Lucinda B Leung1,2, Lisa V Rubenstein3,4,5, Erin Jaske6, Leslie Taylor6, Edward P Post7,8, Karin M Nelson6,9, Ann-Marie Rosland10,11. 1. Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd (111G), Los Angeles, CA, 90073, USA. lleung@mednet.ucla.edu. 2. Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA. lleung@mednet.ucla.edu. 3. Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA. 4. Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA. 5. RAND Corporation, Santa Monica, CA, USA. 6. VA Puget Sound Health Care System, Seattle, WA, USA. 7. VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA. 8. Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. 9. Department of Medicine, University of Washington Medical School, Seattle, WA, USA. 10. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. 11. Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Abstract
BACKGROUND: Integrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management. OBJECTIVE: To examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016. MAIN MEASURE(S): For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA's established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics. KEY RESULTS: Median proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7-8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96-0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92-0.99; p=0.046) lower adjusted odds of having elevated blood pressures. CONCLUSIONS AND RELEVANCE: Primary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.
BACKGROUND: Integrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management. OBJECTIVE: To examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016. MAIN MEASURE(S): For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA's established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics. KEY RESULTS: Median proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7-8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96-0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92-0.99; p=0.046) lower adjusted odds of having elevated blood pressures. CONCLUSIONS AND RELEVANCE: Primary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.
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