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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