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  • Measure Summary
  • NQMC:010200
  • Jan 2013

Major depressive disorder (MDD): percentage of medical records of patients aged 18 years and older with a diagnosis of MDD and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], ESRD or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

This is the current release of the measure.

Measure Hierarchy

Adult Major Depressive Disorder Performance Measurement Set

Age Group

UMLS Concepts (what is this?)

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Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], end stage renal disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.

Rationale

Depressive disorders are more common among persons with chronic conditions (e.g., obesity, cardiovascular disease, diabetes, asthma, arthritis, and cancer) and among those with unhealthy behaviors (e.g., smoking, physical inactivity, and binge drinking) (Centers for Disease Control and Prevention [CDC], 2010). Comorbidities are more common in the elderly. The highest rates of depression are found in those with strokes (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%), and Alzheimer's disease (20% to 40%) (Institute for Clinical Systems Improvement [ICSI], 2010). The coordination of care for patients with depression and certain comorbid conditions is important for managing both the patient's depression and the other present medical condition. Improvements in the coordination of care between clinicians treating a patient with depression and other clinicians treating comorbid conditions can reduce the symptom exacerbation that depression and other conditions may cause to the other. Any (depression) treatment should be integrated with psychiatric management and any other treatments being provided for other diagnoses (American Psychiatric Association [APA], 2010).

For patients with a diagnosis of depression, only 56% of primary care physicians actively document general medical comorbidities (McGlynn et al., 2003). The coordination of care for comorbid conditions is unlikely to occur without the documentation of the comorbid conditions. Additionally, McGlynn and colleagues (2003) found that only 50% of persons hospitalized for depression had a follow-up with a mental health specialist or their primary care doctor within two weeks of discharge.

The following evidence statements are quoted verbatim from the referenced clinical guidelines. Only selected portions of the clinical guidelines are quoted here; for more details, please refer to the full guideline.

In patients with major depressive disorder (MDD), it is important to recognize and address the potential interplay between major depressive disorder and any co-occurring general medical conditions (APA, 2010).

The clinical assessment should include identifying any potential interactions between medications used to treat depression and those used to treat general medical conditions. In addition, the psychiatrist (clinician) should consider the effects of prescribed psychotropic medications on the patient's general medical conditions, as well as the effects of interventions for such disorders on the patient's psychiatric condition (APA, 2010).

Many patients with MDD will be evaluated by or receive treatment from other health care professionals in addition to the psychiatrist (clinician). If more than one clinician is involved in providing the care, all treating clinicians should have sufficient ongoing contact with the patient and with each other to ensure that care is coordinated, relevant information is available to guide treatment decisions, and treatments are synchronized (APA, 2010).

In ruling out general medical causes of depressive symptoms, it is important to ensure that a general medical evaluation has been done (APA, 2010).

In patients with preexisting hypertension or cardiac conditions, treatment with specific antidepressant agents may suggest a need for monitoring of vital signs or cardiac rhythm (e.g., electrocardiogram [ECG] with tricyclic antidepressant [TCA] treatment; heart rate and blood pressure assessment with serotonin norepinephrine reuptake inhibitors [SNRIs] and TCAs) (APA, 2010).

In treating the depressive syndrome that commonly occurs following a stroke, consideration should be given to the potential for interactions between antidepressants and anticoagulating (including antiplatelet) medications (APA, 2010).

The diagnostic work-up for MDD should include evaluation for existing or emerging medical conditions that may exacerbate the depression. These may include: Cardiovascular diseases, Chronic pain syndrome, Degenerative diseases, Immune disorders, Metabolic endocrine conditions (including kidney and lung diseases), Neoplasms, Trauma… [Concurrent] treatment is often required for both the medical problem and psychiatric symptoms and can lead to overall improvement in function (Management of MDD Working Group, 2009).

Indications for referral to a mental health specialist familiar with diabetes management may include gross noncompliance with medical regimen (by self or others), depression with the possibility of self-harm, debilitating anxiety (alone or with depression), indications of an eating disorder, or cognitive functioning that significantly impairs judgment. It is preferable to incorporate psychological assessment and treatment into routine care rather than waiting for identification of a specific problem or deterioration in psychological status. Although the clinician may not feel qualified to treat psychological problems, using the patient-provider relationship as a foundation for further treatment can increase the likelihood that the patient will accept referral for other services. It is important to establish that emotional well-being is part of diabetes management (American Diabetes Association, 2010).

Evidence for Rationale

American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010 Jan;33 Suppl 1:S11-61. PubMed External Web Site Policy

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p.

Centers for Disease Control and Prevention (CDC). Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010 Oct 1;59(38):1229-35. PubMed External Web Site Policy

Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 May. 99 p. [246 references]

Management of MDD Working Group. VA/DoD clinical practice guideline for management of major depressive disorder (MDD). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 May. 203 p.

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-45. PubMed External Web Site Policy

Primary Health Components

Major depressive disorder (MDD); comorbid conditions (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], end stage renal disease [ESRD], congestive heart failure); care coordination

Denominator Description

All medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], end stage renal disease [ESRD] or congestive heart failure) being treated by another clinician (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Medical records of patients with communication to the clinician treating the comorbid condition (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Prevalence and Incidence

  • Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population aged 18 and older in a given year (National Institute of Mental Health [NIMH], 2010).
  • While major depressive disorder can develop at any age, the median age at onset is 32 (NIMH, 2010).
  • Major depressive disorder is more prevalent in women than in men (NIMH, 2010).
  • Depressive disorders are more common among persons with chronic conditions (e.g., obesity, cardiovascular disease, diabetes, asthma, arthritis, and cancer) and among those with unhealthy behaviors (e.g., smoking, physical inactivity, and binge drinking) (Centers for Disease Control and Prevention [CDC], 2010).

Disability

  • Major depressive disorder is the leading cause of disability in the U.S. for ages 15 to 44 (NIMH, 2010).

Suicide

  • Research has shown that more than 90% of people who kill themselves have depression or another diagnosable mental or substance abuse disorder (Conwell & Brent, 1995).
  • Depression is the cause of over two-thirds of the 30,000 reported suicides in the U.S. each year (Depression and Bipolar Support Alliance, 2010).
  • The suicide rate for older adults is more than 50% higher than the rate for the nation as a whole. Up to two-thirds of older adult suicides are attributed to untreated or misdiagnosed depression (Depression and Bipolar Support Alliance, 2010).

Disparities

  • Non-Hispanic blacks, Hispanics, and non-Hispanic persons of other races are more likely to report major depression than non-Hispanic whites, based on responses to the Patient Health Questionnaire 8 (PHQ-8), which covers eight of the nine criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for diagnosis of major depressive disorder (CDC, 2010).
  • For individuals who experienced a depressive disorder in the past year, 63.7% of Latinos, 68.7% of Asians, and 58.8% of African Americans, compared with 40.2% of non-Latino whites, did not access any mental health treatment in the past year (Alegría et al., 2008).

Special Populations: Geriatrics

  • The rate of depression in adults older than 65 years of age ranges from 7% to 36% in medical outpatient clinics and increases to 40% in the hospitalized elderly (Institute for Clinical Systems Improvement [ICSI], 2010).
  • Comorbidities are more common in the elderly. The highest rates of depression are found in those with strokes (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%), and Alzheimer's disease (20% to 40%) (ICSI, 2010).
  • Similar to other groups, the elderly with depression are more likely than younger patients to underreport depressive symptoms (ICSI, 2010).

Evidence for Additional Information Supporting Need for the Measure

Alegría M, Chatterji P, Wells K, Cao Z, Chen CN, Takeuchi D, Jackson J, Meng XL. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. 2008 Nov;59(11):1264-72. PubMed External Web Site Policy

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

Centers for Disease Control and Prevention (CDC). Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010 Oct 1;59(38):1229-35. PubMed External Web Site Policy

Conwell Y, Brent D. Suicide and aging. I: Patterns of psychiatric diagnosis. Int Psychogeriatr. 1995 Summer;7(2):149-64. PubMed External Web Site Policy

Depression and Bipolar Support Alliance. Depression statistics. [internet]. Chicago (IL): Depression and Bipolar Support Alliance; [accessed 2010 Nov 22].

Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 May. 99 p. [246 references]

National Institute of Mental Health (NIMH). The numbers count: mental disorders in America. [internet]. Chicago (IL): National Institute of Mental Health (NIMH); [accessed 2010 Nov 22].

Extent of Measure Testing

This measure is being made available without any prior testing. The Physician Consortium for Performance Improvement (PCPI) recognizes the importance of testing all of its measures and encourages testing of the Adult Major Depressive Disorder measurement set by organizations or individuals positioned to do so. The Measure Testing Protocol was approved by the PCPI in 2010 and is available on the PCPI Web site (see Position Papers at http://www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement.page External Web Site Policy); interested parties are encouraged to review this document.

Evidence for Extent of Measure Testing

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

National Guideline Clearinghouse Link

Practice guideline for the treatment of patients with major depressive disorder, third edition. External Web Site Policy

State of Use

Current routine use

Current Use

Care coordination

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Behavioral Health Care

Transition

Type of Care Coordination

Coordination across provider teams/sites

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Psychologists/Non-physician Behavioral Health Clinicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Effective Communication and Care Coordination
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition* (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], end stage renal disease [ESRD] or congestive heart failure) being treated by another clinician

*Comorbid Condition: For the purposes of this measure, only the following comorbid conditions will be included:

  1. Diabetes
  2. Coronary artery disease
  3. Stroke, including ischemic stroke and intracranial hemorrhage
  4. Chronic kidney disease (Stages 4 and 5) and ESRD
  5. Congestive heart failure

Exclusions
Unspecified

Exceptions
Documentation of patient reason(s) for not communicating to the other clinician (e.g., patient or guardian declined, other patient reasons)

Exclusions/Exceptions

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
Medical records of patients with communication* to the clinician treating the comorbid condition

*Communication: Transmission of relevant clinical information which specifies that the patient has major depressive disorder (MDD).

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Measure #7: coordination of care of patients with specific comorbid conditions.

Measure Collection Name

Adult Major Depressive Disorder Performance Measurement Set

Submitter

American Psychiatric Association - Medical Specialty Society

Developer

American Psychiatric Association - Medical Specialty Society

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Work Group Members: Richard Hellman, MD, FACP, FACE (Co-chair) (endocrinology, methodology); John S. McIntyre, MD, DFAPA, FACPsych (Co-chair) (psychiatry, methodology); Alan A. Axelson, MD (psychiatry); Stanley Borg, DO (family medicine); Andrea Bostrom, PhD, PMHCNS-BC (nursing, psychiatric nursing); Gwendolen Buhr, MD, MHS, CMD (geriatrics); Katherine A. Burson, MS, OTR/L, CPRP (occupational therapy); Mirean Coleman, MSW, LICSW, CT (social work); Thomas J. Craig, MD, MPH, DLFAPA, FACPM (psychiatry); Allen Doederlein (patient representative); William E. Golden, MD, FACP (internal medicine); Molly Finnerty, MD (psychiatry, methodology); Jerry Halverson, MD (psychiatry, methodology); Paul R. Keith, MD (health plan representative); Clifford K. Moy, MD (psychiatry); John M. Oldham, MD (psychiatry); Shaunte R. Pohl, PharmD, BCPS (pharmaceutical science); Mark A. Reinecke, PhD (psychology); Leslie H. Secrest, MD (psychiatry); Carl A. Sirio, MD (critical care medicine, methodology); Sharon S. Sweede, MD (family medicine); Roberta Waite, EdD, APRN, CNS-BC (psychiatric nursing, methodology)

Work Group Staff: Robert Plovnick, MD, MS (American Psychiatric Association); Robert Kunkle, MA; Samantha Shugarman (American Psychiatric Association); Mark Antman, DDS, MBA (American Medical Association); Katherine Ast, MSW, LCSW (American Medical Association); Keri Christensen, MS (American Medical Association); Kendra Hanley, MS (American Medical Association); Karen Kmetik, PhD (American Medical Association); Molly Siegel, MS (American Medical Association); David Marc Small, MS, MPP (American Medical Association); Kimberly Smuk, BS, RHIA (American Medical Association); Samantha Tierney, MPH (American Medical Association); Greg Wozniak, PhD (American Medical Association)

Financial Disclosures/Other Potential Conflicts of Interest

None of the members of the Adult Major Depressive Disorder Work Group had any disqualifying material interests under the Physician Consortium for Performance Improvement (PCPI) Conflict of Interest Policy. A summary of non-disqualifying interests disclosed on Work Group members' Material Interest Disclosure Statements (not including information concerning family member interests) is provided in the original measure documentation. Completed Material Interest Disclosure Statements are available upon request.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2013 Jan

Measure Maintenance

The Physician Consortium for Performance Improvement (PCPI) stipulates a regular review of measures every 3 years or when there is a major change in scientific evidence, results from testing or other issues noted that materially affect the integrity of the measure.

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

Measure Availability

Source not available electronically.

For more information, contact the American Psychiatric Association (APA) at 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209; Phone: 888-357-7924; E-mail: apa@psych.org; Web site: psychiatry.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on October 8, 2015. The information was verified by the measure developer on November 25, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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