VHA/DOD PERFORMANCE MEASURES
VHA/DOD PERFORMANCE MEASURES
FOR THE MANAGEMENT OF
MAJOR DEPRESSIVE DISORDER IN ADULTS
Veterans Health Administration
Department of Defense
Prepared by:
THE MANAGEMENT OF MAJOR DEPRESSIVE DISORDER
Working Group
With support from:
The Office of Performance and Quality, VHA, Washington, DC
&
Quality Management Directorate, United States Army MEDCOM
&
The External Peer Review Program
Contractor and Subcontractors:
West Virginia Medical Institute, Inc.
Birch & Davis Associates, Inc.
Quality Team Associates, Inc.
Contract number: V101(93)P-1633
March 15, 2000
Version 2.0
Table of Contents
Table of Contents 3
Introduction 5
Major Depressive Disorder Guideline Metrics Available for Selection 6
Section 1: Major Depressive Disorder: Detection 7
Purpose: 7
Measure: 7
Review Period: 7
Denominator: 7
Numerator: 7
Guideline Linkage: 7
Sample Sources: 7
Sample Selection Criteria (Denominator): 7
Case Criteria (Numerator): 7
Data to Collect: 7
Comparative Reference Rates: 8
Detection Data Collection Questions and Decision Rules 8
Data Processing Algorithm for Major Depressive Disorder Detection Measure 9
Section 2: Major Depressive Disorder: Assessment 11
Purpose: 11
Measure: 11
Review Period: 11
Denominator: 11
Numerator: 11
Guideline Linkage: 11
Case Finding Sources: 11
Sample Selection Criteria (Denominator): 11
Case Criteria (Numerator): 11
Data to Collect: 11
Comparative Reference Rates: 12
Assessment Data Collection Questions and Decision Rules 12
Data Processing Algorithm for Major Depressive Disorder Assessment/ Diagnosis Measure 13
Section 3: Major Depressive Disorder Metrics: Treatment 14
Purpose: 14
Measure: 14
Review Period: 14
Index Encounter: 14
Denominator: 14
Numerator: 14
Guideline Linkage: 14
Sample Sources: 14
Sample Selection Criteria (Denominator): 14
Case Criteria (Numerator): 15
Data to Collect: 15
Treatment Data Collection Questions and Decision Rules 15
Data Processing Algorithm for Major Depressive Disorder Treatment Measure 17
Section 4: Major Depressive Disorder Metrics: Outcomes 21
Purpose: 21
Measure: 21
Review Period: 21
Denominator: 21
Numerator: 21
Guideline Linkage: 21
Sample Sources: 21
Sampling Selection Criteria (Denominator): 21
Case Criteria (Numerator): 21
Data to Collect: 22
Comparative Reference Rates: 22
Outcomes/Effectiveness Data Collection Questions and Decision Rules: 22
Data Processing Algorithm for the Major Depressive Disorder Outcome/Effectiveness Measure 24
Section 5: Tables 27
Table 1: Diagnosis Codes for Major Depressive Disorders 27
Table 2: Primary Care Clinics 27
Table 3: Depression Screening Methods 28
Table 4: Outpatient Primary and Mental Health Clinics 28
Table 5: Diagnosis Codes for Major Depressive Disorders 29
Table 6: Antidepressant Medications 30
Table 7: Mental Health Clinics 30
Table 8: Examples of Systematic Depression Assessments 31
Section 6: Major Depressive Disorder Participants 32
Working Group 32
Other Participants 34
Introduction
Implementation of developed guidelines is critical to improving patient care. The implementation strategy may differ from facility to facility, due to the scope of available services and the type of organization. In addition, an organization may need to vary implementation strategies because of the guidelines’ scope, intent and content. While the study of implementation strategies is important, the measure of success is the impact created on patient care processes and outcomes.
To measure this impact the Veterans’ Healthcare Administration (VHA) and the United States Department of Defense (DOD) pursuant to directives from the Department of Veterans Affairs Undersecretary for Health and the Department of Defense Assistant Secretary of Defense, Health Affairs and by consultants of the contractor (West Virginia Medical Institute, Inc.) and the subcontractors (Birch & Davis Associates, Inc. and Quality Team Associates, Inc.) have established a methodology for creating guideline specific metrics that will accomplish three main objectives:
• Determine the extent of guideline implementation,
• Determine the changes of patient care practices,
• Identify areas for improvement.
Although the Management of Major Depressive Disorder in Adults Guideline includes many important and evidenced-based interventions, it is impractical and cost-prohibitive to measure all published steps. To make the task of measurement feasible, knowledgeable experts collaborated to identify, select, and convert key process variables into proximal indices of guideline implementation. The methodology for this conversion consists of four phases:
1: Identification of potential measures—Subject matter experts met to discuss and develop a list of potential guideline metrics.
2: Selection of measures—Using a delphi process, subject matter experts ranked all proposed measures and selected a final list of measures to be developed.
3: Definition of selected measures—Each measure was discussed during scheduled teleconferences to clarify content and identify operational issues. Operational definitions, were developed along with support data collection questions and data processing algorithms.
4: Final concurrence—A delphi process was used to obtain concurrence on the operational definitions and data processing algorithm.
This document is the result of the application of the above methodology and reflects the deliberations and consensus of the Major Depressive Disorders working group, including private sector experts provided by the contractors, Veterans Health Administration and Department of Defense Medical Command.
Major Depressive Disorder Guideline Metrics Available for Selection
|Aspect of Care |Measure |Purpose of Measure |Guideline Linkage |
|Detection |Percent of patients seen in a general |To determine if providers are |Module A: Box 1 |
| |medicine, primary care, women’s or mental|screening for depression in their|Module B: Box 1 |
| |health primary care clinic who were |patients. | |
| |screened for depression during the | | |
| |previous 12 months. | | |
|Assessment/Diagnosis |Percent of patients diagnosed with a |To evaluate the prevalence of |Module A: Box 23 |
| |depressive disorder during the previous |depressive disorders in a primary|Module B: Box 15 |
| |12 months. |care population as compared to | |
| | |expected rates. | |
|Treatment |Percent of patients newly diagnosed with |To measure adherence to the |Module A: Boxes 29 and 31|
| |and treated for major depressive |guideline regarding adequacy of |Module B: Box 18 |
| |disorders during a twelve (12) month |treatment. | |
| |period who continue on prescribed | | |
| |medication treatment for at least 90 days| | |
| |in the next 120 days or at least eight | | |
| |(8) psychotherapy sessions in the next | | |
| |180 days. | | |
|Effectiveness/Outcome |Percent of patients who were seen during |To measure whether clinicians are|Module A: Box 43 |
| |the past 12 months with a diagnosis of |assessing the outcome of |Module B: Box 25 |
| |major depression who have a systematic |depression treatment. | |
| |symptom assessment at 12 weeks following | | |
| |diagnosis, or if in remission by week 12,| | |
| |then a systematic symptom assessment is | | |
| |performed at the time of remission. | | |
1: Major Depressive Disorder: Detection
2: Purpose:
To determine if providers are screening for depression in their patients.
Measure:
Percent of patients seen in a general medicine, primary care, women’s or mental health primary care clinic who were screened for depression during the previous twelve (12) months.
Review Period:
The 12 months prior to the date of sample source database query.
Denominator:
A random sample of patients seen at least three times in a primary care, general medicine, internal medicine, family practice, flight medicine, gynecology, women’s or mental health primary care clinics during the previous twelve (12) months.
Numerator:
Patients in the denominator for whom records show evidence of at least one (1) screening for depression during the previous twelve (12) months.
Guideline Linkage:
Module A: Box 1—Patient age >18 with suspected depression presenting to primary care [A]
Module B: Box 1—Patient with suspected depression presenting to Outpatient Mental Health Specialty Care [A]
Sample Sources:
Sample selection criteria will be applied to the following databases to derive separate and representative samples from VA and DoD against which to test the metric.
VHA: DHCP
DoD: CHCS
Sample Selection Criteria (Denominator):
An individual is tested under this metric ONLY IF ALL of the following are TRUE for the review period:
1. The patient made at least three VA or DOD health care visit.
2. A visit occurred in ANY of the clinics listed in Table 2.
Case Criteria (Numerator):
A patient is a “case” if ANY of the following is TRUE during the 12-month review period:
1. ANY systematic depression-screening tool is completed and present in the medical record (Table 3).
2. EITHER progress note or H&P describing an evaluation of BOTH a) mood and b) interest or pleasure in activities (i.e., anhedonia).
Data to Collect:
METRIC-SPECIFIC DATA:
1. Date within the review period of the most recent clinic (see Table 2) encounter.
2. Depression screen noted in the medical record.
3. If yes, then record the screening date.
4. If yes, then record the depression screen result.
DATA ELEMENTS FOR COHORTING AND/ OR RISK ADJUSTMENT:
• History of Major Depressive Disorder
• History of psychosis OR lithium OR an antipsychotic agent use
• Date of birth
• Patient gender
• History of tobacco use
• History of alcohol abuse/dependence
Comparative Reference Rates:
The comparative reference rates will be established through the collection of benchmark data during the first year of data collection and compared to subsequent years to determine guideline implementation and impact.
Detection Data Collection Questions and Decision Rules
|# |Question |Responses |Data Collection Instructions |
|1 |During the past 12 months, did|1, 2* |Decision Rules: If the patient has a 301, 323, 322, 531, BAAA, BCBA,|
| |the patient have at least |If 2 exit MDD metrics, |BGAA, BHAA, or BJAA clinic code during the past 12 months the answer|
| |three health care clinic |else go to question # |is 1. |
| |visit? |2. | |
| |1=Yes | | |
| |2=No | | |
|2 |Enter the date, within the |MM/DD/YYYY |Decision Rules: The date for the most recent clinic visit is the |
| |specified period, for the most| |date of the most recent clinic visit listed in Table 2. If month or|
| |recent clinic visit? | |day is not documented use 01 for either the month or day. |
|3 |Within 12 months prior to the |1,2* |Decision Rules: |
| |most recent clinic visit, did |If 2 then go to MDD |If the patient has one of the following, then the answer is 1: |
| |the patient have a depression |Assessment questions, |Any systematic depression screening tool (i.e. examples in Table 3 |
| |screen administered? |else go to #4 |such as PRIME-MD, MOS, BDI, etc.) |
| |1=Yes | |Progress note describing both a) mood and b) interest or pleasure in|
| |2=No | |activities (Prime-MD questions) |
| | | |History and physical document: describes both a) mood and b) |
| | | |pleasurable activities |
| | | |ICD-9-CM code of ICD-9-CM of 296.2x or 296.3x. |
| | | |If the depression screen was administered more than 12 months prior |
| | | |to the most recent clinic visit, then the answer is a 2. |
| | | |If the depression screen is incomplete, then the answer is 2. |
| | | |If either mood or interest/pleasure in activities documentation is |
| | | |present and it is positive then the answer is 1. |
| | | |If ONLY mood or interest/pleasure in activities is present and it is|
| | | |negative then the answer is 2, because you need both to be negative |
| | | |for an adequate screen. |
|4 |Enter the date of the most |MM/DD/YYYY |Decision Rules: The date for the most recent depression screen that |
| |recent depression screening? | |occurred in a clinic visit listed in Table 2.If month or day is not |
| | | |documented use 01 for either the month or day. |
|# |Question |Responses |Data Collection Instructions |
|5 |What was the result of the most |1, 2 |Decision Rules: |
| |recent depression screening? |Go to MDD |If the depression screen points meet the minimum score needed for |
| |1= positive or depression |Assessment |positive, then the answer is 1. |
| |suspected |questions |If the progress note or history and physical document either |
| |2= negative or depression not | |depressed mood OR lack of pleasure with activities, then the answer |
| |suspected | |is 1. |
| | | |If the patient has an ICD-9-CM of 296.2x or 296.3x, then the answer |
| | | |is 1. |
Data Processing Algorithm for Major Depressive Disorder Detection Measure
3: Major Depressive Disorder: Assessment
Purpose:
A means to evaluate the prevalence of depressive disorders in a primary care population as compared to expected rates.
Measure:
Percent of patients diagnosed with a depressive disorder during the previous 12 months.
Review Period:
The 12 month period of time prior to the date of sample source database query.
Denominator:
The total number of patients with a unique SSN who have at least three encounter in a primary care, general medicine, internal medicine, family practice, flight medicine, gynecology, women’s or mental health primary care team clinic within the past 12 months.
Numerator:
The total number of patients with a unique SSN who have at least one encounter in a primary care, general medicine, internal medicine, family practice, flight medicine, gynecology, women’s or mental health primary care team clinic during the past 12 months whom received a principal or secondary diagnosis of 296.2x, 296.3x, 296.82, 300.4, 311 in any of the clinics in Table 4 during the review period.
Guideline Linkage:
Module A: Box 23—Meets DSM-IV criteria for MDD? [L]
Module B: Box 15—Meets DSM-IV criteria for MDD? [K]
Case Finding Sources:
Sample selection criteria will be applied to the following databases to derive separate and representative samples from VA and DOD against which to test the metric.
VHA: DHCP, VISTA
DoD: CHCS
Sample Selection Criteria (Denominator):
If the patient has at least three encounter in any of the clinics listed in Table 2 during the past 12 months, then INCLUDE in the measure.
Case Criteria (Numerator):
A patient is considered part of the numerator if ALL of the following criteria are met:
1. The patient has a principal or secondary diagnosis of an ICD-9-CM code listed in Table 5 during the 12 months following the first encounter in a clinic listed on table 2.
2. The ICD-9-CM code listed in table 5 is used during an encounter in a clinic listed on Table 4.
Data to Collect:
MEASURE SPECIFIC DATA:
• Date of the first visit to a primary care, general medicine, internal medicine, family practice, flight medicine, gynecology, women’s or mental health primary care team clinic during the previous 12 months.
• Date of the first visit when one of the ICD-9-CM codes listed in Table 5 is recorded as principal or secondary diagnosis in a clinic listed in Table 4.
DATA ELEMENTS FOR COHORTING AND/ OR RISK ADJUSTMENT:
• History of Major Depressive Disorder
• History of psychosis OR lithium OR an antipsychotic agent use
• Date of birth
• Patient gender
• History of tobacco use
• History of alcohol abuse/dependence
• The principal or secondary ICD-9-CM depressive disorder code(s) used during the review period.
Comparative Reference Rates:
The comparative reference rates will be established through the collection of benchmark data during the first year of data collection and compared to subsequent years to determine guideline implementation and impact.
Assessment Data Collection Questions and Decision Rules
|# |Question |Responses |Data Collection Instructions |
|1 |During the past 12 months, did|1,2* |Decision Rules: If patient has at least one (1) encounter on |
| |the patient have at least one |If 2 exit MDD metric, |separate dates in clinic visits 301, 323, 322, 531, BAAA, BACA, |
| |(1) clinic visit? |else go to question 2 |BAFA, BFBA during the past 12 months, then the answer is 1. |
| |1= Yes | | |
| |2= No | | |
|2 |Enter the date, within the |MM/DD/YYYY |Decision Rules: The date for the most recent clinic visit is the |
| |past 12 months of the earliest| |date of the most recent clinic visit listed in Table 2. If month|
| |clinic visit. | |or day is not documented use 01 for either the month or day. |
|3 |During the 12 months following|1,2* |Decision Rules: |
| |the earliest clinic visit did |If 2 then exit MDD |If the patient had an outpatient clinic visit to any of the |
| |the patient have a clinic |assessment metric, else |clinics listed on Table 4 using a principal or secondary |
| |visit in a clinic listed in |go to question 4 |diagnosis listed in Table 5 WITHIN 12 months following the date |
| |Table 4 with a principal or | |of the earliest encounter visit, then the answer is 1. |
| |secondary diagnosis listed on | |If the patient had an outpatient clinic visit to any of the |
| |Table 5? | |clinics listed on Table 4 using a principal or secondary |
| |1=Yes | |diagnosis listed in Table 5 MORE THAN 12 months following the |
| |2=No | |earliest visit, then the answer is 2. |
| | | |If the patient doesn’t have any encounters with a principal or |
| | | |secondary diagnosis listed on Table 5, then the answer is 2. |
|4 |Enter the date of the earliest|MM/DD/YYYY |Decision Rules: The date of the earliest clinic visit listed in |
| |clinic visit when an ICD-9-CM | |Table 2, when a diagnosis listed on Table 5 was first used. If |
| |diagnosis code listed on Table| |month or day is not documented use 01 for either the month or |
| |5 was used. | |day. |
Data Processing Algorithm for Major Depressive Disorder Assessment/ Diagnosis Measure
4: Major Depressive Disorder Metrics: Treatment
5: Purpose:
To measure the adherence to the guideline regarding adequacy of treatment.
Measure:
Percent of patients newly diagnosed with and treated for a major depressive disorder during the past twelve (12) months who continue on prescribed medication for at least 90 days in the next 120 days or at least eight (8) psychotherapy sessions in the next 180 days.
Review Period:
The 12-month period beginning 18 months prior to the date of sample source database query
Index Encounter:
This is the encounter used as the marker for a new depression episode. The index encounter is an encounter in which a diagnosis of major depression is made for the first time in at least one-year. The operational criteria for the index encounter may be found as criteria 1 and 2 under “Sample Selection Criteria (Denominator)”.
Denominator:
A random sample of patients with a primary ICD9-CM code of 296.2x or 296.3x for the first time in 12 months who within the subsequent 30 days of the index encounter receive EITHER an antidepressant prescription fill for up to 30 days OR at least two mental health clinic visits.
Numerator:
Patients in the denominator WHO EITHER 1) filled prescriptions for at least sixty (60) additional days-supply of an antidepressant within 90 days of the index encounter; OR (2) who had at least eight (8) mental health specialty visits in the subsequent 6-months following the index encounter.
Guideline Linkage:
Module A: Box 29—Refer to specialty care for psychotherapy
Module A: Box 31—Initiate pharmacotherapy [S]
Module B: Box 18—Modify, maintain, or initiate interdisciplinary treatment plan [O]
Sample Sources:
Sample selection criteria will be applied to the following databases to derive separate and representative samples from VA and DOD against which to test the metric.
VHA: DHCP, Pharmacy Package
DoD: CHCS
Sample Selection Criteria (Denominator):
An individual is tested under this metric ONLY if 1 AND 2 are TRUE AND at least one of items 3 or 4 are TRUE:
1. The patient has a principal or secondary ICD-9CM code of 296.2x or 296.3x for an encounter during the past 12 months.
2. At least 12 months elapsed between an encounter meeting criteria 1 and the most recent previous encounter involving a principal or secondary diagnosis code of ICD-9-CM 296.2x or 296.3x. An encounter meeting these criteria is called the “index encounter”.
3. Within 30 days following the index encounter, the patient filled a prescription for at least one 30-day supply of an antidepressant listed on Table 6.
4. Within the 30 days following the index encounter, the patient had at least two encounters in a clinic listed in Table 7.
Case Criteria (Numerator):
A patient is a “case” if 1 AND 2 are TRUE, OR ELSE criteria 3 is TRUE during the period immediately following the index encounter:
1. There is at least one antidepressant refill within 90 days of the index encounter.
2. There is a TOTAL of at least 90 days supply of antidepressant filled within 120 days following the index encounter.
3. The patient has eight (8) mental health clinic visits listed in Table 7, on separate dates within 180 days following the index encounter.
Data to Collect:
MEASURE SPECIFIC DATA:
• Date of the index encounter.
• Date of last clinic visit when ICD-9-CM code 296.2x or 296.3x is used prior to the index encounter (or else “no previous visit for depression”).
• Number of Mental Health Specialty Clinic (Table 7) encounters within 180 days of the index encounter (not counting the index encounter).
• Number of days supplied with an antidepressant within 120 days following the index encounter as evidence by the antidepressant prescription fill/refills.
DATA FOR COHORTING AND/ OR RISK ADJUSTMENT:
• History of Major Depressive Disorder
• History of psychosis OR lithium OR an antipsychotic agent use
• Total number of visits in a primary care clinic during the review period
• Date of birth
• Patient gender
• History of tobacco use
• History of alcohol abuse/dependence
• Name of the one antidepressant prescribed in greatest quantity for the individual during the 120 days following the index encounter.
• The number of different antidepressants prescribed for the individual during the 120 days following the index encounter.
• Treatment Data Collection Questions and Decision Rules
|# |Question |Responses |Data Collection Instructions |
|1 |During the past 12 months, did |1,2 |Decision Rules: If patient had a principal or secondary ICD-9-CM |
| |the patient have an initial |If 2 exit MDD metric, |diagnosis code of 296.2x or 296.3x for the first time in at least|
| |principal or secondary ICD-9-CM|else go to question 2 |12 months, then the answer is 1. |
| |diagnosis code, or onset of a | | |
| |new episode of a diagnosis | | |
| |listed on Table 1? | | |
| |1=Yes | | |
| |2=No | | |
|2 |Enter the date when the major |MM/DD/YYYY |Decision Rules: The date for the clinic visit, which first |
| |depressive disorder was | |recorded a principal or secondary ICD-9-CM diagnosis code listed |
| |diagnosed using a principal or | |on Table 1. If month or day is not documented use 01 for either |
| |secondary diagnosis of 296.2x | |the month or day. |
| |or 296.3x? | | |
|# |Question |Responses |Data Collection Instructions |
|3 |Is a principal or secondary |1,2 |Decision Rules: |
| |ICD-9-CM diagnosis code of 296.2x|If 1 exit MDD |If the patient has an encounter using a principal or secondary |
| |or 296.3x used during the 12 |metric, else go to |ICD-9-CM diagnosis code of 296.2x or 296.3x within 12 months |
| |months prior to the clinic visit |question 4 |prior to the index visit date, then the answer is 2. |
| |date recorded in question 2? | |If the patient has NEVER had an encounter using a principal or |
| |1= Yes | |secondary diagnosis of 296.2x or 296.3x, then the answer is 2. |
| |2= No | | |
|4 |Within 30 days of the index |1,2 |Decision Rules: |
| |encounter, did the patient receive|If 1 go to question |If the patient received a prescription for an antidepressant |
| |an antidepressant prescription for|5, else go to |listed in table 6, the answer is 1. |
| |up to 30 days? |question 7 |If the patient received a prescription for an antidepressant list|
| |1= Yes | |in table 3 for more than 30 days, then the answer is 1. |
| |2= No | | |
|5 |Within 90 days of the index |1,2* |Decision Rules: If the patient received a refill or filled a new|
| |encounter, did the patient refill |If 1 go to question |prescription for another antidepressant listed in Table 6, then |
| |the antidepressant prescription or|6, else go to |the answer is 1. |
| |receive a prescription for another|question 7 | |
| |antidepressant? | | |
| |1= Yes | | |
| |2=No | | |
|6 |Enter the TOTAL number of days of |30,31,32,33…. |Decision Rules: Enter the total number of days of antidepressant |
| |antidepressant supplied (Table 6) |Go to question 7 |(Table 6) supplied during the 120 days following the index date. |
| |to the patient within 90 days | |If a prescription is filled after 90 days following the index |
| |following the index encounter? | |encounter, then do not count those supply-days. |
|7 |Within 30 days of the index |1,2 |Decision Rules: |
| |encounter, did the patient have at|If 1 go to question |If the patient had only one clinic visit in a clinic listed in |
| |least two clinic visits at a |8, If 2 exit MDD |Table 7 during the 30 days following the index encounter date, |
| |clinic listed in Table 7? |Metric |then the answer is 2. |
| |1=Yes | | |
| |2=No | | |
|# |Question |Responses |Data Collection Instructions |
|8 |Enter the total number of Table 7 |2,3,4,5,6,… |Decision Rules: |
| |clinic visits that occurred within|Exit MDD Treatment |Do not count the clinic visit that occurs on the date of |
| |the first 180 days following the |Metric |diagnosis (the index encounter). |
| |index encounter date. | |If a patient has two clinic visits listed on Table 7 on the same |
| | | |date, then these visits count as one visit. |
| | | |If a visit is scheduled and the patient does not show at the |
| | | |clinic or cancels the appointment, then the visit does not count.|
| | | |If a clinic visit occurs more than 180 days after the index |
| | | |encounter date, the visit is not counted. |
Data Processing Algorithm for Major Depressive Disorder Treatment Measure
6: Major Depressive Disorder Metrics: Outcomes
Purpose:
To measure whether clinicians are assessing the outcome of depression treatment.
Measure:
Percent of patients who were seen during the past 12 months with a diagnosis of major depression who have a systematic symptom assessment 12 weeks following diagnosis, or if in remission by week 12, then a systematic symptom assessment is performed at the time of remission.
Review Period:
The 12 months prior to the date of sample source database query.
Denominator:
A random sample of patients who were seen at least once in the primary care, general medicine, internal medicine, family practice, women’s, gynecology, flight medicine, mental health primary care team clinic, psychiatry, psychology, social work, psycho-geriatric, mental health, substance abuse, PTSD, or women’s stress disorder treatment team clinics during the past 12 months and who were given an ICD-9-CM diagnosis code of 296.2x or 296.3x.
Numerator:
Patients in the denominator for whom documentation of a systematic symptom assessment is present in the medical record by 12 weeks following initial recording of diagnosis or at the time when remission is documented during the review period.
Guideline Linkage:
Module A: Box 43—Continue for 6 more weeks and reassess response at 12 weeks
Module B: Box 25—Assess at 12 weeks
Sample Sources:
Sample selection criteria will be applied to the following databases to derive separate and representative samples from VA and DoD.
VHA: DHCP
DOD: CHCS
Sampling Selection Criteria (Denominator):
An individual is included under this metric ONLY IF ALL of the following are TRUE for the review period (the past 12 months):
• If a principal or secondary ICD-9-CM code of 296.2x or 296.3x was made no earlier than 52 weeks and no later than 38 weeks prior to the review date.
• A principle or secondary ICD-9-CM code of 296.2x or 296.3x had NOT been made in the 12 months prior to the diagnosis made in #1. OR
• Principle or secondary ICD-9-CM codes of 296.2x or 296.3x made in the 12 months prior to the review period are annotated as “resolved” or “in remission”.
• If the patient has at least three (3) encounters in any clinic listed in Table 4.
Case Criteria (Numerator):
A patient is considered part of the numerator if between 10 and 14 weeks a systematic symptom assessment is performed following the initial diagnosis date OR on the date of remission if in remission by week 12. The systematic assessment documents at least five (5) core symptoms and signs:
• Depressed Mood
• Anhedonia or markedly diminished interest or pleasure
• Feelings of worthlessness or inappropriate guilt
• Fatigue or energy loss
• Poor concentration or memory problems
• Persistent appetite changes and weight loss or gain when not dieting
• Psychomotor slowing or agitation
• Morbid thinking to include suicidal ideation or behaviors.
• Insomnia or hypersomnia nearly every night
Data to Collect:
MEASURE SPECIFIC DATA:
• Date of the clinic visit when ICD-9-CM code 296.2x or 296.3x was initially diagnosed during the past 12 months.
• Date of DSM-IV criteria assessment, which occurs at least 10 weeks after the initial date, but no greater than 14 weeks following the date when ICD-9-CM diagnosis code 296.2x or 296.3x was used.
• Number of depression signs and symptoms documented during at least one visit during the 10 to 14 week period of time following the initial diagnosis date.
DATA FOR COHORTING AND/ OR RISK ADJUSTMENT:
• History of Major Depressive Disorder
• History of psychosis OR lithium OR an antipsychotic agent use
• Total number of visits in a primary care clinic during the review period
• Date of birth
• Patient gender
• History of tobacco use
• History of alcohol abuse/dependence
• History of Major Depressive Disorder
Comparative Reference Rates:
The comparative reference rates will be established through the collection of benchmark data during the first year of data collection and compared to subsequent years to determine guideline implementation and impact.
Outcomes/Effectiveness Data Collection Questions and Decision Rules:
|# |Question |Responses |Data Collection Instructions |
|1 |During the past 12 months, did |1,2 |Decision Rules: If patient has an initial or NEW occurrence of a|
| |the patient have an initial |If 2 exit MDD metric, |principal or secondary diagnosis of 296.2x or 296.3x during the |
| |principal or secondary |else go to question 2 |past 12 months, then the answer is 1. |
| |diagnosis, of an ICD-9-CM | | |
| |diagnosis code listed on Table | | |
| |1? | | |
| |1=Yes | | |
| |2=No | | |
|2 |During the past 12 months, did |1,2* |Decision Rules: If patient had three clinic codes listed in Table|
| |the patient have at least three|If 2 exit MDD metric, |4 during the past 12 months, then the answer is 1. |
| |clinic visits at any clinic |else go to question 3 | |
| |listed in Table 4? | | |
| |1= Yes | | |
| |2= No | | |
|# |Question |Responses |Data Collection Instructions |
|3 |Enter the date, within the |MM/DD/YYYY |Decision Rules: The date of the clinic visit, which first |
| |specified period, when major | |recorded a principal or secondary ICD-9-CM diagnosis code listed |
| |depressive disorder was | |on Table 1. If month or day is not documented use 01 for either |
| |diagnosed using a principal or | |the month or day. |
| |secondary ICD-9-CM code of | | |
| |296.2x or 296.3x? | | |
|4 |Is the diagnosis date for major|1,2* |Decision Rules: The date of review is the date of the chart |
| |depressive disorder more than |If 2 exit MDD metric, |review or when the data is electronically queried. If the date |
| |12 week prior to the date of |else go to question 5. |of diagnosis is less than 98 days prior to the review date the |
| |review? | |answer is a 2. |
| |1=Yes | | |
| |2=No | | |
|5 |Between the 10 and 14 week |1,2* |Decision Rules: Evidence of a systematic assessment included in |
| |following the diagnosis date, |If 2 then go to |Table 8: |
| |was there a systematic symptom |question 6, else go to |Recording at least 5 signs and symptoms in the DSM-IV criteria |
| |assessment during a clinic |question 8. |for major depression. |
| |visit? | |Completion of a Hamilton Depression Scale |
| |1=Yes | |Completion of a Beck Depression Inventory |
| |2=No | |Completion of the Prime-MD: Brief Patient Health Questionnaire |
| | | |If DSM-IV signs and symptoms are documented or a systematic |
| | | |assessment tool is completed prior to the 70 days or after the 98|
| | | |days following the date used in question 3, then the answer is 2.|
|6 |Is there documentation prior to|1,2* |Decision Rules: |
| |70 days following the diagnosis|If 2 exit MDD metric, |If ICD-9-CM diagnosis code of 296.26 or 296.36 is used after the |
| |date that the patient is in |else go to question 7 |initial diagnosis date but prior to 10 weeks, then the answer is |
| |remission? | |1. |
| |1=Yes | |If a progress note states the patient is in remission after the |
| |2=No | |initial diagnosis date but prior to 10 weeks post-diagnosis, then|
| | | |the answer is 1. |
| | | |If the patient problem list states depression is resolved after |
| | | |the initial diagnosis date but before 10 weeks post-diagnosis, |
| | | |then the answer is 1. |
|# |Question |Responses |Data Collection Instructions |
|7 |On the date the patient is |1, 2 |Decision Rules: Evidence of a systematic assessment included in |
| |recorded as in “remission”, was|If 2 then Exit MDD |Table 8: |
| |a systematic symptom assessment|Metric, else go to |Recording at least 5 signs and symptoms in the DSM-IV criteria |
| |performed? |question 8. |for major depression. |
| |1=Yes | |Completion of a Hamilton Depression Scale |
| |2=No | |Completion of a Beck Depression Inventory |
| | | |Completion of the Prime-MD: Brief Patient Health Questionnaire |
| | | |If DSM-IV signs and symptoms are documented or a systematic |
| | | |assessment tool is completed prior to the 70 days or after the 98|
| | | |days following the date used in question 3, then the answer is 2.|
|8 |Enter the date, when the |MM/DD/YYYY |Decision Rules: The date for systematic assessment is the date |
| |depression reassessment was | |when the formal assessment tool was completed OR the date of the |
| |documented. | |progress note recording at least five DSM-IV criteria status. If |
| | | |month or day is not documented use 01 for either the month or |
| | | |day. |
Data Processing Algorithm for the Major Depressive Disorder Outcome/Effectiveness Measure
7: Tables
Table 1: Diagnosis Codes for Major Depressive Disorders
|Code |Description |
|296.2 |Major Depressive Disorder, Single Episode |
|296.20 |Major Depressive Disorder, Single Episode, Unspecified |
|296.21 |Major Depressive Disorder, Single Episode, Mild |
|296.22 |Major Depressive Disorder, Single Episode, Moderate |
|296.23 |Major Depressive Disorder, Single Episode, Severe without Psychotic Features |
|296.24 |Major Depressive Disorder, Single Episode, Severity with Psychotic Features |
|296.25 |Major Depressive Disorder, Single Episode, In Partial Remission |
|296.26 |Major Depressive Disorder, Single Episode, In Full Remission |
|296.3 |Major Depressive Disorders, Recurrent Episode |
|296.30 |Major Depressive Disorders, Recurrent Episode, Unspecified |
|296.31 |Major Depressive Disorders, Recurrent Episode, Mild |
|296.32 |Major Depressive Disorders, Recurrent Episode, Moderate |
|296.33 |Major Depressive Disorders, Recurrent Episode, Severe without Psychotic Features |
|296.34 |Major Depressive Disorders, Recurrent Episode, Severe with Psychotic Features |
|296.35 |Major Depressive Disorders, Recurrent Episode, In Partial Remission |
|296.36 |Major Depressive Disorders, Recurrent Episode, In Full Remission |
Table 2: Primary Care Clinics
|Veterans Healthcare Administration | |Department of Defense |
|Clinic Code |Clinic Descriptions | |Clinic Code |Clinic Description |
|301 |General Medicine | |BAAA |Internal Medicine Clinic |
|323 |Primary Care | |BCBA |Gynecology Clinic |
|322 |Women | |BGAA |Family Practice Clinic |
|531 |Mental Health Primary Care Team- Individual | |BHAA |Primary Medical Care Clinic |
| | | |BJAA |Flight Medicine Care Clinic |
Table 3: Depression Screening Methods
|Current VHA and DoD Accepted Depression Screening Methods |
|PRIME-MD |
|SDDS-PC depression questions |
|MOS Depression items |
|CESD- 5 item versions (modified for geriatrics) |
|BDI-S- 13 item version |
|BDI-21 item version |
|History and Physical/ Progress Note stating either a positive finding for depressed mood OR level of pleasure to activities |
|History and Physical/ Progress Note stating a negative finding for depressed mood AND level of pleasure to activities |
Table 4: Outpatient Primary and Mental Health Clinics
|Veterans Healthcare Administration | |Department of Defense |
|Clinic Code |Clinic Descriptions | |Clinic Code |Clinic Description |
|301 |General Medicine | |BAAA |Internal Medicine Clinic |
|323 |Primary Care | |BCBA |Gynecology Clinic |
|322 |Women | |BFAA |Psychiatric Clinic |
|502 |Mental Health Clinic-Individual | |BFBA |Psychology Clinic |
|509 |Psychiatry-MD Individual | |BFDA |Mental Health Clinic |
|510 |Psychology-Individual | |BFEA |Social Work Clinic |
|513 |Substance Abuse-Individual | |BFFA |Substance Abuse Clinic |
|516 |PTSD-Group | |BGAA |Family Practice Clinic |
|519 |Substance Use Disorder/PTSD Teams | |BHAA |Primary Medical Care |
|525 |Women’s Stress Disorder Treatment Teams | |BJAA |Flight Medicine Care |
|531 |Mental Health Primary Care Team-Individual | | | |
|562 |PTSD-Individual | | | |
|563 |Mental Health Primary Care Team-Group | | | |
|576 |Psycho-Geriatric Clinic-Individual | | | |
|577 |Psycho-Geriatric Clinic-Group | | | |
Table 5: Diagnosis Codes for Major Depressive Disorders
|Code |Description |
|296.2 |Major Depressive Disorder, Single Episode |
|296.20 |Major Depressive Disorder, Single Episode, Unspecified |
|296.21 |Major Depressive Disorder, Single Episode, Mild |
|296.22 |Major Depressive Disorder, Single Episode, Moderate |
|296.23 |Major Depressive Disorder, Single Episode, Severe without Psychotic Features |
|296.24 |Major Depressive Disorder, Single Episode, Severity with Psychotic Features |
|296.25 |Major Depressive Disorder, Single Episode, In Partial Remission |
|296.26 |Major Depressive Disorder, Single Episode, In Full Remission |
|296.3 |Major Depressive Disorders, Recurrent Episode |
|296.30 |Major Depressive Disorders, Recurrent Episode, Unspecified |
|296.31 |Major Depressive Disorders, Recurrent Episode, Mild |
|296.32 |Major Depressive Disorders, Recurrent Episode, Moderate |
|296.33 |Major Depressive Disorders, Recurrent Episode, Severe without Psychotic Features |
|296.34 |Major Depressive Disorders, Recurrent Episode, Severe with Psychotic Features |
|296.35 |Major Depressive Disorders, Recurrent Episode, In Partial Remission |
|296.36 |Major Depressive Disorders, Recurrent Episode, In Full Remission |
|296.82 |Atypical depressive disorder |
|300.4 |Neurotic depression |
|311 |Depressive Disorder, Not Elsewhere Classified |
Table 6: Antidepressant Medications
|Drug Class |Antidepressant Medication | |Drug Class |Antidepressant Medication |
|SSRI |Citalopram | |Dual |Bupropion |
|SSRI |Fluoxetine | |Dual |Nefazodone |
|SSRI |Paroxetine | |Dual |Venlafaxine |
|SSRI |Sertraline | |Dual |Mirtazapine |
|TCA |Amitriptyline | |MAOI |Isocarboxazid |
|TCA |Desipramine | |MOAI |Phenelzine |
|TCA |Doxepin | |MOAI |Tranylcypromine |
|TCA |Imipramine | |Other |Amoxapine |
|TCA |Nortriptyline | |Other |Maprotiline |
|TCA |Protriptyline | |Other |Trazodone |
|TCA |Trimipramine | | | |
Table 7: Mental Health Clinics
|Veterans Healthcare Administration | |Department of Defense |
|Clinic Code |Clinic Descriptions | |Clinic Code |Clinic Description |
|502 |Mental Health Clinic-Individual | |BFAA |Psychiatric Clinic |
|509 |Psychiatry-MD Individual | |BFBA |Psychology Clinic |
|510 |Psychology-Individual | |BFDA |Mental Health Clinic |
|513 |Substance Abuse-Individual | |BFEA |Social Work Clinic |
|516 |PTSD-Group | |BFFA |Substance Abuse Clinic |
|519 |Substance Use Disorder/PTSD Teams | | | |
|525 |Women’s Stress Disorder Treatment Teams | | | |
|531 |Mental Health Primary Care Team-Individual | | | |
|562 |PTSD-Individual | | | |
|563 |Mental Health Primary Care Team-Group | | | |
|576 |Psycho-Geriatric Clinic-Individual | | | |
|577 |Psycho-Geriatric Clinic-Group | | | |
Table 8: Examples of Systematic Depression Assessments
|Currently VHA and DoD Accepted Evidence for Depression Screening |
|PRIME-MD-Brief patient Health Questionnaire |
|BDI-S- 13 item version |
|BDI-21 item version |
|Hamilton Depression Scale |
|DSM-IV Criteria assessment, which contained at least 5 criteria assessment |
|Any VA or DOD approved systematic assessment tool. |
8: Major Depressive Disorder Participants
Working Group
Carolyn Barrett-Ballinger, MA, CAC
Navy Substance Abuse Services, Program Manager
Navy Dept. Bureau of Medicine and Surgery
2300 E St., NW
Washington, DC 29372
202-762-3109
202-762-3133 (fax)
csbarrett-ballinger@us.med.navy.mil
Thomas G. Chulski, MD
Senior Medical Officer
Naval Medical Clinic
47149 Buse Rd.
Patuxent River, MD 20670
301-342-2740
301-342-1502 (fax)
tgchulski@pax10.med.navy.mil
Charles C. Engel, Jr., LTC,MC,USA
Chief, Gulf War Health Center
Walter Reed Army Medical Center
Bldg. 2, Ward 64, Room 6441
Washington, DC 20307
202-782-8939
202-782-3539 (fax)
Charles.Engel@na.amedd.army.mil
Robert Gresen, PhD
Acting Deputy Chief Consultant
Mental Health SHG
VA Headquarters
810 Vermont Avenue, NW
202-273-7322
202-273-9069 (fax)
robert.gresen@mail.
Rodney Haug, PhD
Clinical Psychologist
Chief, Clinical Field Manager-West
Readjustment Counseling Service
789 Sherman St., Suite 570
Denver, CO 80203
303-393-2897
303-860-7614 (fax)
rodneyhau@med.
Peter Hauser, MD
Director of Research Section for MHCC, VAMHCS
Director of VA/University Mood Disorders Program
Mental Health Clinical Center of VA Maryland Health Care System
10 North Greene Street (116A)
Baltimore, MD 21201
410-605-7351
410-605-7918
hauser.peterm@med.
Ron L. James
Chief, Development Section, PASBA
1216 Stanley Rd, Suite 25
Fort Sam Houston, TX 78232
210-295-9113
210-221-2046 (fax)
ron.james@cen.amedd.army.mil
Everett R. Jones, MD
VISN 6 Clinical Director for Mental Health Services
Mid-Atlantic Health Care Network
1970 Roanoke Blvd.
Salem, VA 24153
540-982-2463, ext. 2515
540-983-1080 (fax)
everett.jones@med.
Wendell Jones, MD
San Antonio VAMC
7400 Merton Minter Blvd.
San Antonio, TX 78284
210-617-5300
210-949-3297 (fax)
wendell.jones@med.
Laurent S. Lehmann, MD
Acting Chief Consultant for Mental Health
Veterans Health Administration
810 Vermont Ave., NW (116)
Washington, DC 20420
202-273-8434
202-273-9069 (fax)
larry.lehmann@mail.
Karl O. Moe, COL,MC,USAF
AF/SG Consultant for Clinical Psychology
89 MDOS/SGOH
1050 Perimeter Rd.
Andrews, AFB, MD 20762
240-857-7021
240-857-8367 (fax)
moekar@mgmc.af.mil
David T. Orman, LTC,MC,USA
OTSG Psychiatry Consultant
Dept. of Psychiatry, MCXI-PSY
36000 Darnall Loop
Fort Hood, TX 76544
254-288-8725
254-288-8743 (fax)
david.orman@amedd.army.mil
Richard Owen, MD
Director
HSR&D Center for Mental Healthcare & Outcomes Research
2200 Fort Roots Dr. (152/NLR)
North Little Rock, AR 72114
501-257-1710
501-257-1707 (fax)
owenrichardr@exchange.uams.edu
Ruth Robinson, COL, MC, USAF
Chief of the Medical Staff
Malcolm Grow Medical Center
1050 W. Perimeter Rd.
Andrews AFB, MD 20762
240-857-7079
240-857-6683 (fax)
robinr@mgmc.af.mil
Morgan Sammons, PhD
Head, Mental Health
USNH Keflavik
PSC 1003 Box 8
FPO AE 09728
011-354-425-6394
011-354-425-3203 (fax)
mtsammons@us.med.navy.mil
G. Richard Smith, MD
Professor and Director
Center for Outcomes Research & Effectiveness (CORE)
5800 W. 10th St., Suite 605
Little Rock, AR 72204
501-660-7505
501-660-7545 (fax)
smithgrichard@exchange.uams.edu
Chip Taylor, CDR,MC, USN
Bureau of Medicine and Surgery
(MED 32DM)
2300 E St., NW
Washington, DC, 20372
202-762-3116
202-762-3133 (fax)
HATaylor@us.med.navy.mil
Shana K. Trice, PharmD
Drug Information Specialist
DoD Pharmacoeconomic Center
1750 Greeley Rd.
Building 4011, Room 217
Fort Sam Houston, TX 78234
210-295-9551
210-295-0323 (fax)
shana.trice@amedd.army.mil
William Van Stone, MD
Chief, Treatment Services
VA headquarters
810 Vermont Ave., NW (116C)
Washington, DC 20420
202-273-8435
202-273-9069
bill.vanstone@mail.
Richard Westphal, RN, CS, MSN
Psychiatric/MH Nursing Specialist
Naval School of Health Science
1001 Holcomb Rd.
Portsmouth, VA 23708
757-953-5062
757-953-5033 (fax)
westphalri@hsp10.med.vany.mil
John Williams, Jr., MD, MHS
Research Scientist
Audie Murphy Veterans Hospital (1106)
7400 Merton Miner Blvd.
San Antonio, TX 78274
210-617-5110
210-567-4423 (fax)
jwilliam@verdict.uthscsa.edu
Antonette M. Zeiss, PhD
Clinical Coordinator and Director of Training,
Psychology Service
VA Palo Alto Health Care System
3801 Miranda Ave. (116B)
Palo Alto, CA 94304
650-493-5000, ext. 64743
tmz@icon.palo-alto.med.
Other Participants
Rosalie Fishman, RN, MSN
Clinical Coordainator
Birch & Davis Associates, Inc.
890 Fairview Rd.
Silverspring, MD 20910
301-650-0218
301-650-0398 (fax)
rfishman@
Arthur Kaufman, MD
Medical Director
Birch & Davis Associates, Inc.
8905 Fairview Rd.
Silver Spring, MD 20910
301-650-0268
301-650-0398 (fax)
akaufman@
Louise H. Nelson, RN
Education and CQI Coordinator
West Virginia Medical Institute, Inc.
3001 Chesterfield Place
Charleston, WV 25304
304-346-9864
304-342-3352 (fax)
lnelson@
George Pickett, MD, MPH
Clinical Project Director
West Virginia Medical Institute, Inc.
3001 Chesterfield Place
Charleston, WV 25304
304-346-4590, ext. 270
304-346-9863 (fax)
gpickett@
Janet Spinks, RN, MS
Senior Consultant
Birch & Davis Associates, Inc.
8905 Fairview Rd.
Silver Spring, MD 20910
301-650-0285
301-650-0398 (fax)
jspinks@
Oded Susskind, MPH
Guideline Facilitator
PO Box 112
Brookline, MA 02146
617-232-3558
617-713-4431 (fax)
oded@
Debby Walder, RN, MSNPerformance Management Facilitator
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
202-273-8336
202-273-9030 (fax)
debby.walder@mail.
Debbie Wall, RN, MA
Metrics Facilitator
Vice President of Consulting Services
Quality Team Associates, Inc.
8196 SW Durham Rd.
Tigard, OR 97224
503-443-2102
503-620-4167
debbie@qta-
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