Variations in the Process and Outcomes of Care for Depression. Executive Summary and Final Report

摘要

The paper attempts to identify variations in quality and outcomes of care for depressed adults who were either outpatients in prepaid or fee-for-service plans, or elderly hospitalized patients in acute care general medical hospitals. The study analyzed secondary data from the Medical Outcomes Study (MOS) and Prospective Payment System Quality of Care (PPSQOC) Study for over 22,000 adult outpatients and over 2700 depressed elderly inpatients hospitalized. Speciality of treating provider and type of ward placement (general medical or psychiatric) strongly affected quality of care and level of service use, with speciality settings having higher levels of use and quality. Prepaid care was associated with lower rates of counseling within the general medical sector, lower utilization and lower continuity of individual providers within mental health specialty, and greater decline over time in use of appropriate antidepressant medications as well as worse outcomes with psychiatry. Quality of inpatient care increased over the period of prospective payment implementation, especially in nonexempt settings; but outcome improvement was greater in exempt psychiatric units. Moderate-sized teaching hospitals had better quality of care and those with a disproportional share of Medicaid patients had poorer quality of care. Quality of care was highly variable and associated with provider, patient and system characteristics.