Elsevier

General Hospital Psychiatry

Volume 32, Issue 6, November–December 2010, Pages 636-643
General Hospital Psychiatry

Original Contribution
Implementing composite quality metrics for bipolar disorder: towards a more comprehensive approach to quality measurement☆

https://doi.org/10.1016/j.genhosppsych.2010.09.011Get rights and content

Abstract

Objective

We implemented a set of processes of care measures for bipolar disorder that reflect psychosocial, patient preference and continuum of care approaches to mental health, and examined whether veterans with bipolar disorder receive care concordant with these practices.

Method

Data from medical record reviews were used to assess key processes of care for 433 VA mental health outpatients with bipolar disorder. Both composite and individual processes of care measures were operationalized.

Results

Based on composite measures, 17% had documented assessment of psychiatric symptoms (e.g., psychotic, hallucinatory), 28% had documented patient treatment preferences (e.g., reasons for treatment discontinuation), 56% had documented substance abuse and psychiatric comorbidity assessment, and 62% had documentation of adequate cardiometabolic assessment. No-show visits were followed up 20% of the time, and monitoring of weight gain was noted in only 54% of the patient charts. In multivariate analyses, history of homelessness (OR=1.61; 95% CI=1.05–2.46) and nonwhite race (OR=1.74; 95%CI=1.02–2.98) were associated with documentation of psychiatric symptoms and comorbidities, respectively.

Conclusions

Only half of patients diagnosed with bipolar disorder received care in accordance with clinical practice guidelines. High-quality treatment of bipolar disorder includes not only adherence to treatment guidelines but also patient-centered care processes.

Section snippets

Background

Bipolar disorder is a chronic illness affecting up to 5.5% of the population [1] and is associated with substantial functional limitations [2], [3] and health care costs [4], [5]. Persons with bipolar disorder often require intensive pharmacologic and psychosocial treatment [2], because the illness is uniquely characterized by alternating periods of mania and depression, which can lead to treatment interruptions and self-medication with substance abuse that impede overall treatment adherence [6]

Study population and sample

We analyzed data from a longitudinal, naturalistic, population-based study of 435 veterans with mood disorders [19]. The target population was patients being treated for bipolar disorder presenting for inpatient or outpatient care during a 2-year period (July 2004–July 2006) at a large VA mental health facility. Patients who were clinically diagnosed with bipolar disorder (including bipolar I disorder as well as the spectrum disorders including bipolar II or schizoaffective disorder–bipolar

Results

The sample (N=433) was 86% male, 77% white and had a mean age of 49 years (range 21–78). Overall, 74% of the sample was diagnosed with bipolar I, 9% diagnosed with bipolar II and 17% diagnosed with schizoaffective disorder-bipolar subtype. Half (54%) reported a history of homelessness and 28% reported a history of illicit drug use (Table 2).

The denominator was the same for each indicator (N=433). Overall, 17% had documented assessment of all symptoms (delusional, psychotic, hallucinatory), 56%

Discussion

To our knowledge, this is one of the few studies to apply operationalized processes of care that represent a wider range of services beyond medication use for patients with bipolar disorder and determine the patient factors associated with receipt of adequate processes of care in this group. This is also one of the first studies to propose patient-centered composite measures for assessing quality of care for bipolar disorder. We found that, although certain aspects of bipolar care were

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    ☆

    This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (IIR 02-283) and by the National Institute of Mental Health (MH 74509; MH 79994, T32 MH19986). The funding source had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript. All authors warrant having no actual or perceived conflicts of interest — financial or nonfinancial — in the procedures described in this manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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