Patient Race or Ethnicity, Health Care System Characteristics, and Community Factors Associated with Quality of Antidepressant Medication Management ( AMM )

Abstract

Research Objective: Clinical practice guidelines emphasize the importance of effective antidepressant medication management (AMM). One marker of AMM quality is if the patient remains on the medication through the acute phase of treatment (about 3 months), which has been shown to improve psychosocial functioning and reduce risk of suicide. The quality of AMM is monitored by many health care organizations to evaluate and improve depression care. Furthermore, data on AMM quality are now being stratified by race and ethnicity and reported publicly for Medicare Advantage plans due to concern for persistent racial and ethnic disparities in the U.S. However, there are few studies of the multiple, interacting factors important to stakeholders who conduct quality improvement efforts aimed at reducing racial/ethnic disparity in quality. This study analyzed patient, health care system, and community factors associated with AMM quality for patients with major depression, especially among Black/African American and Hispanic/Latino populations. Study Design: This national cohort study analyzed health record data from 129 U.S. Veterans Health Administration (VA) facilities. Race/ethnicity was identified from medical record data following U.S. federal standards for categorization. We identified patients' demographics, medical and mental health comorbidities, past-year health care utilization before initiating an antidepressant, and county-level factors. Using the Healthcare Effectiveness Data and Information Set AMM acute phase measure as a marker of quality, we calculated each facility's percentage of patients who were dispensed at least 84 days of antidepressant medication. A mixed effects logistic regression tested associations between patient, health care system, and community factors and a patient's likelihood of meeting the AMM measure. Population Studied: VA patients whose health care met criteria for inclusion in the AMM measure denominator in 2017 (N = 104,287): a major depression diagnosis and initiating antidepressant treatment. Principal Findings: Adjusting for socio-demographics, comorbidities, healthcare utilization, and community factors in the regression model, care provided to Black/African American patients (odds ratio [OR] =0.62, 95% CI 0.59-0.64, p < 0.01) or to Hispanic/Latino patients (OR = 0.85, 95% CI 0.80-0.90, p < 0.01) was less likely to meet the AMM measure, compared to White or Non-Hispanic/Latino patients, respectively. Care for men met the measure less often than for women (OR = 0.92, 95% CI 0.88-0.96, p < 0.01). Outpatient mental health visits before starting an antidepressant was positively associated with meeting the AMM measure, whereas violent crime rate and severe housing problems in a patient's county were negatively associated with meeting the AMM measure. Conclusion(s): Among people with major depression treated with anti-depressants, racial/ethnic minority patients had a lower likelihood of receiving treatment that meets quality standards. Future research should investigate causality more thoroughly to inform quality improvement efforts that would reduce disparities, such as the utilization of healthcare, socioeconomic factors, or institutionalized racism. Implications for Policy or Practice: Given the mounting evidence that Black/African American and Hispanic/Latino patients receive lower quality of mental health care, it is important for health care organizations to move beyond identifying disparities in quality to understanding and addressing the systematic barriers that patients and providers must overcome to improve overall quality of mental health care for racial/ethnicity minorities.