Racial Differences in Quality of Care for Bipolar Disorder

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

Amy M. Kilbourne, Gretchen L. Haas, Xiaoyan Han, Joseph Conigliaro, Patrick Elder, C. Bernie Good, Mark S. Bauer, Mujeeb Shad, Harold Alan Pincus

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 diagnosisDemographic 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, nonveteransBivariate analysesMultiple 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

83

67 71

54

74

0

10

20

30

40

50

60

70

80

90

100

MoodStabilizer(n=2316)

Visit <=90Days (n=2316)

Visit orContact <=90days (n=2316)

Post-hosp.Visit (n=556)

Post-hosp.Visit orContact(n=556)

%

Quality Indicator Results by Race

80

6672

45

68

84

6771

57

75

0102030405060708090

100

MoodStabilizer(n=2316)

Visit <=90Days (n=2316)

Visit orContact <=90days (n=2316)

Post-hosp.Visit (n=556)

Post-hosp.Visit orContact(n=556)

African-American

White

% *

†p=.08, *p<.05

†

Quality Indicator Results by Age

76

5963

58

71

86

7074

54

74

0102030405060708090

100

MoodStabilizer(n=2316)

Visit <=90Days (n=2316)

Visit orContact <=90days (n=2316)

Post-hosp.Visit (n=556)

Post-hosp.Visit orContact(n=556)

>=60 Years

<60 Years

%

*p<.05, **p<.001

**

** **

Mood Stabilizer PrescriptionMultiple 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  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

Visit <30 Days Post-DischargeMultiple 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

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

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)