything frm paid emplyment t vlunteering r attending classes. The intent is t knw if the patient is currently engaged in purpseful activity, regardless f being paid. Dcumenting the patient is trained as a beautician r likes t vlunteer wuld nt be sufficient unless the element f current activity is assessed Acceptable evidence f assessment culd include statements such as, Trained as a beautician and is currently emplyed Currently vlunteering at the church Just lst jb Student, taking classes, etc. Hmemaker takes care f their children/relatives, etc. Retired, but has daily purpseful activity (e.g., hbbies) dcumented. On disability, but prvider ntes hw patient spends the day. Enrlled in a day treatment facility (i.e., 8-hur day treatment) Cmpleted patient prfile r needs assessment that addresses current emplyment activity 214

217 Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Nt clear yet whether this will be descriptive r evaluative Analyses f apprpriate behavir fr thse in specialty care will be cnducted pst hc. Specialty care will be defined per the Key Definitins Dcument as ne r mre specialty care encunters in the 30 days fllwing the start f the new treatment episde. 215

218 Perfrmance Measure Technical Dcumentatin Mdule: Psychscial Indicatrs Indicatr Statement: Patients with identified need shuld be ffered services fr: -Scial supprts -Husing -Emplyment status (wrk r ther purpseful daily activity) Indicatr Number: 3 Executive Summary: This indicatr was develped t supprt the evaluatin f Prgram Outcmes prpsed by VA in all diagnsis-specific Appendices A under the dmain f "Rehabilitatin," the title f which has since been mdified t address "Rehabilitatin and Recvery Supprt". In each Appendix A, VA prpsed addressing the fllwing Rehabilitatin-related prgram utcmes and prpsed perfrmance measures (termed as such in the Appendices A): VA patients shuld demnstrate imprved functining in life activities. VA patients shuld receive assistance in btaining full r part time emplyment that is apprpriate t their interests and abilities. VA patients shuld receive husing assistance and be apprpriately hused. Effectively assessing these VA-prpsed Outcmes required defining key terms like "imprved," "apprpriate(ly)," and "assistance," as well as creating a related set f assessment-fcused perfrmance indicatrs t identify patients' baseline "functining in life activities" and needs fr emplyment and husing. This indicatr was develped t identify thse patients wh received services apprpriate t their level f need, as identified in the related psychscial assessment indicatr(s). Cnsultatin with the VA Mental Health Prgram Evaluatin Cnsultatin Grup and ther VA experts knwledgeable in the system-wide prvisin f VA services revealed that there is n clear dcumentatin f VA expectatins regarding which specific services shuld be prvided t patients with areas f need identified in the dmains f Scial Supprts, Husing, r Emplyment. Despite this lack f explicit VA expectatins, the Statement f Wrk (SOW) fr the current prgram evaluatin clearly sets sme expectatins via the Appendices A. Namely, bth the VA-prpsed gal fr the Rehabilitatin dmain ( Imprve ability t functin in sciety ) and VA-prpsed Prgram Outcme #11 (#12 in MDD Appendix A; "VA patients shuld demnstrate imprved functining in life activities ) require that services aim nt nly t diminish symptms but t imprve functinal adaptatin as well. Therefre, althugh this indicatr is currently nly descriptive, further and nging cnsideratin will be made as t ptential evaluative framewrk(s). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Efficiency, Effectiveness, Timeliness, and Patient-Centeredness. Numeratr: Patients frm the denminatr wh are ffered services acrss the fllwing dmains during the study perid: -Husing -Scial supprts -Emplyment status Denminatr: All patients with a new treatment episde AND have evidence f need/deficit acrss scial supprts, husing r emplyment status 216

219 Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Mental Health r SUD Diagnses: See Table 1A in the Key Definitins dcument Evidence f need/deficit acrss all dmains culd cme frm subjective evidence as stated by the patient (regardless f the lack f any bjective evidence frm the prvider), the prvider r administrative data. Sme examples culd include: Patient writes, hmeless n prfile r needs assessment but prvider desn t cmment n husing issue. Patient is severely depressed and can t care fr herself in current living situatin. Patient needs t increase scializatin skills Patient needs t change t an envirnment mre cnducive t recvery. Patient is psychtic and needs immediate care/husing Evidence that services were ffered acrss dmains: Scial Supprt (medical recrd): Any dcumentatin that indicates the prvider attempted t help patient with scial supprts. Fr example, sme cmments wuld be sufficient evidence, Prvider encurages depressed patient t increase scial situatins despite the fact that the patient desn t agree. Prvider prvides suggestins fr alternative living situatin t prmte recvery. Encuraged patient t arrange a scial uting with a friend. Helped patient establish a strategy fr dealing with unsupprtive husband. Husing (medical recrd): Any dcumentatin that indicates the prvider attempted t help patient with scial supprts. Fr example, sme cmments wuld be sufficient evidence, Prvider intervenes t find safe husing fr patient wh is psychtic and unaware f his/her need fr shelter. Discussed alternative living situatins that wuld be a mre apprpriate recvery envirnment. Encuraged patient t apply fr husing assistance Emplyment (medical recrd) Patient wrks at a bar. Discussed strategies fr seeking emplyment pprtunities that wuld be mre cnducive t recvery. Discussed cmmunicatin strategies that will help patient maintain emplyment status. Scial Supprt Services (administrative data): Defined as tw r mre utpatient visits with the fllwing stp cdes in the study perid: 505, Day Treatment Individual 506, Day Hspital Individual 520, Lng Term Enhancement Individual 521, Lng Term Enhancement Grup 527, Mental Health Telephne 532, Psychscial Rehabilitatin Individual 217

220 537, Telephne Psychscial Rehabilitatin 546, Telephne MHICM 547. SUD Intensive Outpatient 552, Mental Health Intensive Case Management (MHICM) 553, Day Treatment Grup 554, Day Hspital Grup 559, Psychscial Rehabilitatin Grup 560, SUD Grup 564, Mental Health Team Case Management 567, Mental Health Intensive Case Management (MHICM) Grup Husing Services (administrative data): Defined as tw r mre utpatient visits with the fllwing stp cdes in the study perid r an inpatient r residential facility admissin using the fllwing bed sectin cdes during the study perid (based n BEDSECN in the Medical SAS Inpatient Dataset): Stp cdes 522, HUD-VASH 528, Telephne Hmeless Mentally Ill 529, Health Care fr Hmeless Veterans/Hmeless Chrnically Mentally Ill (HCHV/HCMI) 530, Telephne HUD-VASH 590, Cmmunity Outreach t Hmeless Veterans by Staff Other Than HCHV and RRTP Prgrams 725, Residential Rehabilitatin Treatment Prgram (RRTP) Outreach Services 726, RRTP Aftercare Cmmunity 727, RRTP Aftercare VA 728, RRTP Admissin Screening Services 729, Telephne RRTP Bed Sectins (NOTE: if admissin date is within study perid, include in measure even if discharge ccurs after the end f the study perid.) 25, Psychiatric Residence Rehabilitatin Treatment 26, PTSD Residence Rehabilitatin 27, Substance Abuse Residence Rehabilitatin 37, Dmiciliary Care fr Hmeless Veterans 77, Psychiatric Residence Rehabilitatin 84, Psychiatric Substance Abuse (Intermediate Care) 85, Dmiciliary 86, Dmiciliary Substance Abuse 88, Dmiciliary PTSD 89, Sustained Treatment and Rehabilitatin (STAR) I, II, and III 90, Substance Abuse STAR I, II, and III Emplyment Services (administrative data): Defined as tw r mre utpatient visits with the fllwing stp cdes in the study perid (based n CL1-CL15 frm the Medical SAS Outpatient Dataset): 568: Mental Health Cmpensated Wrk Therapy/ Supprted Emplyment (CWT/SE), Face-t-Face 218

221 569: Mental Health Cmpensated Wrk Therapy/ Supprted Emplyment (CWT/SE), Nt Face-t-Face 570: Mental Health Cmpensated Wrk Therapy/ Transitinal Wrk Experience (CWT/TWE), Nt Face-t- Face 574: Mental Health Cmpensated Wrk Therapy/ Transitinal Wrk Experience (CWT/TWE), Face-t-Face 575: Mental Health Vcatinal Assistance Grup Feasibility/Data Cllectin Issues: Denminatr will cme frm bth medical recrd and administrative data Numeratr will cme frm bth medical recrd and administrative data Prvider interventin alne is cnsidered a service. If we see a nte that patient refused services, we will cllect it separately fr analysis. Analyses f apprpriate behavir fr thse in specialty care will be cnducted pst hc. Specialty care will be defined per the Key Definitins Dcument as ne r mre specialty care encunters in the 30 days fllwing the start f the new treatment episde. The VA cnsiders the veteran t have a husing need if he is nt independently hused r in a residential treatment facility. This definitin was applied fr chart abstractin. Living in a shelter r in a semi-permanent husing arrangement cnstitutes husing need. 219

222 Perfrmance Measure Technical Dcumentatin Mdule: Psychscial Indicatrs Indicatr Statement: Prprtin f patients admitted t psychiatric inpatient unit r residential treatment unit with >= 24 hur stay wh received husing services Indicatr Number: 4 Executive Summary: This indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management f Pst-Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. Fr example, the VA guideline fr psychses recmmends that "if husing assessment indicates that patient is nt currently hused, arrange immediate shelter." This indicatr was develped t supprt Prgram Outcme #13 (MDD #14) prpsed by VA in all diagnsis-specific Appendices A: "VA patients shuld receive husing assistance and be apprpriately hused." VA prpsed measuring this using dcumented evidence f husing. The develpment f this indicatr was cmplicated by the discvery that there is n clear VA definitin f "apprpriately hused r dcumentatin f VA expectatins regarding which specific service(s) shuld be prvided t inpatients with husing needs, as indicated by the VA Mental Health Prgram Evaluatin Cnsultatin Grup (February - August 2007) and ther VA experts knwledgeable in the system-wide prvisin f VA services. Despite this bstacle and despite the apparent lack f suitable previusly develped perfrmance indicatrs supprting the use f this measurement in evaluating quality f care helping t secure adequate husing fr patients is an vital cmpnent f patient-centered care, and therefre this indicatr is f high imprtance t VA as well as t veterans and plicy-makers. VA experts recmmended that VA husing assistance may be reasnably expected fr thse patients in psychiatric inpatient units r in residential treatment; this indicatr des nt include a threshld Glbal Assessment f Functining (GAF) scre requirement in the denminatr n the assumptin that inpatients have GAF scres belw 50. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Efficiency, Effectiveness, Timeliness, and Patient- Centeredness. Nte: This is an evaluative perfrmance indicatr. Numeratr: Prprtin f patients wh received husing assistance Denminatr: All patients discharged frm psychiatric inpatient unit r residential treatment unit with >= 24 hur stay and wh were nt apprpriately hused prir t discharge Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: Mental Health r SUD Diagnses: See Table 1A in the Key Definitins dcument Psychiatric inpatient unit: Defined as any discharge t the cmmunity frm an inpatient psychiatric facility where length f stay was greater than r equal t 24 hurs and with the relevant mental health r SUD diagnsis as the primary diagnsis n the discharge (based n bed sectin cde frm final discharge frm hspital PLDISCH in the Medical SAS Inpatient Dataset): 220

223 70, Acute Psychiatry 72, Alchl Dependence High Intensity 73, Drug Dependence High Intensity 74, Substance Abuse High Intensity 79, Special Inpatient PTSD Unit 84, Psychiatric Substance Abuse (Intermediate Care) 91, Evaluatin/Brief Treatment PTSD 92, Psychiatry General Interventin 93, High Intensity General Psychiatry Inpatient Exclusin: Patients admitted and discharged n the same day. Patients wh expired (where DISTO=-2 n Medical SAS Inpatient file) Patients with an unplanned departure resulting in discharge due t failing t return frm leave (where BOS= 2 r 3 n Medical SAS Inpatient file) Nte: Keep inpatient discharges where admissin date ccurred during study perid but discharge ccurred after the end f the study perid. Residential Treatment Prgram: Defined as any discharge t the cmmunity frm a residential treatment prgram where length f stay was greater than r equal t 24 hurs with the relevant mental health r SUD diagnsis as the primary diagnsis n the discharge (based n bed sectin cde frm final discharge frm hspital PLDISCH in the Medical SAS Inpatient Dataset): 25, Psychiatric Residence Rehabilitatin Treatment 26, PTSD residential rehabilitatin 27, Substance Abuse Residence Rehabilitatin 37, Dmiciliary Care fr Hmeless Veterans 77, Psychiatric Residence Rehabilitatin 85, Dmiciliary 86, Dmiciliary Substance Abuse 88, Dmiciliary PTSD 89, Sustained Treatment and Rehabilitatin (STAR) I, II, and III 90, Substance Abuse STAR I, II, and III Exclusin: Patients admitted and discharged n the same day. Patients wh expired (where DISTO=-2 n Medical SAS Inpatient file) Patients with an unplanned departure resulting in discharge due t failing t return frm leave (where BOS= 2 r 3 n Medical SAS Inpatient file) Nte: Keep inpatient discharges where admissin date ccurred during study perid but discharge ccurred after the end f the study perid. Evidence f need/deficit acrss all dmains culd cme frm subjective evidence as stated by the patient (regardless f the lack f any bjective evidence frm the prvider), the prvider r administrative data. Sme examples culd include: Patient writes, hmeless n prfile r needs assessment but prvider desn t cmment n husing issue. Patient is severely depressed and can t care fr herself in current living situatin. 221

224 Patient needs t change t an envirnment mre cnducive t recvery. Patient is psychtic and needs immediate care/husing. Husing services: This is an indicatin in the medical recrd that the patient received cunseling abut husing services, was referred fr husing services r a stp cde indicative f husing services. It des nt require that the patient actually be hused. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data The date f relevant inpatient discharges will be prvided frm administrative data fr chart abstractin. Abstractrs lk fr evidence f a referral fr husing services. Receiving list f husing ptins, fr example, is cnsidered husing service, as lng as it is an imprvement ver the patient s previus hmelessness. 222

225 Perfrmance Measure Technical Dcumentatin Mdule: Psychscial Indicatrs Indicatr Statement: Prprtin f patients admitted t psychiatric inpatient unit r residential treatment unit with >= 24 hur stay wh were apprpriately hused at discharge frm unit Indicatr Number: 5 Executive Summary: This indicatr is based n indicatrs prpsed by VA in all diagnsis-specific Appendices A under Prgram Outcme #13 (MDD #14), "VA patients shuld receive husing assistance and be apprpriately hused" and has been mdified and develped with the VA Mental Health Prgram Evaluatin Cnsultatin Grup (February - August 2007). Cnsultatin with the VA Mental Health Prgram Evaluatin Cnsultatin Grup and ther VA experts knwledgeable in the system-wide prvisin f VA services revealed that there is n clear VA definitin f "apprpriately hused r dcumentatin f VA expectatins regarding which specific service(s) shuld be prvided t inpatients with husing needs. Therefre, this indicatr is descriptive nly. VA experts did recmmend that VA husing assistance may be reasnably expected fr thse patients in psychiatric inpatient units r in residential treatment, and that fr patients discharged frm these facilities, the discharge plan may be reasnably expected t indicate where the patient is being discharged. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Efficiency, Effectiveness, Timeliness, and Patient-Centeredness. Numeratr: Prprtin f patients whse discharge plan indicates that they were apprpriately hused at discharge frm unit Denminatr: All patients discharged frm psychiatric inpatient unit r residential treatment unit with >= 24 hur stay Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: Psychiatric inpatient unit: Defined as any discharge t the cmmunity frm an inpatient psychiatric facility where length f stay was greater than r equal t 24 hurs and with the relevant mental health r SUD diagnsis as the primary diagnsis n the discharge (based n bed sectin cde frm final discharge frm hspital PLDISCH in the Medical SAS Inpatient Dataset): 70, Acute Psychiatry 72, Alchl Dependence High Intensity 73, Drug Dependence High Intensity 74, Substance Abuse High Intensity 79, Special Inpatient PTSD Unit 84, Psychiatric Substance Abuse (Intermediate Care) 91, Evaluatin/Brief Treatment PTSD 92, Psychiatry General Interventin 93, High Intensity General Psychiatry Inpatient Exclusin: Patients admitted and discharged n the same day. 223

226 Patients wh expired (where DISTO=-2 n Medical SAS Inpatient file) Patients with an unplanned departure resulting in discharge due t failing t return frm leave (where BOS= 2 r 3 n Medical SAS Inpatient file) Nte: Keep inpatient discharges where admissin date ccurred during study perid but discharge ccurred after the end f the study perid. Residential Treatment Prgram: Defined as any discharge t the cmmunity frm a residential treatment prgram where length f stay was greater than r equal t 24 hurs with the relevant mental health r SUD diagnsis as the primary diagnsis n the discharge (based n bed sectin cde frm final discharge frm hspital PLDISCH in the Medical SAS Inpatient Dataset): 25, Psychiatric Residence Rehabilitatin Treatment 26, PTSD residential rehabilitatin 27, Substance Abuse Residence Rehabilitatin 37, Dmiciliary Care fr Hmeless Veterans 77, Psychiatric Residence Rehabilitatin 85, Dmiciliary 86, Dmiciliary Substance Abuse 88, Dmiciliary PTSD 89, Sustained Treatment and Rehabilitatin (STAR) I, II, and III 90, Substance Abuse STAR I, II, and III Exclusin: Patients admitted and discharged n the same day. Patients wh expired (where DISTO=-2 n Medical SAS Inpatient file) Patients with an unplanned departure resulting in discharge due t failing t return frm leave (where BOS= 2 r 3 n Medical SAS Inpatient file) Nte: Keep inpatient discharges where admissin date ccurred during study perid but discharge ccurred after the end f the study perid. Mental Health r SUD Diagnses: See Table 1A in the Key Definitins dcument Evidence f need/deficit acrss all dmains culd cme frm subjective evidence as stated by the patient (regardless f the lack f any bjective evidence frm the prvider), the prvider r administrative data. Sme examples culd include: Patient writes, hmeless n prfile r needs assessment but prvider desn t cmment n husing issue. Patient is severely depressed and can t care fr herself in current living situatin. Patient needs t change t an envirnment mre cnducive t recvery. Patient is psychtic and needs immediate care/husing Apprpriately hused: Fr patients discharged frm a residential facility r an inpatient psych facility, discharge plan shuld nte where patient is being discharged t. These are the 2 acceptable settings fr husing: Patient is independently hused (in wn rm r huse r SRO setting) Patient is in a residential treatment facility. Living in a shelter nt cnsidered apprpriately hused. 224

227 Feasibility/Data Cllectin Issues: Numeratr will cme frm medical recrd data ( apprpriately hused ) Denminatr will cme frm administrative data The date f relevant inpatient discharges will be prvided frm administrative data fr chart abstractin. We were nt able t cllect qualitative infrmatin abut where patients were discharged t and thus will nt evaluate apprpriateness based n this qualitative infrmatin. Instead, medical recrd reviewers will abstract whether the patient was apprpriately hused after discharge. We will have the ability t cmpute this indicatr with three denminatrs: all discharges, discharges frm a psychiatric inpatient unit, and discharges frm a residential treatment facility. 225

228

229 CROSS-CUTTING: SUICIDALITY INDICATORS Perfrmance Measure Technical Dcumentatin Mdule: Suicide (All Mdules) Indicatr Statement: Percentage f patient charts that dcument assessment fr suicide ideatin (SI) Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n the VA/DD Clinical Practice Guidelines fr Management f SUD, PTSD, MDD, and Psychses (applies t Schizphrenia and Biplar Disrder). The assessment and management f suicidal patients is an essential cmpnent f standard clinical care (Bngar, 2002), yet there are n empirically-based perfrmance indicatrs evaluating suicide risk. This indicatr was created based n suicide expert cnsultatin and has been apprved by ur VA Mental Health Prgram Evaluatin Cnsultatin Grup. These prfessinals reached the cnsensus that suicide risk shuld be assessed mre frequently fr patients with Schizphrenia and Biplar diagnses, and fr patients with higher depressin and PTSD severity (i.e., GAF < 50). Diagnsis-specific threshlds were used based n the Key Definitins dcument f acute and new treatment episdes. Threshlds fr glbal assessment f functining (GAF) scres were determined under the advisement f the VA Mental Health Prgram Evaluatin Cnsultatin Grup, based n previus research (Niv et al., 2007). Assessing suicide ideatin is part f the mental status examinatin cnducted in psychiatry and has been recmmended as part f standard practice (APA, 2006). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and Effectiveness. References: Bngar B. The Suicidal Patient Clinical and Legal Standards f Care (2 nd Washingtn, D.C.: American Psychlgical Assciatin ed.) Niv N, Chen AN, Sullivan G, Yung AS. The MIRECC versin f the Glbal Assessment f Functining scale: reliability and validity. Psychiatr Serv Apr; 58(4): American Psychiatric Assciatin: Practice Guideline fr the Psychiatric Evaluatin f Adults, Secnd Editin. Washingtn, DC: American Psychiatric Assciatin (APA); 2006 Numeratr: Patients frm the denminatr with a dcumented assessment fr current suicide ideatin (SI) at least nce during the study perid Denminatr: All patients Patient chrts: Patients with a chrt diagnsis Strength f Evidence: Grade III Definitins: Assessment f suicide ideatin (SI): Dcumentatin f the presence r absence f suicide ideatin. Using the PHQ-9 wuld cunt fr assessment f SI, but a PHQ f 227

230 fewer items wuld nt. Outpatients wh are subsequently admitted t the hspital fr elevated suicide risk still must be assessed fr SI within 24 hurs f that admissin. The presence r endrsement f current SI includes any reference t the patient s nt wanting t live anymre, cmments abut killing neself r ding neself serius harm, verwhelming hpelessness, thughts f death as a slutin, r entertaining any similar thughts. Absence f SI is dcumentatin f specific denial f SI (e.g., n suicidal thughts, n thughts f self harm, etc.). Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Data cllectrs will be made aware f any standardized tls that may be used (similar t the PHQ-9) that culd ptentially evaluate SI and fllw up with help cnsultatin as needed t determine if the use f the tl wuld suffice fr this indicatr. In analysis, we will separate results ut by: All patients, and Thse wh are in specialty mental health care (defined as tw r mre encunters during the study perid) 228

231 Perfrmance Measure Technical Dcumentatin Mdule: Suicide (All Mdules) Indicatr Statement: Percentage f utpatient charts with endrsement f suicide ideatin, suicide intent r suicide behavir that receive apprpriate fllw-up Indicatr Number: 2 Executive Summary: The fllwing indicatr is based n the VA/DD Clinical Practice Guidelines fr Management f SUD, PTSD, MDD, and Psychses (applies t Schizphrenia and Biplar Disrder). The assessment and management f suicidal patients is an essential cmpnent f standard clinical care (Bngar, 2002), yet there are n empirically-based perfrmance indicatrs evaluating suicide risk. This indicatr was created based n suicide expert cnsultatin and has been apprved by ur VA Mental Health Prgram Evaluatin Cnsultatin Grup. Prviding a fllw-up assessment f suicidal ideatin is the standard f care if the patient had a recent endrsement f suicidal ideatin. This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Safety and Effectiveness. Reference: Bngar B. The Suicidal Patient Clinical and Legal Standards f Care (2 nd Washingtn, D.C.: American Psychlgical Assciatin ed.) Numeratr: Dcumentatin f apprpriate fllw up (per the definitins belw) fr the ideatin, intent r behavir endrsed Denminatr: Outpatient visits/cntacts where the patient endrsed suicide ideatin, intent r behavir Patient chrts: Patients with a chrt diagnsis Strength f Evidence: Grade III Definitins: Presence r endrsement f current Suicidal Ideatin includes any cmments abut killing neself r ding neself serius harm, verwhelming hpelessness, thughts f death as a slutin, r entertaining any similar thughts. Apprpriate interventin fr suicidal ideatin: Prvisin f resurce list (t utpatient): Patient given a list f resurces t call r visit if in danger. Appintment fr fllw up Assessment fr suicidal intent Presence r endrsement f suicidal intent: Dcumentatin indicating imminent threat f suicide, patient has a specific plan fr hurting r killing him/herself (e.g., lcatin, hw, when), r indicatin abut chsen means t self-harm r suicide r access t lethal means (e.g., pills, firearms). Apprpriate interventin fr suicidal intent: Family (f utpatient) interventin: Dcumented prvider discussin with patient and family members regarding patient s suicide intent and effrts fr keeping the patient safe. Patient was referred fr admissin t an inpatient unit. 229

232 Suicidal behavir is characterized by a successful r unsuccessful attempt t kill neself. It includes attempted suicide, suicidal gestures and cmpleted suicide. An attempted suicide is a suicidal actin that is nt fatal. If an attempted suicide invlves a suicidal actin unlikely t have any ptential f being fatal, it is called a suicide gesture. A persn taking such an actin (fr example, ingesting six Tylenl tablets) may be making a plea fr help r attentin withut having any intentin f actually ending his/her life. A cmpleted suicide is a suicidal actin that results in death. Apprpriate interventin fr suicidal behavir: Patient was admitted t an inpatient unit. Inpatient admissin includes dcumentatin f Suicidal Prtcl/Precautins/Standing Orders. Inpatient suicide prtcl: (e.g., remval f persnal effects, clse bservatin, safe envirnment, etc.) Feasibility/Data Cllectin Issues: Denminatr will cme frm medical recrd data Numeratr will cme frm medical recrd data NOTE: Data cllectrs will have t be aware f any standardized tls that may be used (similar t the PHQ-9) that culd ptentially evaluate SI and fllw up with help cnsultatin as needed t determine if the use f the tl wuld suffice fr this indicatr. In analysis, we will separate results ut by: All patients, and Thse wh are in specialty mental health care (defined as tw r mre encunters during the study perid) 230

233 CROSS-CUTTING INDICATORS Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatr (All Mdules) Indicatr Statement: Medical Assessment (Histry) Indicatr Number: 1 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management Pst- Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. In particular, the 2001 VA/DD Clinical Practice Guideline fr the Management f Substance Use Disrders (SUD) prvides specific recmmendatins fr the specific categries that a cmprehensive SUD Assessment fr patients beginning an acute treatment episde shuld address, including current medical status and medical histry (ASAM, 1996; Senay, 1997; Strauss, 1995). This indicatr addresses the fllwing IOM dmains: Effectiveness and patient-centeredness. Numeratr: Number f patients whse past medical histry is assessed by a qualified prvider 1) Within 30 days f the start f the new treatment episde 2) In the study perid Denminatr: 1) All patients with a new treatment episde 2) All patients Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Past medical histry: The general medical histry includes available infrmatin n knwn general medical illnesses (e.g., hspitalizatins, prcedures, treatments, and medicatins), allergies r drug sensitivities, and undiagnsed health prblems that have caused the patient majr distress r functinal impairment. This includes histry f any episdes f imprtant physical injury r trauma; sexual and reprductive histry; and any histry f endcrinlgical, infectius (including but nt limited t HIV, tuberculsis, and hepatitis C), neurlgical disrders, sleep disrders (including sleep apnea), and cnditins causing pain and discmfrt. Of particular imprtance is a specific histry regarding diseases and symptms f diseases that have a high prevalence amng individuals with the patient s demgraphic characteristics and backgrund fr example, infectius diseases in users f intravenus drugs r pulmnary and cardivascular disease in peple wh smke. Infrmatin regarding all current and recent medicatins, including hrmnes (e.g., birth cntrl pills, andrgens), ver-the-cunter medicatins, herbal supplements, vitamins, cmplementary and alternative medical treatments, and medicatin side 231

234 effects, is part f the general medical histry. With all aspects f the general medical histry, btaining crrbrating infrmatin (e.g., frm medical recrds, treating clinicians, family) can be helpful, since rdinary errrs in cmprehensin, recall, and expressin can lead t errrs in patient reprts. Qualified prvider: Any physician (MD r DO), physician s assistant, r nurse practitiner Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm the medical recrd 232

235 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatrs Indicatr Statement: Cmprehensive Assessment: C-mrbid psychiatric cnditins, psychiatric histry, and respnse t treatment Indicatr Number: 2 Executive Summary: The fllwing indicatr cmes frm the 2001 VA/DD Clinical Practice Guidelines fr SUD. The VA Clinical Practice Guideline recmmends that a cmprehensive SUD Assessment and an assessment f gals shuld address each f the fllwing 10 general categries fr patients beginning a new treatment episde (ASAM, 1996; Senay, 1997; Strauss, 1995): 1. Patient's demgraphics and identifying infrmatin, including husing, legal, and ccupatinal status 2. Patient's chief cmplaint and histry f the presenting cmplaint 3. Recent substance use and severity f substance-related prblems 4. Lifetime and family histry f substance use 5. C-mrbid psychiatric cnditins and psychiatric histry 6. Scial and family cntext 7. Develpmental and military histry 8. Current medical status and medical histry, including risk fr HIV r hepatitis C 9. Mental status and physical examinatins 10. Patient s perspective n current prblems and treatment gals r preferences This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Effectiveness and patient-centeredness. References: American Sciety f Addictin Medicine (ASAM) (1996). Patient Placement Criteria fr the Treatment f Substance-Related Disrders (2 nd ed.). Washingtn, D.C.: ASAM, Inc. Senay, E. C. (1997). Diagnstic interview and mental status examinatin. In J. H. Lwinsn, P. Ruiz, R. B. Millman, & J. G. Langrd, (Eds.), Substance Abuse, A Cmprehensive Textbk, (3 rd ed.), (pp ). Baltimre, MD: Williams & Wilkins. Strauss, G. D. (1995). The psychiatric interview, histry, and mental status examinatin. In H. I. Kaplan & B. J. Sadck (Eds.), Cmprehensive Textbk f Psychiatry (6 th ed.), Vl. 1, (pp ). Baltimre, MD: Williams & Wilkins. Numeratr: Patients frm the denminatr wh are assessed within 30 days befre r after the start f the new treatment episde fr: a) c-mrbid psychiatric cnditins, and b) past psychiatric histry c) respnse t previus treatment Denminatr: Patients with a new treatment episde Patient chrts: All diagnses 233

236 Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument C-mrbid psychiatric cnditin: Includes dcumentatin f presence r absence f any c-ccurring mental health cnditin such as biplar disrder, majr depressin r psychsis/schizphrenia, r PTSD. Past psychiatric histry: This culd include a nte abut previus hspitalizatins r treatments fr ne f these cnditins. We are lking fr characteristics, frequency r length f previus episdes. Chart dcumentatin that patient has n previus treatment f all f the patient s chrt diagnses is cnsidered evidence f a psychiatric treatment histry assessment. Respnse t previus treatment: Ntatin f histry f medicatin r psychtherapy trials in the past and respnse t thse trials. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data Analyses f assessments fr thse in specialty care will be cnducted pst hc. We defined specialty care per the Key Definitins Dcument, identifying thse wh have 1+ specialty care encunters in the 30 days fllwing the start f the new treatment episde. The date f the first diagnsis-related visit (primary r secndary diagnsis) at the start f each new treatment episde (up t 5 episdes) will be prvided frm administrative data fr chart abstractin. 234

237 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatrs Indicatr Statement: Assessment f recent substance use type, quantity and frequency Indicatr Number: 3 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the 2004 VA/DD Clinical Practice Guideline fr Management f Pst-Traumatic Stress. The Center fr Substance Abuse Treatment Imprvement Prtcl # 42 recmmends that all patients with mental health disrders be assessed fr c-ccurring substance use, as patients with mental illness and c-mrbid drug r alchl use experience greater impairment and wrse treatment utcmes than peple with nly ne f these disrders. In additin, alchl use interacts negatively with medicatins prescribed fr mental health cnditins, including antidepressants (Schuckit, 1986; Dackis et al., 1986; Gdwin, 1983; Kfed et al., 1988; Friedman et al., 1983). The 2001 VA/DD Clinical Practice Guideline fr the Management f Substance Use Disrders (SUD) recmmends that this assessment include recent substance use (ASAM, 1996; Senay, 1997; Strauss, 1995). This indicatr addresses the fllwing IOM dmains: Effectiveness and patient-centeredness. Numeratr: Patients in the denminatr wh have an assessment f recent substance abuse, including type, quantity, and frequency, within the first 30 days f the new treatment episde. Denminatr: Patients in a new treatment episde Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New treatment episde: See the Key Definitins dcument Recent substance abuse: Past 3 mnths Assessment: Dcumentatin f n recent alchl and n recent drug use OR dcumentatin f recent alchl and drug use including type, quantity, and frequency fr all substances used. Type: Specifically ask abut alchl, marijuana, ccaine, herin/narctics, methamphetamine/stimulants, intravenus drug use; r nte abut denying all ther drug use Quantity (nly needed fr alchl): May include nte in chart n any f the fllwing: Number f drinks per day, number f drinks per week, any nte abut binge drinking (>5 drinks per day), any evidence f quantity Frequency: Nte abut daily, mnthly, weekly, r ccasinal use Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data The date f the first diagnsis-related visit (primary r secndary diagnsis) at the start f each new treatment episde (up t 5 episdes) will be prvided frm administrative data fr chart abstractin. 235

238 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatr (All Mdules) Indicatr Statement: Physical Exam Indicatr Number: 4 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management Pst- Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. In particular, the 2001 VA/DD Clinical Practice Guideline fr the Management f Substance Use Disrders (SUD), which prvides specific recmmendatins as t the specific categries that a cmprehensive SUD Assessment fr patients beginning an acute treatment episde shuld address a number f categries including physical examinatins (ASAM, 1996; Senay, 1997; Strauss, 1995). This indicatr addresses the fllwing IOM dmains: Effectiveness and patientcenteredness. Numeratr: Number f patients wh receive a physical exam by a qualified prvider 1) Within 30 days f the start f the new treatment episde 2) In the study perid Denminatr: 1) All patients with a new treatment episde 2) All patients Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Physical Exam: A physical exam must include all 6 f the fllwing t pass: vital signs, heart, lungs, abdmen, extremities and cgnitin/ neurpsychlgical status. Qualified prvider: Nn-mental health prescriber which includes an MD (nt a psychiatrist unless dually bard certified) r DO; physician s assistant, nurse practitiner. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm the medical recrd 236

239 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatr (All Mdules) Indicatr Statement: Assessment f substance use disrder, and trauma and patient strengths cmpleted Indicatr Number: 5 Executive Summary: The fllwing indicatr cmes frm the 2006 Hspital-Based Inpatient Psychiatric Services (HBIPS) measures develped by the Jint Cmmissin n Accreditatin f Healthcare Organizatins (JCAHO). This indicatr addresses the fllwing Institute f Medicine (IOM) dmains: Patient-centeredness and effectiveness. JCAHO prvides the fllwing ratinale: There is substantial evidence that there is a high prevalence f c-ccurring substance use disrders as well as histry f trauma amng persns admitted t acute psychiatric settings. Prfessinal literature suggests that these factrs are under identified yet integral t current psychiatric status and shuld be assessed in rder t develp apprpriate treatment (Ziednis, 2004, NASMHPD, 2005). Similarly, persns admitted t inpatient settings require a careful assessment f risk fr vilence and the use f seclusin and restraint. Careful assessment f risk is critical t safety and treatment. Effective, individualized treatment relies n assessments that explicitly recgnize patients strengths. These strengths may be characteristics f the individuals themselves, supprts prvided by families and thers, r cntributins made by the individuals cmmunity r cultural envirnment (Rapp, 1998). In the same way, inpatient envirnments require assessment fr factrs that lead t cnflict r less than ptimal utcmes. Numeratr: Patients whse recrds include dcumentatin f initial assessment cmpleted: Within 72 hurs f admissin: Presence/absence f c-ccurring substance use disrder in past 12 mnths Presence/absence f histry f psychlgical trauma and cntributin f trauma t current presentatin Assessment f patient strengths Denminatr: All psychiatric inpatient discharges with at least a 72 hur stay Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: Psychiatric inpatient discharges where ne f the chrt diagnses is the primary diagnsis n the inpatient recrd respnsible fr the length f stay in the selected bed sectin (DXLSB) (see exclusin criteria belw): 70, Acute Psychiatry 92, Psychiatry General Interventin 93, High Intensity General Psychiatry Inpatient 72, Alchl dependence, high intensity 73, Drug dependence, high intensity 237

240 74, Substance abuse, high intensity Exclusin criteria: Patients wh expired (where DISTO=-2 n Medical SAS Inpatient file) within 72 hurs f admissin t the specified bed sectin Patients transferred t a different bed sectin within 72 hurs f admissin t the specified bed sectin (based n date and time f admissin t the selected bed sectin [BSINDAY, ADTIME] and date and time patient was discharged frm the selected bed sectin [BSOUTDAY, BSOUTIME]) Patients discharged frm the hspital within 72 hurs f admissin t the specified bed sectin (where DISTO=-1, 0-35) Patient strengths: Dcumentatin in the medical recrd that the initial assessment cntained a screening fr patient strengths which shuld include, but is nt limited t tw r mre f the fllwing: an appraisal f the patient s vcatinal interests (interests, hbbies, etc.), interpersnal relatinships and supprts (family, peers, etc.), cultural/spiritual/religius and cmmunity invlvement, access t husing/residential stability. C-ccurring SUD: Dcumentatin in the medical recrd that the initial assessment cntained a screening fr the use f alchl r substance abuse ver the past twelve (12) mnths. If there is a psitive histry f use ver the past twelve (12) mnths, then an assessment fr the negative effect n ne r mre f the fllwing must be included: imprtant relatinships (e.g., family, friends, schlmates, cwrkers), wrk r schl, daily functining (e.g., persnal hygiene, caring fr self r thers in yur charge, attending t medical and emtinal health, driving, shpping r paying bills) and sickness r physical withdrawals when quitting use f alchl r substances. Histry f psychlgical trauma: Dcumentatin in the medical recrd that the initial assessment cntained a screening fr psychlgical trauma which must address if the patient has ever experienced any psychlgical trauma (event) that was s frightening, hrrible r upsetting that it is impacting current cping by ne r mre f the fllwing: having nightmares abut it, having thughts abut it when yu did nt want t, trying hard nt t think abut it (e.g., went ut f yur way t avid situatins reminding yu f it), being excessively n guard, watchful r easily startled and feeling numb r detached frm thers, activities r surrundings. Dcumentatin f military trauma alne wuld suffice fr this, whether r nt the patient shws symptms. Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data We will cllect each numeratr item separately in rder t assess which area may have prblems Regardless f what chrt a patient is assigned t, the numeratr applies t everyne with a psychiatric inpatient discharge. 238

241 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatr (All Mdules) Indicatr Statement: (Cmprehensive) Mental status examinatin cnducted in patients with a new treatment episde Indicatr Number: 6 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management Pst- Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. The VA guideline fr majr depressive disrder directs prviders t "Perfrm Mental Status Examinatin (MSE)" in Primary care, Outpatient Mental Health Specialty and Inpatient Mental Health care settings in rder t "develp an apprpriate clinical understanding f the patient that will infrm subsequent prvider decisins" (7-8). The guideline further states: Particularly in the elderly patient, a full Mental Status Examinatin (MSE) includes cgnitive screening assessment that may cnsist f a standardized instrument such as the Flstein Mini-Mental State Examinatin (MMSE) (Crum RM, et al., 1993; Cummings JL, 1993; Flstein MF, et al., 1975) (See Psychses Guideline). Other MSE findings f imprtance include slw speech, sighing, psychmtr retardatin r agitatin, dwncast eyes, and little r n smiling. This indicatr addresses the fllwing IOM dmains: Efficiency, Effectiveness, and Timeliness. Numeratr: 1) Patients wh received a Mental Status Exam (MSE) within the first 30 days f a new treatment episde 2) Patients wh received a Mental Status Exam (MSE) during the study perid. (Reprt descriptively) Denminatr: 1) Patients in new treatment episde 2) All patients Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Mental Status Exam (MSE): The mental status examinatin cntains the fllwing cre elements: The patient's appearance which may include: Presenting appearance including sex, chrnlgical and apparent age, ethnicity, apparent height and weight (average, stcky, healthy, petite), any physical defrmities (hearing impaired, injured and bandaged right hand) Basic grming and hygiene, dress and whether it was apprpriate attire fr the ccasin (e.g. like a heavy cat in ht 239

242 summer weather) and persnal hygiene (e.g. ful dr, being unkempt, dirty clthes, evidence f nt bathing) The patient s general behavir which may include: Level f distress, degree f eye cntact, attitude tward the interviewer The patient's expressins f md and affect which may include: Md r hw they feel mst days (happy, sad, despndent, melanchlic, euphric, elevated, depressed, irritable, anxius, angry). Think f the climate in an area. Affect r hw they felt a given mment (cmments can include range f emtins like brad, restricted, blunted, flat, inapprpriate, labile, cnsistent with the cntent f the cnversatin and facial expressins, pessimistic, ptimistic) as well as inapprpriate signs (began dancing in the ffice, verbally threatened examiner, cried while discussing recent happy event and unable t explain why). Think f the weather, which varies slightly frm day t day. Rapprt (easy t establish, initially difficult but easier ver time, difficult t establish, tenuus, easily upset) Facial and Emtinal Expressins (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicius, tearful when discussing such and such) Respnse t Failure n Test Items (unaware, frustrated, anxius, bsessed, unaffected) Anxiety (nte level f anxiety, any behavirs that indicated anxiety, ways they handled it) Characteristics f the patient's speech and language (e.g., rate, rhythm, can yu understand what the patient is saying r is speech slurred r difficult t understand), The patient's mvement and psture. Includes gait and mtr crdinatin (awkward, staggering, shuffling, rigid, trembling with intentinal mvement r at rest), psture (sluched, erect), wrk speed, any ntewrthy mannerisms r gestures. The patient's thughts and perceptins: Spntaneusly expressed wrries, cncerns, thughts, impulses, and perceptual experiences. Cgnitive and perceptual symptms f specific mental disrders, usually elicited by specific questining and including hallucinatins, delusins, ideas f reference, bsessins, and cmpulsins. Hallucinatins and Delusins (presence, absence, denied visual but admitted lfactry and auditry, denied but shwed signs f them during testing, denied except fr times assciated with the use f substances, denied while taking medicatins). 240

243 Suicidal, hmicidal, vilent, r self-injurius thughts, feelings, r impulses. If present, details are elicited regarding their intensity and specificity, when they ccur, and what prevents the patient frm acting them ut (19). (Make SI/HI its wn specific sectin f the MSE) Cherence and thught prcesses, such as lse r idisyncratic assciatins and self-cntradictry statements. This may include: Cherence (respnses were cherent and easy t understand, simplistic and cncrete, lacking in necessary detail, verly detailed and difficult t fllw, vague, tangential, circumstantial) Thught Prcesses (difficult t understand line f reasning, shwed lse assciatins, cnfabulatins, flight f ideas, ideas f reference, illgical thinking, grandisity, magical thinking, bsessins, perseveratin,) The patient's understanding f his r her current situatin. Judgment and Insight (based n explanatins f what they did, what happened, and if they expected the utcme, gd, pr, fair, strng) Elements f the patient's cgnitive status, including the fllwing: Level f cnsciusness/alertness (sleepy, alert, tired fr wrking late, dull and uninterested, highly distractible Orientatin (persn, place, time, presidents, yur name) Cncentratin and Attentin (based n Digit Span and attentin t yur questins, serial 7's r 3's in which they cunt backwards frm 100 t 50 by 7s r 3s, naming the days f the week r mnths f the year in reverse rder, spelling the wrd "wrld", their wn last name, r the ABC's backwards) Language functins (naming, fluency, cmprehensin, repetitin, reading, writing) Memry Fund f knwledge (apprpriate t scicultural and educatinal backgrund) Calculatin (apprpriate t educatinal attainment) Drawing (e.g., cpying a figure r drawing a clck face) Abstract reasning (e.g., explaining similarities r interpreting prverbs). Executive (frntal system) functins (e.g., list making, inhibiting impulsive answers, resisting distractin, recgnizing cntradictins) Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data MSE dcumentatin defined fr chart abstractin as evidence f an encunter that includes at least 5 f the 10 cre MSE elements (defined abve) by the same practitiner. Abstractrs lk fr the mst cmprehensive MSE (cntains the mst cre elements). 241

244 Perfrmance Measure Technical Dcumentatin Mdule: Crss Cutting Indicatr (All Mdules) Indicatr Statement: Reassess severity f symptms between the beginning f the secnd mnth and the end f the furth mnth Indicatr Number: 7 Executive Summary: The fllwing indicatr is based n clinical care recmmendatins in the VA/DD Clinical Practice Guidelines fr Management Pst- Traumatic Stress (2004), Majr Depressive Disrder (2000), Substance Use Disrders (2001), and Psychses (2004), and applies acrss all diagnses relevant t this evaluatin. Althugh the imprtance f symptm reassessment has been affirmed and supprted by the VA clinical guidelines referenced abve and by the VA Mental Health Prgram Evaluatin Cnsultatin Grup, this is a descriptive indicatr due t the lack f substantial r sufficient evidence t supprt the assertin that the time perid specified in this indicatr is demnstrably related t quality f care. This indicatr addresses the fllwing IOM dmains: Effectiveness and patient-centeredness. Numeratr: All patients fr whm severity f symptms were reassessed between the secnd and furth mnth after the start f the new treatment episde Denminatr: Patients in a new treatment episde Patient chrts: All diagnses Strength f Evidence: Grade III Definitins: New Treatment Episde: See the Key Definitins dcument Symptms reassessed: Findings frm the assessment are likely t be in the mental status exam. Any nte that refers t assessment f symptms will suffice fr passing, including whether they have imprved, gtten wrse r stayed the same. The Mental Status Exam (MSE) may be used and that includes the fllwing cre elements (althugh it shuld be tailred based n the prblems fund in the first assessment): The patient's appearance which may include: Presenting appearance including sex, chrnlgical and apparent age, ethnicity, apparent height and weight (average, stcky, healthy, petite), any physical defrmities (hearing impaired, injured and bandaged right hand) Basic grming and hygiene, dress and whether it was apprpriate attire fr the ccasin (e.g. like a heavy cat in ht summer weather) and persnal hygiene (e.g. ful dr, being unkempt, dirty clthes, evidence f nt bathing) The patient s general behavir which may include: Level f distress, degree f eye cntact, attitude tward the interviewer The patient's expressins f md and affect which may include: Md r hw they feel mst days (happy, sad, despndent, melanchlic, euphric, elevated, depressed, irritable, anxius, angry). Think f the climate in an area. 242

245 Affect r hw they felt a given mment (cmments can include range f emtins like brad, restricted, blunted, flat, inapprpriate, labile, cnsistent with the cntent f the cnversatin and facial expressins, pessimistic, ptimistic) as well as inapprpriate signs (began dancing in the ffice, verbally threatened examiner, cried while discussing recent happy event and unable t explain why). Think f the weather, which varies slightly frm day t day. Rapprt (easy t establish, initially difficult but easier ver time, difficult t establish, tenuus, easily upset) Facial and Emtinal Expressins (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicius, tearful when discussing such and such) Respnse t Failure n Test Items (unaware, frustrated, anxius, bsessed, unaffected) Anxiety (nte level f anxiety, any behavirs that indicated anxiety, ways they handled it) Characteristics f the patient's speech and language (e.g., rate, rhythm, can yu understand what the patient is saying r is speech slurred r difficult t understand), The patient's rate f mvement and the presence f any purpseless, repetitive, r unusual mvements r pstures. Includes gait and mtr crdinatin (awkward, staggering, shuffling, rigid, trembling with intentinal mvement r at rest), psture (sluched, erect), wrk speed, any ntewrthy mannerisms r gestures. The patient's current thughts and perceptins, including the fllwing: Spntaneusly expressed wrries, cncerns, thughts, impulses, and perceptual experiences. Cgnitive and perceptual symptms f specific mental disrders, usually elicited by specific questining and including hallucinatins, delusins, ideas f reference, bsessins, and cmpulsins. Hallucinatins and Delusins (presence, absence, denied visual but admitted lfactry and auditry, denied but shwed signs f them during testing, denied except fr times assciated with the use f substances, denied while taking medicatins) 243

246 Suicidal, hmicidal, vilent, r self-injurius thughts, feelings, r impulses. If present, details are elicited regarding their intensity and specificity, when they ccur, and what prevents the patient frm acting them ut (19). (Make SI/HI its wn specific sectin f the MSE) Features f the patient's assciatins, such as lse r idisyncratic assciatins and self-cntradictry statements. This may include: Cherence (respnses were cherent and easy t understand, simplistic and cncrete, lacking in necessary detail, verly detailed and difficult t fllw, vague, tangential, circumstantial) Thught Prcesses (difficult t understand line f reasning, shwed lse assciatins, cnfabulatins, flight f ideas, ideas f reference, illgical thinking, grandisity, magical thinking, bsessins, perseveratin,) The patient's understanding f his r her current situatin. Judgment and Insight (based n explanatins f what they did, what happened, and if they expected the utcme, gd, pr, fair, strng) Elements f the patient's cgnitive status, including the fllwing: Level f cnsciusness/alertness (sleepy, alert, tired fr wrking late, dull and uninterested, highly distractible Orientatin (persn, place, time, presidents, yur name) Cncentratin and Attentin (based n Digit Span and attentin t yur questins, serial 7's r 3's in which they cunt backwards frm 100 t 50 by 7s r 3s, naming the days f the week r mnths f the year in reverse rder, spelling the wrd "wrld", their wn last name, r the ABC's backwards) Language functins (naming, fluency, cmprehensin, repetitin, reading, writing) Memry Fund f knwledge (apprpriate t scicultural and educatinal backgrund) Calculatin (apprpriate t educatinal attainment) Drawing (e.g., cpying a figure r drawing a clck face) Abstract reasning (e.g., explaining similarities r interpreting prverbs). Executive (frntal system) functins (e.g., list making, inhibiting impulsive answers, resisting distractin, recgnizing cntradictins) Feasibility/Data Cllectin Issues: Denminatr will cme frm administrative data Numeratr will cme frm medical recrd data. Chart abstractrs lk fr evidence f an bjective measure r a subjective/interview assessment f symptms as lng as it includes a cmparisn with a previus scre r assessment. Fr dually-diagnsed patients, a reassessment f severity f either diagnses is abstracted as a reassessment. Patient self-reprt f feeling better is abstracted as evidence f a re-assessment f severity. 244

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