Racial Differences in Quality of Care
for Bipolar Disorder
Amy M. Kilbourne, Gretchen L. Haas, Xiaoyan Han,
Joseph Conigliaro, Patrick Elder, C. Bernie Good,
Mark S. Bauer, Mujeeb Shad, Harold Alan Pincus
Center for Health Equity Research and Promotion
Departments of Medicine and Psychiatry,
University of Pittsburgh
RAND-University of Pittsburgh Health Institute
VA Providence Medical Center
Background
Bipolar disorder is a chronic illness
associated with functional impairment, costs
Despite practice guidelines, outcomes
remain suboptimal
Potential disparities in guideline-based
quality of care unexplored
Implementation of quality indicators- first step
in quality improvement
Objective
 Assess whether quality of care for bipolar I
disorder differs by race, age, and other
patient characteristics
Methods
Data source: VA National Patient Care Database
» Retrospective analysis- FY 2001
» VISN 4 (10 medical centers)
» FY 2001 (10/1/00-9/30/01)
Study population: bipolar I disorder diagnosis
Demographic and utilization data from NPCD
VA Pharmacy Benefits Management data
Quality Indicators
1. Current mood stabilizer prescription in 1 yr
2. Mental health outpatient contact <90 days*
3. Mental health outpatient contact <=30 days
after psychiatric hospitalization discharge*
*Two definitions: 1) outpatient visits only; 2) outpatient visits
or telephone contact
Analyses
Excluded other race/ethnicity, nonveterans
Bivariate analyses
Multiple logistic regression
» Controlled for patient demographics, comorbidities
» Adjusted for facility as a fixed effect
Sensitivity analyses
» Alternative definitions for outpatient, inpatient visits
produced similar results
Results
2316 patients diagnosed with bipolar I disorder
»
»
»
»
»
Mean age = 52
13% African-American
9% women
6% required to pay copayment (means test)
32% married
556 (24%) had psychiatric hospitalization
Quality Indicator Results: Bipolar I Disorder
100
90
80
%
83
67
70
60
74
71
54
50
40
30
20
10
0
Mood
Stabilizer
(n=2316)
Visit <=90
Visit or
Days (n=2316) Contact <=90
days (n=2316)
Post-hosp.
Visit (n=556)
Post-hosp.
Visit or
Contact
(n=556)
Quality Indicator Results by Race
100
90
80
70
% 60
50
40
30
20
10
0
80
African-American
White
84 †
66 67
75
72 71
68
57 *
45
Mood
Stabilizer
(n=2316)
Visit <=90
Visit or
Post-hosp.
Days (n=2316) Contact <=90 Visit (n=556)
days (n=2316)
†p=.08, *p<.05
Post-hosp.
Visit or
Contact
(n=556)
Quality Indicator Results by Age
100
90
80
70
% 60
50
40
30
20
10
0
>=60 Years
<60 Years
86 **
76
59
Mood
Stabilizer
(n=2316)
74
70 **
63
**
71 74
58
54
Visit <=90
Visit or
Post-hosp.
Days (n=2316) Contact <=90 Visit (n=556)
days (n=2316)
*p<.05, **p<.001
Post-hosp.
Visit or
Contact
(n=556)
Mood Stabilizer Prescription
Multiple Logistic Regression*
n=2316
OR
95% CI
p
African-American
.64
.45, .90
.01
Age >60 Years
.51
.39, .66
<.001
Female
.84
.58, 1.22
.36
No Copayment
.63
.37, 1.10
.10
Not Married
.74
.57, .95
.02
# Comorbidities
1.02
.95, 1.09
.61
Sub. Use Disorder
1.20
.91, 1.59
.19
*Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility
Outpatient Visit <90 Days
Multiple Logistic Regression*
n=2316
OR
95% CI
African-American
.68
.51, .91
.009
Age >60 Years
.55
.44, .69
<.001
Female
1.31
.95, 1.80
.10
No Copayment
.71
.48, 1.06
.09
Not Married
1.03
.85, 1.26
.76
# Comorbidities
1.14
1.08, 1.21
<.001
Sub. Use Disorder
.87
.70, 1.08
.21
*Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility
p
Visit <30 Days Post-Discharge
Multiple Logistic Regression*
n=553
OR
95% CI
African-American
.62
.38, 1.00
.05
Age >60 Years
1.03
.59, 1.78
.93
Female
2.56
1.30, 5.03
.006
No Copayment
.53
.20, 1.36
.19
Not Married
.56
.36, .86
.008
# Comorbidities
1.15
1.05, 1.31
.006
Sub. Use Disorder
.84
.55, 1.26
.39
*Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility
p
Visit or Tele. Contact <=30 Days
Post-Discharge: Multiple Logistic Regression*
n=553
OR
95% CI
African-American
.98
.56, 1.70
.93
Age >60 Years
.67
.36, 1.26
.21
Female
1.92
.79, 4.65
.15
No Copayment
.61
.19, 4.65
.15
Not Married
.42
.24, .73
.002
# Comorbidities
1.06
.93, 1.20
.40
Sub. Use Disorder
.67
.41, 1.10
.11
*Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility
p
Limitations
 Secondary analyses of administrative data
 Few women
 Limited generalizability
Conclusions
Most patients with bipolar I disorder received
guideline concordant pharmacotherapy
Many did not receive adequate outpatient care
Suboptimal care apparent for African-American
and older patients
Implications
Further research- reasons for gaps in quality
» Pharmacotherapy
» Continuity of outpatient care
Telephone contacts might reduce quality gaps
Future quality improvement interventions should
focus on older and minority patients
Acknowledgements
 VA Health Services Research and Development Merit
Review (IIR 02-283-2, A. Kilbourne, PI)
 VA HSR&D MREP Career Dev. Award (Dr. Kilbourne)
 VA Center for Health Equity Research and Promotion
(M. Fine, MD MSc; PI)
 VA Mental Illness Research Education and Clinical
Center (G. Haas and I. Katz, Co-PIs)
 Mental Health Intervention Research Center
(MH30915, D. Kupfer, PI)