Improving Quality and Outcomes for Low Income Children with Depression in the US

提高美国低收入抑郁症儿童的质量和结果

• 批准号: 10630139
• 负责人: Cynthia Ann Fontanella
• 金额: $ 39.07万
• 依托单位: RESEARCH INST NATIONWIDE CHILDREN'S HOSP
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-06-01 至 2025-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10630139
• 关键词: Improving; Quality; Outcomes; Low; Income

ABSTRACT Reducing suicide deaths and premature mortality among youth with depression has been identified as a national priority and important goal for health systems. Effective, evidence-based pharmacological and psychosocial therapies exist to treat pediatric depression and clinical practice guidelines, quality indicators, and medication algorithms have been developed in an effort to apply evidence-based practices to its real-world management. Unfortunately, little is known about the degree to which the depression care delivered to publicly insured youth meets existing quality standards, and these widely accepted standards have not been properly validated, meaning that the impact of care meeting quality standards on important patient outcomes such as recurrence of depression, self-harm, suicide, and overall mortality is essentially unknown. Relatedly, although the landmark Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility and mandated that mental health services be included as basic Medicaid services, whether expanded insurance coverage for Medicaid enrolled youth has improved depression care quality and/or outcomes is unknown. Specific aims of this proposed study are three-fold: 1) to identify patient, provider, community and system factors associated with guideline concordant care for youth with major depressive disorder (MDD); 2) to determine whether guideline concordant care is associated with depression recurrence, self-harm, suicide, and all-cause mortality; and 3) to determine the effect of state Medicaid expansion under ACA on access to and quality of care for Medicaid enrolled youth with MDD. We propose to conduct a retrospective longitudinal cohort study using national Medicaid data linked with National Death Index records of all youth aged 10-17 (N= 350,00) with new episodes of MDD between 2015 and 2019. These youth will be followed for up to 24 months up until 2019. Cox regression models will be used to examine the association between 12 -month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics using propensity score methods. Quality measures include: 1) effective antidepressant management during the acute phase; 2) effective antidepressant management during the continuation phase; 3) adequate antidepressant dosage; 4) optimal provider contacts among those taking antidepressants; and 5) adequate dose of psychotherapy. The contribution of the proposed research is expected to be an increased understanding of factors that impact adherence to quality of care treatment guidelines for depression. In addition, the proposed study will help narrow the gap between community practice and optimal care by determining which recommended clinical practice guidelines improve critical outcomes for youth with MDD. This contribution will be significant because understanding factors associated with adherence to guideline concordant care will enhance our ability to develop models of interventions to modify those factors and processes to increase adherence.

抽象的 减少患有抑郁症的青少年的自杀死亡和过早死亡已被确定为 卫生系统的国家优先事项和重要目标。有效的、基于证据的药理学和 存在用于治疗儿童抑郁症的心理社会疗法和临床实践指南、质量指标和 药物算法的开发是为了将基于证据的实践应用于现实世界 管理。不幸的是，人们对抑郁症护理向公众提供的程度知之甚少。 参保青年符合现有的质量标准，但这些广泛接受的标准尚未得到适当的落实 已验证，这意味着满足质量标准的护理对重要患者结果的影响，例如 抑郁症、自残、自杀和总体死亡率的复发基本上是未知的。相关地，虽然 具有里程碑意义的《患者保护和平价医疗法案》(ACA) 扩大了医疗补助资格，并强制规定 将精神卫生服务纳入基本医疗补助服务，是否扩大保险覆盖范围 加入医疗补助的青少年改善了抑郁症护理质量和/或结果未知。具体目标 这项拟议的研究分为三部分：1）确定患者、提供者、社区和系统相关因素 为患有重度抑郁症 (MDD) 的青少年提供符合指南的一致护理； 2）判断是否 指南一致护理与抑郁症复发、自残、自杀和全因死亡率相关； 3) 确定根据《平价医疗法案》扩大州医疗补助计划对获得医疗服务的机会和质量的影响 医疗补助计划将患有 MDD 的青少年纳入其中。我们建议使用以下方法进行回顾性纵向队列研究 国家医疗补助数据与所有 10-17 岁青少年 (N= 350,00) 的国家死亡指数记录相关联，并新增 2015 年至 2019 年期间发生的 MDD。这些青少年将被跟踪长达 24 个月，直至 2019 年。Cox 回归模型将用于检查 12 个月死亡率与 5 名患者水平之间的关联 质量措施，同时使用倾向评分方法对患者特征进行风险调整。质量 措施包括：1）急性期有效的抗抑郁治疗； 2）有效的抗抑郁药 延续阶段的管理； 3）足够的抗抑郁药剂量； 4) 最佳供应商联系方式 服用抗抑郁药的人； 5）足够剂量的心理治疗。的贡献 拟议的研究预计将加深对影响遵守质量的因素的理解 抑郁症护理治疗指南。此外，拟议的研究将有助于缩小两者之间的差距 通过确定哪些推荐的临床实践指南可以改善社区实践和最佳护理 重度抑郁症青少年的关键结果。这一贡献将非常重要，因为理解因素 与遵守指南一致护理相关将增强我们开发模型的能力 改变这些因素和过程的干预措施以提高依从性。