Cheryl S. Hankin

Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

Measuring the quality of depression care in a large integrated health system.

Background. Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement. Objectives. To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care. Research Design. This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care. Subjects. There were 12,678 patients eligible for depression care profiling. Results. Adequate dosage was identified in 90%; 45% of patients had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), black race, and treatment exclusively in primary care. Conclusions. Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

Background.Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. Objectives.To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. Research Design. A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Methods.Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days–the sum of a patient’s inpatient and outpatient visit days), were fitted and cross-validated. Results.Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. Conclusions.Although “off-the-shelf” case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population’s disease burden with respect to the resource needs of all patients.

Posttraumatic stress disorder and health status: the veterans health study.

This article examines the association between self-reported prevalence of posttraumatic stress disorder (PTSD) and health status in a sample of 2425 male Department of Veterans Affairs (VA) ambulatory care patients who participated in the Veterans Health Study. Participants were recruited at 1 of 4 VA outpatient clinics in the Boston area. They completed self-report measures of PTSD (using the PTSD Checklist and measures of exposure to traumatic events), depression (using the Center for Epidemiologic Studies—Depression scale), and health status (using the Short-Form-36) and a medical history interview assessing 22 conditions and a history of psychiatric treatment. The screening prevalence of PTSD was 20.2% among all patients (24.3% among those exposed to traumatic events); another 15.5% met the criteria for depression but not PTSD. The health status of patients with either PTSD or depression was significantly worse than that of patients with neither disorder, even after controlling for age, education, and number of comorbid medical conditions. Patients with PTSD reported more medical conditions than did other patients. Patients with PTSD currently in mental health treatment had worse health status than did those who reported no treatment; the health status of patients who reported past mental health treatment was generally comparable to that of those with no treatment. The prevalence and comorbidity of PTSD among this sample of VA ambulatory care patients were higher than previously reported among samples of community-residing adults. The association of PTSD with health status was substantial, suggesting that the burden of PTSD is at least comparable to, and may be worse than, that of depression. Mental health treatment alleviated some of this burden. The potential impact of PTSD on health status should be more widely recognized.

The illness burden of alcohol-related disorders among VA patients: the veterans health study.

Little is known about the illness burden associated with alcohol-related disorders (ie, problem drinking, alcohol abuse, and alcohol dependence) among patients in outpatient medical care. The objective of this study was to examine several aspects of illness burden—medical comorbidities, patterns of health services use, and functional status—among Veterans Health Administration (VA) ambulatory care patients with alcohol-related disorders. Male participants (N = 2425) were recruited at 1 of 4 Boston-area VA outpatient clinics. They completed self-report screening measures of current alcohol-related disorders (CAGE score ≥2 with past year alcohol consumption), health behaviors, medical comorbidities, and functional status (SF-36). A medical history interview, which assessed comorbid conditions and use of recent health services, was also administered. Screening criteria for current alcohol-related disorders were satisfied by 12%; however, only 40% of these reported ever receiving treatment specifically for alcohol-related disorders. Patients who screened positive for alcohol-related disorders reported significantly greater limitations in mental health function, longer hospitalizations for medical care in the prior year, and fewer outpatient medical visits in the previous 3 months. Findings suggest considerable illness burden associated with alcohol-related disorders among VA ambulatory care patients. Efforts to increase detection and treatment of alcohol-related disorders may lessen the illness burden and cost of alcohol-related disorders.