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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 - PowerPoint PPT Presentation
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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)