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Performance Measurement

Diagnosis and Treatment of Depression: Review of the Performance Measures by the Performance Measurement Committee of the American College of Physicians

Writing Committee

Amir Qaseem, MD, David Baker, MD, J Thomas Cross, MD, Andrew Dunn, MD, Ana Maria Lopez,

MD, Sarah West, MSN, RN

ACP Performance Measurement Committee Members*

David W. Baker, MD, MPH (Chair); J. Thomas Cross, MD, MPH; Andrew Dunn, MD, MPH; Mary Ann Forciea, MD; Robert A. Gluckman, MD; Robert H. Hopkins, MD; Eve Kerr, MD; Kesavan

Kutty, MD; Ana Maria López, MD, MPH; Catherine MacLean, MD, PhD; Stephen D. Persell, MD, MPH; and Terrence Shaneyfelt, MD

Corresponding author: A. Qaseem 190 N. Independence Mall West Philadelphia, PA 19106 Email aqaseem@acponline.org * Individuals who served on the Performance Measurement Committee from initiation of the project until its approval

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Introduction Depression represents a major disease burden in the US, affecting an estimated 9% of the population and accounting for some $83 billion per year (in 2003 dollars) in lost productivity and medical costs (1-2). Antidepressants are the third most prescribed class of medications in the US, and nearly 80% of such prescriptions are written by primary care physicians (3). Yet fewer than 5% of primary care patient encounters include screening for depression (4-5). There is also evidence of flaws in diagnostic accuracy – most commonly false positives – among primary care physicians (6). The ACP Performance Measurement Committee (PMC) reviewed performance measures related to the diagnosis and treatment of depression to assess whether the measures are evidence-based, methodologically sound, and clinically meaningful. Methods We performed a search to identify relevant performance measures from the National Quality Forum (NQF), the American Medical Association-Physician Consortium for Performance Improvement (AMA-PCPI), and National Quality Measures Clearinghouse (NQMC) websites. The inclusion criteria were performance measures currently used in the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System (PQRS) or currently used in the CMS Electronic Record Incentive program. The PMC identified and reviewed 4 performance measures. Conclusion

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Recommendation ACP does not support PQRS 106: “Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity.” Rationale The two issues with this measure are: 1) it specifically requires using DSM-IV criteria rather than any standardized valid and reliable instrument to diagnose depression; 2) documentation of complete DSM-IV criteria as described in this measure is highly burdensome to the provider without improvements in current electronic data entry systems; and 3) the current American Psychiatric Association (APA) guideline recommends a thorough diagnostic assessment in order to establish a diagnosis of MDD and does not state that formal DSM-IV criteria need to be met (7-8). In addition, there is no evidence that there is a current gap in patient care. Measure Specifications PQRS 106: Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity Status: Removed from PQRS January 2015, No Longer NQF Endorsed (Formerly

NQF 0103) Measure Steward:

American Medical Association - Physician Consortium for Performance Improvement

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified

Numerator Statement:

Patients with evidence that they met the DSM-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified

Denominator Statement:

All patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD)

Exclusions: None Type of Measure:

Process

Level of Analysis:

Clinician: Group/Practice, Clinician: Individual, Clinician: Team

Care Setting: Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care, Behavioral Health/Psychiatric: Outpatient, Other

Data Source: Electronic Clinical Data: Electronic Health Record, Electronic Clinical Data: Registry

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Recommendation ACP does not support NQF 0104: “Adult Major Depressive Disorder (MDD): Suicide Risk Assessment.” Rationale Although assessment of suicide risk is good clinical practice in patients with a new diagnosis of MDD or with initial prescription of antidepressive pharmacotherapy (8), the denominator specification is unclear. In particular, it is not well defined what a “recurrent” episode constitutes. If it is specified that this is an episode with the initiation of new treatment for depression, then ACP could support this measure. However, as currently stated, it could be applied to all follow-up visits with the mention of even well-controlled depression. In addition, the performance gap presented in support for this measure is small (96.5% performance rate). Measure Specifications NQF 0104: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Status: NQF Endorsed, Updated February 28, 2014 (2015 PQRS Measure #107) Measure Steward:

American Medical Association - Physician Consortium for Performance Improvement

Description: Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Numerator Statement:

Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Denominator Statement:

All patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD)

Exclusions: None Type of Measure:

Process

Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Clinician: Team Care Setting: Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care,

Behavioral Health/Psychiatric: Outpatient, Other Data Source: Electronic Clinical Data: Electronic Health Record, Electronic Clinical Data:

Registry

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Recommendation ACP does not support NQF 0105: “Antidepressant Medication Management (AMM).” Rationale ACP does not support this measure because it has several issues even though the intent of this measure is important. First, the time frame used in the measure (12 weeks for acute phase and 6 months for continuation) contradicts the recommendations from evidence-based guidelines [4-6 weeks for acute phase, 4-9 months for continuation (8-9)]. This measure does not consider alternative interventions such as psychotherapy, electroconvulsive therapy (ECT) or the combination of somatic and psychotherapy that are as effective as pharmacological treatment (8, 10). The measure excludes patient choice to switch to another modality of effective therapy due to the side effects associated with pharmacological medications. In the management of patients with depression, a provider-patient discussion on the benefits, harms, and costs of treatment is important and not accounted for in this measure. The exclusions should include lack of patient adherence due to the side effects of medication with documentation of alternative therapy. ACP suggests deleting the requirement for acute phase treatment. Measure Specifications NQF 0105: Antidepressant Medication Management (AMM) Status: NQF Endorsed, Updated February 28, 2014 (2015 PQRS Measure #9) Measure Steward:

National Committee for Quality Assurance

Description: The percentage of members 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported: a) Effective Acute Phase Treatment. The percentage of newly diagnosed

and treated members who remained on an antidepressant medication for at least 84 days (12 weeks).

b) Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months).

Numerator Statement:

a) Effective Acute Phase Treatment: At least 84 days (12 weeks) of continuous treatment with antidepressant medication during the 114-day period following the Index Prescription Start Date (IPSD) (inclusive). The continuous treatment allows gaps in medication treatment up to a total of 30 days during the 114-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication. Regardless of the number of gaps, there may be no more than 30 gap days. Count any combination of gaps (e.g., two washout gaps of 15 days each, or two washout gaps of 10 days each and one treatment gap of 10 days). b) Effective Continuation Phase Treatment: At least 180 days (6 months) of continuous treatment with antidepressant medication (Table AMM-D)

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during the 231-day period following the IPSD (inclusive). Continuous treatment allows gaps in medication treatment up to a total of 51 days during the 231-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication. Regardless of the number of gaps, gap days may total no more than 51. Count any combination of gaps (e.g., two washout gaps, each 25 days or two washout gaps of 10 days each and one treatment gap of 10 days).

Denominator Statement:

Members 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication

Exclusions: Exclude members who filled a prescription for an antidepressant 90 days (3 months) prior to the IPSD.

Type of Measure:

Process

Level of Analysis: Health Plan, Integrated Delivery System Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:

Pharmacy Recommendation ACP does not support NQF 0418: “Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan.” Rationale ACP does not support this measure because the denominator should reflect patients seen in the calendar year instead of all patients. Also, this measure is not supported by the current United States Preventive Services Task Force (USPSTF) guideline; “Depression in Adults: Screening”, that says that support services must be available before screening a patient for depression. USPSTF recommends against screening in the absence of a support system or follow-up services (11). In addition, this measure does not address frequency of screening for depression and it is not clear whether this measure applies to all patients in a providers’ panel or only those seen during the calendar year in a face-to-face visit. Measure Specifications NQF 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Status: NQF Endorsed, Updated February 28, 2014, (2015 PQRS Measure #134) Measure Steward:

Centers for Medicare & Medicaid Services

Description: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented

Numerator Statement:

Patient’s screening for clinical depression using an age appropriate standardized tool AND follow-up plan is documented

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The standardized screening tools help predict a likelihood of someone developing or having a particular disease. The screening tools suggested in this measure screen for possible depression. Questions within the suggested standardized screening tools may vary but the result of using a standardized screening tool is to determine if the patient screens positive or negative for depression. If the patient has a positive screen for depression using a standardized screening tool, the provider must have a follow-up plan as defined within the measure. If the patient has a negative screen for depression, no follow-up plan is required.

Denominator Statement:

All patients aged 12 years and older

Exclusions: Not Eligible/Not Appropriate – A patient is not eligible if one or more of the following conditions exist:

• Patient refuses to participate • Patient is in an urgent or emergent situation where time is of the

essence and to delay treatment would jeopardize the patient’s health status

• Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases

• Patient was referred with a diagnosis of depression • Patient has been participating in on-going treatment with screening

of clinical depression in a preceding reporting period • Severe mental and/or physical incapacity where the person is

unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools

Type of Measure:

Process

Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Clinician: Team, Population: Community, Population: County or City, Population: National, Population: Regional, Population: State

Care Setting: Ambulatory Care: Clinician Office/Clinic, Hospital/Acute Care Facility, Post Acute/Long Term Care Facility: Inpatient Rehabilitation Facility, Post Acute/Long Term Care Facility: Long Term Acute Care Hospital, Post Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility

Data Source: Administrative claims, Electronic Clinical Data: Electronic Health Record, Paper Medical Records

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Gaps in Performance Measurement — Opportunities to Promote High-Value Care There is a need for health care systems to develop support systems and necessary resources to help individual providers manage patients with MDD. A structural measure would be more appropriate to address gaps in depression care. This measure would allow physicians to opt out if they do not have systems of care in place. Consumers would be made aware of the decision to opt out, thereby better informing patients in their decisions about where to seek care and encouraging healthcare systems to implement care coordination.

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References

1. US Department of Health and Human Services. Centers for Disease Control and Prevention. Current Depression Among Adults --- United States, 2006 and 2008. MMWR. 2010; 59(38):1229-1235.

2. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in

the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry. 2003; 64:1465-1475.

3. Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric

diagnosis is growing. Health Affairs. 2011;30:1434-1442.

4. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Health System Measurement Project. Percentage of Primary Care Physician Office Visits that Include Depression Screening. https://healthmeasures.aspe.hhs.gov/measure/26 (Accessed July 8, 2014).

5. Hepner KA, Rowe M, Rost K, Hickey SC, Sherbourne CD, Ford DE, Meredith LS,

Rubenstein LV. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007; 147(5):320-329

6. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374:609-619.

7. American Psychiatric Association. Practice guideline for the psychiatric evaluation of adults (2nd ed.). 2006;1-62.

8. American Psychiatric Association. Practice Guideline for the Treatment of Patients with

Major Depressive Disorder (3rd ed). 2010.

9. Qaseem A, Snow V, Denberg TD, Forciea MA, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2008;149:725-733. doi:10.7326/0003-4819-149-10-200811180-00007

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10. Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. International Journal of Psychiatry in Medicine. 2011;41(1):15-28

11. O’Connor EA, Whitlock EP, Gaynes B, Beil TL. Screening for Depression in Adults and

Older Adults in Primary Care: An Updated Systematic Review. Evidence Synthesis No. 75. AHRQ Publication No. 10-05143-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, December 2009

Financial Statement: Financial support for the Performance Measurement Committee comes exclusively from the ACP operating budget. Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC meeting and conference call and can be viewed at: http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.htm APPROVED BY THE ACP BOARD OF REGENTS ON: April 27, 2015 Members of the PMC: Individuals who served on the Performance Measurement Committee from initiation of the project until its approval: David W. Baker, MD, MPH J. Thomas Cross, Jr., MD, MPH Andrew Dunn, MD, MPH Mary Ann Forciea, MD Robert A. Gluckman, MD Robert H. Hopkins, MD Kesavan Kutty, MD Eve Askanas Kerr, MD, MPH Ana María López, MD, MPH Catherine MacLean, MD, PhD Stephen D. Persell, MD, MPH Terrence Shaneyfelt, MD, MPH Requests and inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106: email, aqaseem@acponline.org