BACKGROUND: Large health care organizations may use administrative data to target primary care patients with depression for quality improvement (QI) activities. However, little is known about the patients who would be identified by these data or the types of QI activities they might need. We describe the clinical characteristics and outcomes of patients identified through administrative data in 2 family practice clinics.
METHODS: Patients with depression aged 18 to 65 years were identified through review of encounter/administrative data during a 16-month period. Patients agreeing to participate (N=103) were interviewed with the Primary Care Evaluation of Mental Disorders questionnaire and completed the Depression Outcomes Modules (with an embedded Medical Outcomes Short Form-36 [SF-36]), Symptom Check List-25 (SCL-25), and Alcohol Use Disorders Identification Test. Follow-up assessments were completed by 83 patients at a median of 7 months.
RESULTS: A large majority of identified patients (85%) met full criteria for a Diagnostic and Statistical Manual of Mental Disorders depressive disorder; those not meeting criteria usually had high levels of symptoms on the SCL-25. Seventy-seven percent of the patients reported recurrent episodes of depressed mood, and 60% reported chronic depression. Although most improved at follow-up, they continued to have substantial functional deficits on the SF-36, and 60% still had high levels of depressive symptoms.
CONCLUSIONS: QI programs that use administrative data to identify primary care patients with depression will select a cohort with relatively severe, recurrent depressive disorders. Most of these patients will receive standard treatments without QI interventions and will continue to be symptomatic. QI programs targeting this population may need to offer intensive alternatives rather than monitor standard care.
Depressive disorders affect 5% to 20% of primary care patients and are associated with significant morbidity, functional impairment, and increased medical costs.1-5 Yet depression often remains undiagnosed, and even when diagnosed, patients may experience continued morbidity.6-10 Because patients with depression incur high costs and may have disappointing outcomes, researchers and quality improvement (QI) specialists have become interested in monitoring and improving their care.
The resources that can be devoted to improving the care of depressed patients, however, are limited. The large health care organizations that conduct the majority of QI activities in the United States operate in highly competitive markets. They must conduct all components of their QI activities (identification, treatment monitoring, and patient/provider intervention) with an eye on attendant costs.
Many organizations use administrative data to identify patients with depression for QI programs. Reviewing these data for pertinent encounter diagnoses or coding is less expensive and faster than identifying patients through other means, such as querying primary care physicians (PCPs) or reviewing medical charts. For off-site or “carved out” managed behavioral health care organizations, administrative data are often the only information available on the mental health care delivered in affiliated primary care clinics.
However, administrative data will identify only a small subset of the primary care patients with depression. Studies that use direct physician inquiry, nonspecific notation of distress, or depressive diagnoses in the medical chart identify progressively smaller proportions of depressed patients.11 Because many PCPs deliberately miscode depression on encounter or billing forms,12 claims and billing data will likely identify the smallest proportion. This select group of patients may have more severe depressive disorders or receive different treatments than patients identified through other means, such as screening, chart review, or PCP inquiry. They may also require different QI approaches.
Several studies have reported that patients whose disorders are detected by their PCPs are more likely to have a past history of depression, more severe depressive symptoms, more anxiety, and more occupational disability than those with undetected disorders.7 These characteristics may be even more pronounced among patients who are given an administrative diagnosis of depression. If these patients have relatively severe depressive disorders and are not receiving standard treatments, they might comprise an ideal population for common process-oriented QI programs, such as those that monitor adherence to guidelines or accepted standards of care. However, if they have relatively refractory disorders and are already receiving appropriate treatment, they might comprise a relatively poor target group for these types of activities.
We need to know more about the patients who would be identified through administrative data as having depression: their clinical characteristics, functional status, treatments, or the degree to which they might show change over time on instruments used to monitor clinical progress. Such information would be helpful for determining whether these patients comprise a suitable target group for common QI activities or for determining the types of activities that might be more appropriate.