6/25/2004
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
This talk is focused on racial differences in quality of care for bipolar disorder
I would like to thank my colleagues who collaborated with me on this
research, from the VA Pittsburgh Center for Health Equity Research and
Promotion; the Departments of medicine and psychiatry, University of
Pittsburgh; RAND Pittsburgh, and the VA Providence medical center and
brown university
Kilbourne, Amy
1
6/25/2004
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
Bipolar disorder is a chronic illness associated with functional impairment
and significant health care costs
Despite the existence of practice guidelines, subsequent outcomes for this
illness remain suboptimal
Furthermore, potential disparities in guideline-based quality of care for
bipolar disorder have been unexplored.
The implementation of guideline-based quality indicators is an important first
step in identifying where gaps in quality for bipolar disorder exist, and
subsequently developing customized quality improvement strategies that
redress these gaps
Kilbourne, Amy
2
6/25/2004
Objective
™ Assess whether quality of care for bipolar I
disorder differs by race, age, and other
patient characteristics
Therefore, we assessed whether the quality of care for bipolar I disorder
differs by race, age, and other patient characteristics
Kilbourne, Amy
3
6/25/2004
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
Our data source was the VA national patient care database, which is the
VA’s administrative database containing comprehensive information on
inpatient and outpatient utilization.
We conducted a retrospective analysis of data from fiscal year 2001 from
patients receiving care in the VA integrated services network, or VISN 4,
which encompasses 10 VA facilities primarily in Pennsylvania and Delaware
Our study population consisted of all patients in VISN 4 with either one
inpatient or two outpatient diagnoses of bipolar I disorder with complete
demographic data. Bipolar I disorder is typically distinguished from bipolar II
disorder based on the duration of the manic episode: notably 7 days of
elevated mood versus 4 days of elevated mood, respectively.
We focused on bipolar I disorder in this study as opposed to including bipolar
I and II disorders because the evidence for these guidelines is strongest for
bipolar I disorder. The diagnostic criteria for bipolar I disorder is also more
clear cut
All demographic and utilization data on these patients were extracted from
the national patient care database, and
We also the VA Pharmacy benefits management dataset to ascertain
pharmacotherapy data
Kilbourne, Amy
4
6/25/2004
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
We focused on pharmacotherapy and outpatient quality indicators derived from the
American Psychiatric Association practice guidelines for bipolar disorder
These indicators highlight appropriate pharmacotherapy and continuity of care for bipolar I
disorder, and apply to the vast majority of patients regardless of current episode (i.e.,
manic or depressive episode), and can be derived from available administrative data
sources . These indicators include:
1. Current prescription for mood stabilizer recommended during a 1 year period. This
indicator represents the minimum necessary standard of care for bipolar disorder.
2. Mental health outpatient follow up contact >=90 days from initial visit. While to date
there is no “gold standard” for appropriate continuity of care, prior research has
defined the minimum necessary standard of care as a visit occurring no more than 90
days after a previous visit.
3. Mental health outpatient contact <= 30 days after a psychiatric hospitalization
discharge. This is another accepted definition of adequate continuity of care. We
applied this indicator to the patient’s first psychiatric hospitalization in FY 2001.
For these last 2 indicators for outpatient care, two different definitions were used: one
that only included outpatient mental health visits, and another that included both
mental health outpatient or telephone contacts with a MH specialist
Kilbourne, Amy
5
6/25/2004
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
For all analyses, we excluded patients of other race/ethnicity, focusing on
African-Americans and whites, because of the limited sample (1%) of those of
other race-ethnicity groups. We also excluded nonveterans based on the
means test
We present bivariate analysis results for key patient factors. We focused on
race (American-Americans compared to white) as well as age-related
differences, given that older patients may also be vulnerable to suboptimal
mental health care.
Multiple logistic regression analyses was used to assess the probability of
receiving adequate care based on each aforementioned quality indicator. In all
analyses, we controlled for patient demographics, including race, age, gender,
means test, and marital status. We also controlled for comorbidities including
number of medical comorbidities and substance use disorder diagnosis. In
these multivariable analyses, we adjusted for VA facility as a fixed effect.
A number of sensitivity analyses were conducted based on different definitions
of inpatient and outpatient visits. For example, we counted substance use
treatment visits as outpatient visits. In all cases, alternative definitions for
outpatient, and inpatient visits produced similar results
Kilbourne, Amy
6
6/25/2004
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
Overall, 2316 patients had either one inpatient or two outpatient diagnoses
of bipolar I disorder and complete demographic data:
No observed differences in age or gender were evident in patients with and
without complete demographic data
The mean age of our sample = 52
13% African-American
9% women
6% were required to pay a copayment based on the means test. Patients not
requiring a copayment are considered lower income, which comprises the
majority of our sample
32% married
24% had psychiatric hospitalization in FY 2001
Kilbourne, Amy
7
6/25/2004
Quality Indicator Results: Bipolar I Disorder
100
90
80
83
67
70
74
71
54
% 60
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)
Here are the descriptive statistics for each quality indicator for bipolar I
disorder
The first bar on the left represents the overall frequency for the
pharmacotherapy indicator, Then the lavender and turquoise bars represent
the outpatient continuity of care indicators
From the left, you can see that overall, 83 % of patients with bipolar I
disorder were receiving a mood stabilizer
For outpatient care, the percentages were somewhat lower: two thirds
received an outpatient visit, and a slightly higher percentage received either
an outpatient visit or telephone contact
Even fewer received outpatient care after a psychiatric hospitalization
discharge. Only 54% receive a visit within 30 days. However, when
telephone contacts were counted- the percentage went up to 74% receiving
care
Kilbourne, Amy
8
6/25/2004
Quality Indicator Results by Race
100
90
80
70
% 60
50
40
30
20
10
0
80
African-American
White
84 †
66 67
72 71
68
75
57 *
45
Mood
Stabilizer
(n=2316)
Visit <=90
Visit or
Post-hosp.
Days (n=2316) Contact <=90 Visit (n=556)
days (n=2316)
Post-hosp.
Visit or
Contact
(n=556)
†p=.08, *p<.05
Here are the bivariates for each quality indicator by race
Note that for pharmacotherapy, most African-Americans and whites received
adequate care, although African-Americans were less likely to receive
adequate pharmacotherapy, although this difference in mood stabilizer use
approached significance
African-Americans were also less likely to receive an outpatient visit after
hospitalization discharge, although, as you can see in the right set of bars,
this difference was reduced and no longer significant when telephone
contacts were included.
Kilbourne, Amy
9
6/25/2004
Quality Indicator Results by Age
100
90
80
70
% 60
50
40
30
20
10
0
>=60 Years
<60 Years
86 **
76
70 **
59
Mood
Stabilizer
(n=2316)
74
63
**
71 74
58
54
Visit <=90
Visit or
Post-hosp.
Days (n=2316) Contact <=90 Visit (n=556)
days (n=2316)
Post-hosp.
Visit or
Contact
(n=556)
*p<.05, **p<.001
Here are the bivariates for each quality indicator by age
Again on the left side is the indicator for appropriate pharmacotherapy, and
the remainder represent appropriate outpatient care.
Note that for both pharmacotherapy and outpatient care, older compared to
younger patients were less likely to receive guideline concordant care.
Kilbourne, Amy
10
6/25/2004
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
The next few slides present the logistic regression results for each indicator
In each of these tables, in the left column we list each independent dummy
variable included in the regression, and then in subsequent columns, the
corresponding odds ratio for that variable, the 95% confidence intervals, and
p-value
Highlighted in yellow are the significant correlates of not receiving adequate
care based on the indicator, and in this case, mood stabilizer prescription.
As seen here, African-Americans, those 60 years old or older, and those
who were not married were less likely to receive a mood stabilizer than their
white, younger, married counterparts.
Kilbourne, Amy
11
6/25/2004
Outpatient Visit <90 Days
Multiple Logistic Regression*
n=2316
OR
95% CI
p
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
For outpatient visits, African-Americans and older patients were less
likely to receive guideline concordant care.
Of note, when we included both outpatient visits or telephone
contacts, the results were similar.
Kilbourne, Amy
12
6/25/2004
Visit <30 Days Post-Discharge
Multiple Logistic Regression*
n=553
OR
95% CI
p
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
For outpatient care after a hospitalization discharge, African-Americans were
less likely to receive adequate care. Women were more likely to receive
adequate care
Kilbourne, Amy
13
6/25/2004
Visit or Tele. Contact <=30 Days
Post-Discharge: Multiple Logistic Regression*
n=553
OR
95% CI
p
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
However, when telephone contacts were included, again, the gaps in
outpatient care for African –Americans and women were no longer
significant.
Kilbourne, Amy
14
6/25/2004
Limitations
™ Secondary analyses of administrative data
™ Few women
™ Limited generalizability
There are limitations to this study that warrant consideration
Our results are based on a secondary analysis of administrative data, which
restricts our ability to determine why these differences exist. Specifically,
these data do not take into account patient preferences or specific
socioeconomic barriers to care.
Currently, we are conducting a study that will examine in greater detail some
of these patient factors based on survey and chart review data.
Second, our sample included few women, which reflects the VA patient
population. Nonetheless, the women in our sample seemed to do well in the
continuity of care indicators compared to men
Finally, our study may be limited in generalizability to settings outside of
VISN 4 or the VA; however, our VISN4 patient population demographic
characteristics are comparable to those of the U.S. veteran patient
population with bipolar disorder--with a mean age of 52 years, 10% women,
and 15% racial and ethnic minorities.
Administrative data also do not distinguish between provider adherence to guidelines
and patient treatment adherence. For example, administrative data cannot
distinguish between providers scheduling follow up visits versus patients actually
completing these visits. Nonetheless, we focused on measures that represented
minimum necessary standard of care, and in these cases, we gave providers the
benefit of the doubt.
Kilbourne, Amy
15
6/25/2004
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
To conclude, most VA patients with bipolar I disorder in VISN 4 received
guideline concordant pharmacotherapy.
Still, many patients did not receive adequate outpatient care
Moreover, suboptimal care is especially apparent for African-American and
older patients,
even though our indicators are based on the minimum necessary standard
Kilbourne, Amy
16
6/25/2004
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
The implications of this study are as follows:
Further research should focus on the reasons for these observed gaps in
quality of care for bipolar disorder
For example, pharmacotherapy gaps in care may possibly reflect treatment
preferences, especially among African-Americans.
In addition, lack of continuity of outpatient care may reflect transportation
barriers, especially for older patients
Furthermore, our results suggest that telephone contacts might reduce
quality gaps, especially for care after hospitalizations
Overall, future quality improvement interventions should focus on redressing
potential gaps in quality of care for older and minority patients
(Some emerging research in the VA suggests that transportation to VA
facilities is a key barrier to access to care for veterans with mental
disorders.)
Kilbourne, Amy
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6/25/2004
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)
Kilbourne, Amy
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