Skip to main content

Abstract

Objective:

This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness.

Methods:

VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators.

Results:

The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50–64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease.

Conclusions:

Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.

HIGHLIGHTS

Differences in prevention and chronic disease management metrics among VHA patients with and without mental illness were examined following the national implementation of a patient-centered medical home model.
The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%.
Differences of 5.0% or greater were detected in six of 33 indicators.
Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.
The burden of medical conditions is higher among individuals diagnosed as having mental illness compared with those without mental illness (1, 2). Individuals with schizophrenia, bipolar disorder, or major depressive disorder are more likely to experience obesity and diabetes, cardiovascular diseases, and musculoskeletal diseases, among others (3). Individuals with posttraumatic stress disorder (PTSD) are at increased risk of cardiovascular disease and diabetes (4). Substance use and substance use disorders have also been associated with increased risk of a number of negative health outcomes (1, 5). The co-occurrence of mental illness and chronic medical conditions has been linked with greater functional and occupational impairment, reduced quality of life, and higher health care costs compared with individuals with only one of these conditions (1, 2, 68). Many studies have shown that individuals diagnosed as having mental illness die prematurely (9, 10), often due to preventable causes, such as diabetes and cardiovascular disease (11).
Delivery of poorer-quality preventive and chronic disease management care may play a key role in contributing to poor general health outcomes among those with mental illness (12, 13). Such services may be particularly important among U.S. veterans seen within the Veterans Health Administration (VHA), a population that experiences disproportionately high rates of mental and medical illnesses (1416). Past studies conducted within the VHA showed that veterans with mental illness were less likely to receive certain forms of preventive care (e.g., cancer screening) and chronic disease management care (e.g., diabetes performance measures) compared with those without mental illnesses (1720).
Previous research has focused largely on quality indicators related to a single preventive procedure (e.g., cancer screening) or medical condition (e.g., diabetes) or have examined outcomes in veterans with or without “any mental illness” or veterans with a select few mental illnesses (1720). Since these initial studies, the VHA has undertaken two large-scale national implementation efforts to enhance the primary care services offered in VHA facilities. In 2007, the VHA began to systematically integrate mental health care services into the primary care setting (primary care–mental health integration [PC-MHI]; 21). In 2010, the VHA also became the largest integrated health care system to implement a patient-centered medical home model (22). The VHA model, called Patient-Aligned Care Team (PACT), was designed to deliver coordinated, patient-centered care by improving access and providing care management through continuous team-based care. Core PACT teams consist of a primary care provider, a nurse care manager, a clinical associate (licensed practical nurse [LPN] or LPN equivalent), and a clerk (23).
Importantly, the PACT model was designed to include both behavioral health specialists as well as PC-MHI providers within the expanded PACT teams (23). As a result, the PACT model may be well positioned to provide high-quality care to veterans with mental illness. This study sought to evaluate the quality of preventive care and chronic disease management care among VHA primary care–enrolled patients with and without mental illness following the nationwide implementation of PACT.

Methods

The study used an observational cohort design that included veterans seen within VHA primary care between 2010 and 2013. This study was deemed exempt from institutional review board approval because it was nonresearch and analyzed nonidentifiable data. The Primary Care Management Module contained within the VHA’s Corporate Data Warehouse was used to identify all veterans who were enrolled and assigned to a VHA primary care provider in the 3 years after PACT implementation. An initial observational cohort of 4,461,247 veterans who had an assigned primary care provider and who attended at least one primary care appointment within the VHA between April 2010 and March 2011 was identified.
Because many of the quality indicators of interest are completed on an annual basis, this identification method was then used again for the following periods: 2011–2012 and 2012–2013. Additional information regarding methods used to define the primary care cohort are detailed elsewhere (10). Patients were then categorized into six mental illness groups: depression, PTSD, anxiety disorder, serious mental illness (bipolar or schizophrenia), substance use disorder, any mental illness (any of the five diagnoses) or a comparison group with no mental illness (none of the five diagnoses) (10).
Because veterans often have more than a single psychiatric condition, the mental illness groupings were not mutually exclusive (e.g., a veteran with PTSD and depression was included in both the PTSD and depression groups). A substance use disorder was considered present if there was one or more hospitalization or outpatient visit with a relevant ICD-9 diagnosis code. We considered all other mental illness conditions to be present if there were two or more outpatient visits or one or more inpatient hospitalizations with a relevant ICD-9 diagnosis code (10).
Although veterans with some mental illnesses (e.g., eating disorders) may have been included in the no mental illness comparison group, the prevalence of these disorders (particularly without comorbid depression, PTSD, anxiety disorders, serious mental illness, or substance use disorders) appears to be low in the VHA (24).

Analytic Sample

Data from the VHA External Peer Review Program (EPRP) were used to examine quality of care. The EPRP is an external audit program that assesses clinical performance by using standard criteria based on clinical care guidelines (25). EPRP data are abstracted manually from the electronic health record by an independent external contractor and reported by fiscal year (October–September). Interrater reliability (k=0.9) measured among abstractors in the EPRP program has been high (26). The analytic sample for this study consisted of primary care patients whose electronic medical records were selected for review as part of the EPRP. Approximately 5% of veterans who were enrolled and assigned to a VA primary care provider were selected for EPRP review in each of the 3 years examined (5.3% in 2010, 4.6% in 2011, and 4.8% in 2012). Thus the sample size for the analytic sample ranged from 210,864 to 236,421. Denominators for each quality metric varied based on the specific inclusion-exclusion criteria for that indicator.

Quality-of-Care Indicators

Thirty-three quality indicators assessed by the VHA EPRP were examined. Quality indicators related to preventive care included tobacco screening, cancer screening, and immunizations. Quality indicators related to the management of common chronic diseases included diabetes mellitus, hypertension, ischemic heart disease, and chronic heart failure.

Patient Characteristics

To characterize the sample, additional descriptive information about patient demographic characteristics (age, gender, race-ethnicity, and marital status) and prevalence of mental illness and common medical conditions (diabetes, hypertension, ischemic heart disease, and chronic heart failure) was abstracted from the VHA’s Corporate Data Warehouse for the initial cohort of veterans identified (veterans enrolled and assigned to a VHA primary care provider from April 2010 through March 2011; N=4,461,247). Because the sample size varied across the 33 clinical quality indicators in each of the 3 years examined, similar data are not presented for each analytic sample. [For ICD-9 codes used to define mental illness and medical conditions, see online supplement.]

Analyses

Our goal was to describe the proportions of eligible patients who met the 33 preventive care and chronic disease management clinical quality indicators across the six mental illness groups and the group without mental illness. The proportion of patients meeting a quality indicator in each mental illness group was compared with the proportion of patients without mental illness meeting the same quality indicator. These descriptive analyses were conducted to examine the quality of overall care provided within PACT irrespective of clinical site or patient characteristics. In our preliminary descriptive analyses, we determined that most quality indicators were met for at least 80% of all veterans with and without mental illness, and were frequently over 90%. Such a ceiling effect could obfuscate disparities between groups. Moreover, because our large sample size would make Type I error likely and result in statistically significant differences that were not clinically meaningful, we focused our efforts on identifying minimum clinically important differences when comparing adherence to quality indicators.
Because there are no current guidelines on detecting such differences when comparing adherence to quality indicators, we consulted with VHA primary care and mental health subject matter experts to determine a meaningful metric to compare veterans with and without mental illness. Through consensus, we determined that a consistent difference of at least 5% across all years examined would be meaningful in evaluating VHA policy. Therefore, we compared the proportion of veterans with and without a mental illness to identify the quality indicators with differences of at least 5% in 2010–2011, 2011–2012, and 2012–2013.

Results

Patient characteristics are presented in Table 1. The proportion of eligible veterans meeting each quality indicator within the depression, PTSD, anxiety disorder, serious mental illness, and substance use disorder mental illness groups can be found in Table 2. (For number of patients eligible for each indicator and graphs depicting quality indicator completion for veterans with and without any mental illness, see the online supplement.)
TABLE 1. Characteristics of veterans who were enrolled in VHA, were assigned to a primary care provider, and attended at least one VHA primary care appointment between April 2010 and March 2011, by mental illness group
 No mental illness (N=3,346,462)Any mental illness (N=1,114,785)Depression (N=587,194)PTSD (N=403,872)Anxiety disorder (N=207,380)Serious mental illness (N=144,114)Substance use disorder (N=360,495)
VariableN%N%N%N%N%N%N%
Age (M±SD)64.7±15.1 55.8±13.8 55.7±13.8 54.4±14.2 54.6±15.2 53.9±12.0 53.7±12.2 
Male3,177,02694.91,019,42591.5520,94388.7371,69692.0182,53288.0126,40687.7344,99295.7
Married2,008,57760.0510,12945.8277,47747.3228,55856.696,19946.443,51130.2112,32531.2
Racea              
 White2,380,74871.1705,45363.3378,17564.4254,63463.1146,46970.685,69759.5206,77257.4
 Black407,83412.2193,80517.493,35215.970,56417.522,10410.726,96218.786,48624.0
 Hispanic154,5204.667,6586.135,9706.128,3967.011,7915.78,3165.819,9185.5
 Other94,3962.843,0233.922,6083.919,4254.87,2783.56,0204.213,0113.6
≥50% service-connected disabilityb761,63722.8577,58951.8301,81551.4336,43683.398,75347.674,89052.0133,02236.9
Diabetes803,19724.0242,84421.8137,58123.495,92923.838,42218.534,05423.652,03814.4
Hypertension1,810,59854.1555,08449.8295,91450.4200,27249.698,31947.468,90547.8166,95346.3
Ischemic heart disease703,31921.0170,11215.398,74816.860,76115.032,72715.816,07611.238,79810.8
Heart failure138,3904.140,0943.623,3734.012,2573.07,1313.44,1852.910,5392.9
a
Race data were missing for 7.6% to 11.9% of veterans across groups.
b
Service-connected disability data were missing for 7.4% to 55.1% of veterans across groups.
TABLE 2. Proportion of eligible veterans meeting quality indicators from 2010–2011, 2011–2012, and 2012–2013, by mental illness groupa
 No mental illnessDepressionPTSDAnxiety disorderSerious mental illnessSubstance use disorder
Variable201020112012201020112012201020112012201020112012201020112012201020112012
Preventive care
Cancer screening                  
 Breast cancer (women ages 40–49)83.483.181.884.081.881.283.681.880.383.481.580.580.380.278.479.976.975.7
 Breast cancer (women ages 50–69)87.987.387.188.788.286.588.988.186.686.987.186.586.384.881.185.082.881.2
 Cervical cancer (women ages 21–64)93.893.291.394.192.890.894.792.690.494.493.091.493.291.089.693.791.690.8
 Colorectal cancer (ages 50–75)b 82.882.2 83.383.0 85.085.1 82.681.5 77.776.0 77.777.0
Tobacco use screening and referral                  
 Screened for tobacco use99.699.699.699.499.499.499.299.399.299.499.499.399.299.399.399.199.199.1
 If using tobacco, provided counsel96.696.295.996.996.396.696.896.396.797.296.496.697.096.896.997.296.796.9
  If using tobacco, offered medication94.094.094.095.094.995.094.594.695.095.295.094.695.195.395.194.995.195.2
  If using tobacco, offered referral96.696.195.797.196.496.397.096.496.697.496.496.197.397.096.797.296.896.8
Immunizations                  
 Influenza immunization (ages 50–64)65.264.764.972.771.773.072.672.775.272.170.773.070.572.073.266.365.667.2
 Influenza immunization (ages ≥65)78.576.576.683.681.082.582.078.780.984.081.881.275.578.281.573.173.873.5
 Pneumococcal immunization93.993.592.695.095.193.793.193.492.794.893.893.791.892.992.291.891.990.1
Chronic disease
Diabetes                  
 HbA1c annual98.598.598.698.899.098.798.798.998.798.899.098.998.398.799.098.498.798.6
 HbA1c >9 or not done, poor control (inverted)83.082.381.980.179.578.582.282.181.480.981.281.680.979.480.278.678.678.4
 Blood pressure ≥160/100 or not done (inverted)95.895.895.596.295.895.696.296.096.095.796.095.496.795.995.895.094.894.7
 Blood pressure <140/9081.480.479.182.381.179.781.881.180.281.681.280.882.681.981.279.378.977.2
 Retinal exam88.389.689.591.092.391.692.493.293.090.192.891.989.790.289.489.189.589.7
 Renal testing96.196.396.295.194.594.494.994.594.494.594.394.792.792.392.093.893.293.5
 Foot inspection92.692.291.892.592.792.292.792.591.992.592.792.990.791.391.690.090.891.0
 Foot sensory exam using monofilament88.588.187.388.588.287.788.788.287.788.488.188.587.687.486.385.986.685.8
 Foot pedal pulses90.490.290.190.690.890.790.890.590.590.791.291.589.289.989.388.189.589.1
 ASA listed in current medication78.179.077.975.175.373.675.676.475.774.475.574.970.471.169.570.371.870.1
 ACEI or ARB listed in current medication80.079.178.375.874.373.576.274.973.974.174.772.370.768.066.373.671.672.0
Hypertension                  
 HTN diagnosis: blood pressure <140/9079.778.577.779.779.077.679.778.977.779.479.278.779.478.177.975.975.374.1
 HTN diagnosis: blood pressure ≥160/100 or not recorded (inverted)95.495.295.095.595.394.895.595.495.095.295.894.995.395.094.693.893.993.5
 No HTN diagnosis: blood pressure ≤140/9092.191.591.391.591.690.791.090.790.491.991.190.591.091.091.188.988.588.5
 No HTN diagnosis: blood pressure ≥160/100 or not recorded (inverted)98.798.598.398.197.797.597.997.397.298.397.497.497.597.497.497.396.396.9
Ischemic heart disease                  
 Hyperlipidemia screen98.197.897.798.598.498.198.698.398.198.598.398.098.798.598.197.997.597.3
 ACEI or ARB listed in current medication of AMI patients with LVEF <4089.088.587.984.786.486.484.986.984.579.591.183.879.282.481.584.385.585.2
 ASA listed in current medication at most recent outpatient visit of AMI patient93.193.493.692.591.891.692.792.392.392.792.292.589.088.489.491.090.590.6
 Discharged AMI patient received persistent beta blocker91.292.193.391.489.492.692.787.192.989.794.894.992.287.897.591.691.993.8
 LDL-C measured96.896.896.596.996.696.796.796.996.696.696.696.995.696.295.995.395.895.8
Heart failure                  
 LVEF documented86.887.387.691.093.192.992.190.492.593.893.193.194.191.192.794.394.094.5
 ACEI or ARB listed in current medication for patient with LVEF <4088.888.088.389.089.087.689.889.687.681.187.884.589.883.281.989.088.385.9
a
Analytic sample included veterans enrolled and assigned to a VHA primary care provider who were selected for External Peer Review Program review. For number of patients eligible for each indicator see online supplement. Values are percentages. Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; ASA, acetylsalicylic acid; HbA1c, hemoglobin A1c; HTN, hypertension; LDL-C, low-density lipoprotein cholesterol; LVEF, left ventricular ejection fraction.
b
Assessed only in 2011 and 2012.
Approximately 25% of the initial cohort were diagnosed as having at least one of the five included mental illnesses, with 13.2% of veterans diagnosed as having depression, 9.1% with PTSD, 4.7% with an anxiety disorder, 8.1% with a substance use disorder, and 3.2% with a serious mental illness. Across the three time periods examined, the quality indicator met by the highest proportion of veterans was tobacco screening; nearly all veterans received this preventive care (>99.1% ). Conversely, the quality indicator met by the lowest proportion of veterans was influenza immunizations specifically among veterans without mental illness (65.2%, 64.7%, and 64.9%; Table 2).
For most (27 of 33) of the clinical quality indicators, there was no consistent clinically important difference of 5% or greater between those with and without mental illnesses. For six indicators, there were consistent differences of ≥5% between those with and without mental illness in each of the three time periods examined, with differences ranging from 5.0% to 12.0% (Table 3). A greater proportion of veterans (ages 50–64) received an influenza immunization in five of the six mental illness groups (any mental illness, depression, PTSD, anxiety disorder, and serious mental illness) compared with veterans without mental illness. Additionally, a greater proportion of veterans with chronic heart failure had documented left ventricular ejection fraction (LVEF) in three of the six mental illness groups (any mental illness, anxiety disorder, and substance use disorder) compared with veterans without mental illness.
TABLE 3. Quality indicators demonstrating consistent differences of 5% or greater between veterans with and without a mental illness, by yeara
 Any mental illnessDepressionPTSDAnxiety disorderSerious mental illnessSubstance use disorder
Quality indicator201020112012201020112012201020112012201020112012201020112012201020112012
Immunizations                  
 Influenza immunization (ages 50–64)5.7b6.0b6.9b7.5b7.0b8.1b7.4b8.0b10.3b6.9b6.0b8.1b5.3b7.3b8.3b   
Heart failure                  
  Documented LVEF5.1b5.0b4.9b      7.0b5.8b5.5b   7.5b6.7b6.9b
Cancer screening                  
  Colorectal cancerc             5.1d6.2d 5.1d5.2d
Diabetes mellitus                  
 ASA listed in current medications            7.7d7.9d8.4d7.8d7.2d7.8d
 ACEI or ARB listed in current medications            9.3d11.1d12.0d6.4d7.5d6.3d
Ischemic heart disease                  
 ACEI or ARB listed in current medications of AMI patients with LVEF <40            9.8d6.1d6.4d   
a
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; ASA, acetylsalicylic acid; LVEF, left ventricular ejection fraction.
b
Rate of achieving a quality indicator was higher among veterans with mental illness compared with veterans without mental illness.
c
Assessed only in 2011 and 2012.
d
Rate of achieving a quality indicator was lower among veterans with mental illness compared with veterans without mental illness.
Conversely, the proportion of veterans meeting the preventive care quality indicator for colorectal cancer screening was lower for veterans with a substance use disorder or a serious mental illness than among veterans without mental illness. Likewise, the proportion of veterans meeting the chronic disease management indicator for having acetylsalicylic acid (ASA) included in their current medications was lower for veterans with a substance use disorder and diabetes. The proportion of veterans meeting the indicator for having angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) therapy included in their current medications was also lower for veterans with a substance use disorder and diabetes. Similarly, fewer veterans with a serious mental illness and diabetes met the same indicators related to having ASA and/or ACE inhibitor or ARB therapy in their current medications. Additionally, fewer veterans with a serious mental illness and ischemic heart disease met indicators for use of ACE inhibitor or ARB therapy.

Discussion

We found that veterans with mental illness generally received high-quality preventive and chronic disease management care, similar to those without mental illnesses, in the 3 years following the national PACT implementation, the VHA’s patient-centered medical home model. Consistent clinically important differences in the proportion of veterans meeting quality indicators were detected in just six of 33 indicators; furthermore, in two of these cases, the proportion achieving the quality indicator was in fact higher among those with mental illnesses. Contrary to earlier reports of lower quality care for those with mental illnesses before PACT implementation, we found few disparities between veterans with and without mental illness. Such findings are consistent with previous investigations demonstrating high-quality care in the VHA compared with similar metrics from the private sector (27, 28).
Influenza immunizations for veterans ages 50–64 were higher among individuals with any mental illness, depression, PTSD, anxiety disorders, or serious mental illness compared with veterans without mental illness. This finding is contrary to earlier VHA-based research showing that influenza immunization rates were higher among veterans without mental illness compared with those with psychiatric conditions or substance use disorders who were at least age 65 or considered high-risk (18). Increased receipt of influenza immunization may have resulted from overall increased VHA health care utilization by veterans with mental illness, including the VHA’s provision of access points outside primary care that do not require an appointment (8).
We found higher proportions of documented LVEF among veterans with chronic heart failure and any mental illness, anxiety disorders, or substance use disorders compared with veterans with no mental illness. As previously noted, increased health care utilization is often observed among individuals with mental illness, possibly providing more opportunities for screening and care (8). It is also possible that knowledge of health risks associated with long-term illicit drug use, including negative cardiovascular effects (5), contributes to providers being more likely to monitor heart functioning in individuals with substance use disorders. Additionally, anxiety disorders often include somatic symptoms (e.g., chest pain or discomfort experienced during panic attacks) (29, 30),which may prompt primary care providers to monitor or rule out other health conditions.
The proportion of veterans meeting a quality indicator was lower among veterans with mental illness for one prevention indicator (colorectal cancer screening) and three chronic disease management indicators (ASA included in current medication for individuals with diabetes, ACE inhibitor or ARB therapy included in current medication for individuals with diabetes, ACE inhibitor or ARB therapy included in current medication for individuals with ischemic heart disease with LVEF <40%). However, these differences were only detected when comparing veterans with substance use disorders or serious mental illness with those with none of the five included mental illnesses.
Such findings align with prior studies suggesting failure to meet care quality indicators may be more common among veterans with substance use disorders or serious mental illness (17, 19). Additionally, a prior study of veterans enrolled in VHA primary care found that those diagnosed as having a substance use disorder, serious mental illness, or depression demonstrated poorer outcomes (e.g., were more likely to be hospitalized or die within 1 year when compared with veterans without that mental illness; 10). Although widespread disparities in care quality were not observed, it remains problematic that these differences were detected, particularly given the health risks already faced by individuals with a substance use disorder or serious mental illness (3, 5). It is notable that the proportions of veterans receiving colorectal cancer screening were higher in this study than in prior VHA-based work, suggesting promising overall improvements in VHA care delivery (18).
The PACT model was designed to improve access to and coordination of care and may represent an important opportunity to reach veterans with mental illness. However, the PACT model was not designed to provide the longer-term mental health care that is often indicated for individuals with substance use disorders or serious mental illness. Patients with more severe levels of acuity, whose mental health care needs are unlikely to be met by the brief interventions offered through PC-MHI, are often referred to specialty mental health care (31). Furthermore, research has suggested that veterans with substance use disorders or serious mental illness may be less likely to engage in primary care services (32, 33). Thus veterans with a substance use disorder and/or a serious mental illness may have less contact with their PACT and PC-MHI providers and may have less exposure to the coordinated care provided in this setting compared with veterans with other forms of mental illness (e.g., depression or anxiety). Taken together with the results of this study, such findings suggest that engagement in care and certain aspects of care delivered (e.g., colorectal screens) may need to be enhanced for these high-risk groups.
Improving the understanding of the role that individual-level (e.g., beliefs about and trust in medical care, demographic characteristics, clinical differences) and system-level (e.g., PACT model implementation status, use of integrated behavioral health care) variables play in the delivery and receipt of high-quality care may allow providers to further leverage the PACT model and enhance care provided to veterans with and without mental illness. Additional research is also needed into the complex factors that contribute to poor health among individuals with mental illness (e.g., impact of chronic stress on the body; poor health behaviors such as tobacco and alcohol use, physical inactivity, and poor diet; side effects of psychiatric medications).
Understanding these variables may provide insight into how best to provide care for veterans with mental illness, particularly veterans with substance use disorders or serious mental illness who appear to be at higher risk for worse outcomes. This work will likely require ongoing coordination of care with specialty mental health services, as has been examined in other public health care systems (34). Such enhancements may improve care quality of colorectal cancer screening and chronic disease management care for diabetes and ischemic heart disease, indicators where we found greater differences among veterans with a substance use disorder or a serious mental illness.
Although this study examined comprehensive prevention and chronic disease care indicators among individuals diagnosed as having a range of mental illnesses, limitations existed. After consultation with VHA subject matter experts, a cutoff of ≥5% was used to define meaningful differences, which is different from statistical methods used in prior studies with similar aims (1720). Specifically, multivariate models have been used in previous VHA studies examining similar research questions. Such models were not included in the present investigation given our goal of examining the overall quality of care provided within PACT irrespective of clinical site or patient characteristics and our efforts to identify minimum clinically important differences when comparing adherence to quality indicators. Use of VHA administrative data involved additional limitations. For instance, use of ICD-9 codes to identify patients, although a common approach, may under detect mental illness, and such an approach does not allow for examination of symptom severity. Finally, this is a study of veterans enrolled in VHA primary care, limiting generalizability of results to veterans receiving care outside of the VHA and to civilian populations.

Conclusions

Contrary to prior studies, we found few disparities in preventive and chronic disease management care when comparing veterans with and without mental illness enrolled in VHA primary care services, suggesting that the VHA’s new patient-centered medical home approach to primary care delivery, including integrated mental and behavioral health services, is effective for those with mental illnesses. To further improve care and associated health outcomes, additional efforts to enhance services for veterans with substance use disorders or serious mental illness should be considered.

Supplementary Material

File (appi.ps.201800474.ps2018004740ds.pdf)

References

1.
Kessler RC, Ormel J, Demler O, et al: Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey. J Occup Environ Med 2003; 45:1257–1266
2.
Deschênes SS, Burns RJ, Schmitz N: Associations between depression, chronic physical health conditions, and disability in a community sample: a focus on the persistence of depression. J Affect Disord 2015; 179:6–13
3.
De Hert M, Correll CU, Bobes J, et al: Physical illness in patients with severe mental disorders. I. prevalence, impact of medications and disparities in health care. World Psychiatry 2011; 10:52–77
4.
Dedert EA, Calhoun PS, Watkins LL, et al: Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence. Ann Behav Med 2010; 39:61–78
5.
Han B, Gfroerer JC, Colliver JD: Associations between duration of illicit drug use and health conditions: results from the 2005–2007 national surveys on drug use and health. Ann Epidemiol 2010; 20:289–297
6.
Lyketsos CG, Dunn G, Kaminsky MJ, et al: Medical comorbidity in psychiatric inpatients: relation to clinical outcomes and hospital length of stay. Psychosomatics 2002; 43:24–30
7.
Baumeister H, Balke K, Härter M: Psychiatric and somatic comorbidities are negatively associated with quality of life in physically ill patients. J Clin Epidemiol 2005; 58:1090–1100
8.
Boyd C, Leff B, Weiss C, et al: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations. Hamilton, NJ, Center for Health Care Strategies, 2010. www.chcs.org/media/clarifying_multimorbidity_patterns.pdf. Accessed Apr 26, 2019
9.
Kilbourne AM, Ignacio RV, Kim HM, et al: Are VA patients with serious mental illness dying younger? Psychiatr Serv 2009; 60:589
10.
Trivedi RB, Post EP, Sun H, et al: Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health 2015; 105:2564–2569
11.
Druss BG, Bradford WD, Rosenheck RA, et al: Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001; 58:565–572
12.
Mitchell AJ, Malone D, Doebbeling CC: Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies. Br J Psychiatry 2009; 194:491–499
13.
Osborn DP: The poor physical health of people with mental illness. West J Med 2001; 175:329–332
14.
Gierisch JM, Beadles C, Shapiro A, et al: Health Disparities in Quality Indicators of Healthcare Among Adults With Mental Illness. Washington, DC, Department of Veterans Affairs, 2014.
15.
Hoerster KD, Lehavot K, Simpson T, et al: Health and health behavior differences: US military, veteran, and civilian men. Am J Prev Med 2012; 43:483–489
16.
Seal KH, Bertenthal D, Miner CR, et al: Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med 2007; 167:476–482
17.
Desai MM, Rosenheck RA, Druss BG, et al: Mental disorders and quality of diabetes care in the Veterans Health Administration. Am J Psychiatry 2002; 159:1584–1590
18.
Druss BG, Rosenheck RA, Desai MM, et al: Quality of preventive medical care for patients with mental disorders. Med Care 2002; 40:129–136
19.
Frayne SM, Halanych JH, Miller DR, et al: Disparities in diabetes care: impact of mental illness. Arch Intern Med 2005; 165:2631–2638
20.
Kilbourne AM, Welsh D, McCarthy JF, et al: Quality of care for cardiovascular disease-related conditions in patients with and without mental disorders. J Gen Intern Med 2008; 23:1628–1633
21.
Post EP, Van Stone WW: Veterans Health Administration primary care-mental health integration initiative. N C Med J 2008; 69:49–52
22.
Rosland AM, Nelson K, Sun H, et al: The patient-centered medical home in the Veterans Health Administration. Am J Manag Care 2013; 19:e263–e272
23.
Kearney LK, Post EP, Zeiss A, et al: The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs. Transl Behav Med 2011; 1:624–628
24.
Maguen S, Cohen B, Cohen G, et al: Eating disorders and psychiatric comorbidity among Iraq and Afghanistan veterans. Womens Health Issues 2012; 22:e403–e406
25.
Perlin JB, Kolodner RM, Roswell RH: The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care 2004; 10:828–836
26.
Jha AK, Perlin JB, Kizer KW, et al: Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003; 348:2218–2227
27.
Asch SM, McGlynn EA, Hogan MM, et al: Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004; 141:938–945
28.
Trivedi AN, Grebla RC: Quality and equity of care in the Veterans Affairs health-care system and in Medicare advantage health plans. Med Care 2011; 49:560–568
29.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Publishing, 2013
30.
White KS, Craft JM, Gervino EV: Anxiety and hypervigilance to cardiopulmonary sensations in non-cardiac chest pain patients with and without psychiatric disorders. Behav Res Ther 2010; 48:394–401
31.
Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC, National Academies Press, 2018
32.
Bradford DW, Kim MM, Braxton LE, et al: Access to medical care among persons with psychotic and major affective disorders. Psychiatr Serv 2008; 59:847–852
33.
Chwastiak LA, Rosenheck RA, Kazis LE: Utilization of primary care by veterans with psychiatric illness in the national Department of Veterans Affairs health care system. J Gen Intern Med 2008; 23:1835–1840
34.
Gilmer TP, Henwood BF, Goode M, et al: Implementation of integrated health homes and health outcomes for persons with serious mental illness in Los Angeles County. Psychiatr Serv 2016; 67:1062–1067

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 816 - 823
PubMed: 31310189

History

Received: 17 October 2018
Revision received: 31 January 2019
Accepted: 22 March 2019
Published online: 16 July 2019
Published in print: September 01, 2019

Keywords

  1. Quality of health care
  2. veterans’ health
  3. mental health
  4. prevention
  5. chronic disease management

Authors

Details

Kendall C. Browne, Ph.D. [email protected]
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Katherine D. Hoerster, Ph.D., M.P.H.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Rebecca Piegari, M.S.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
John C. Fortney, Ph.D.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Karin N. Nelson, M.D., M.S.H.S.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Edward P. Post, M.D., Ph.D.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Stephan D. Fihn, M.D., M.P.H.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Alaina M. Mori, B.A.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).
Ranak B. Trivedi, Ph.D.
Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi).

Notes

Send correspondence to Dr. Browne ([email protected]).
Data included in this article were presented at the annual research meeting of the Academy of Health, June 26–28, 2016, Boston.

Competing Interests

Drs. Hoerster and Trivedi were supported by VA grants CDA-12-263 and CDA-09-206, respectively. Funding for the PACT Demonstration Laboratory Initiative was provided by the VHA Office of Primary Care. This work was undertaken as part of the VHA PCAT, funded by the VA Office of Primary Care. The VHA Office of Reporting, Analytics, Performance, Improvement and Deployment provided the External Peer Review Program data used in this study. Data for this report were prepared by PCAT.

Competing Interests

The views expressed are those of the authors and do not necessarily reflect the position or policy of the VA.

Competing Interests

The authors report no financial relationships with commercial interests.

Funding Information

Health Services Research and Developmenthttp://dx.doi.org/10.13039/100007217: CDA-09-206, CDA-12-263

Metrics & Citations

Metrics

Citations

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Get Access

Login options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Personal login Institutional Login Open Athens login
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share