The quality of mental health care for veterans of Operation Enduring Freedom/Operation Iraqi Freedom.

BACKGROUND: Some Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans experience serious mental health (MH) problems. As OEF/OIF soldiers leave active military duty, their growing numbers pose a challenge to the Department of Veterans Affairs (VA) in delivering high-quality mental health/substance-use disorder (MH/SUD) care. OBJECTIVE: To determine whether the quality of MH/SUD care provided by the VA differs by OEF/OIF veteran status. METHODS: Veterans with selected MH/SUDs were identified from administrative records using diagnostic codes. OEF/OIF service was determined based on Defense Manpower Data Center separation files. Eleven processes of care and 7 utilization performance indicators were examined. Regression analyses were adjusted for veteran demographic and clinical characteristics to test for differences in care by OEF/OIF status. RESULTS: Of the 836,699 veterans with selected diagnoses who received MH/SUD treatment in FY2007, 52,870 (6.3%) were OEF/OIF veterans. In unadjusted analyses, OEF/OIF veterans were more likely to receive evidence-based care processes captured by 6 of the 11 dichotomous performance indicators examined; however, among those receiving psychotherapy encounters, OEF/OIF veterans received significantly fewer visits (6.9 vs. 9.7, P<0.0001). In adjusted analyses, only postdischarge follow-up remained meaningfully higher for OEF/OIF veterans. CONCLUSIONS: Efforts to maintain and/or increase OEF/OIF veteran participation in VA MH/SUD services should be informed by their characteristics, such as younger age and better physical health relative to other veterans.

Developing medical record-based performance indicators to measure the quality of mental healthcare.

Recent attention has focused on validity and feasibility of different approaches to developing performance indicators for the purposes of quality improvement and value-based purchasing. This paper presents the methodology used to develop a comprehensive set of performance indicators that will be used for a national evaluation of the mental healthcare provided by the Veterans Health Administration. The paper report on the indicators' technical specifications and the United States Public Health System Task Force defined strength of supporting evidence. Indicators were reviewed iteratively for meaningfulness, utility, feasibility, and supporting evidence until a final set of measures of acceptable validity and feasibility was produced with technical specifications. Fifty-seven mental health performance indicators that use information from both the medical record and administrative data (hybrid indicators) and 31 administrative-data only indicators are presented. Of the 57 hybrid indicators, 13 indicators are supported by Agency for Healthcare Research and Quality grade I evidence, 5 indicators are grade II, and 39 indicators are grade III. This paper describes the methodology used to develop 88 performance indicators of the quality of mental health and substance abuse treatment, and presents the technical specifications associated with each indicator.

Transforming mental healthcare in the Veterans Health Administration: a model for measuring performance to improve access, quality, and outcomes.

In this paper we present the conceptual framework and research design of a national evaluation of the quality of mental healthcare provided to veterans by the Veterans Health Administration, and present results on the reported availability of evidence-based practices. We used the Donabedian paradigm to design a longitudinal evaluation of the quality of mental healthcare. To evaluate the structure of care we used a combination of survey and administrative data and designed a web-based facility survey to examine the availability and characteristics of 12 evidence-based practices and other mental health services. We identified 138 unique facilities that provided mental healthcare to 783,280 veterans. With the exception of opiate substitution therapies, every evidence-based practice was reported in at least one location in each service network. We use maps to estimate the maximum number of veterans that might benefit from expanding the availability of an evidence-based practice. We demonstrate the feasibility of overcoming several major challenges typically associated with measuring the quality of healthcare systems. This framework for evaluation of mental healthcare delivery provides a model upon which other stakeholders can continue to build and expand.

A study of the workforce in emergency medicine: 1999.

STUDY OBJECTIVE: We estimate the total number of physicians practicing clinical emergency medicine during a specified period, describe certain characteristics of those individuals to estimate the total number of full-time equivalents (FTEs) and the total number of individuals needed to staff those FTEs, and compare the data collected with those data collected in 1997. METHODS: Data were gathered from a survey of a random sample of 2,153 hospitals drawn from a population of 5,329 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, and the total number of physicians working during the period from June 6 to June 9, 1999. Demographic data on the individuals were also collected. RESULTS: A total of 940 hospitals responded (a 44% return rate). These hospitals reported that a total of 6,719 physicians were working during the specified period, or an average of 7.85 persons scheduled per institution. The physicians were scheduled for a total of 347,702 hours. The average standard for FTE was 40 clinical hours per week. This equates to 4,346 FTEs or 5.29 FTEs per institution. The ratio of persons to FTEs was 1.48:1. With regard to demographics, 83% of the physicians were men, and 82% were white. Their average age was 42.6 years. As for professional credentials, 42% were emergency medicine residency trained, and 58% were board certified in emergency medicine; 50% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 5,064 hospitals with EDs and given that the data indicate that there are 5.35 FTEs per ED, the total number of FTEs is projected to be 27,067 (SE=500). Given further that the data indicate a physician/FTE ratio of 1.47:1, we conclude that there are 39,746 persons (SE=806) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 31,797. When the 1999 data are compared with those collected in 1997, we note a statistically significant decline in the number of hospital EDs, from 5,126 in 1997 to 5,064 in 1999 (P =.02). The total number of emergency physicians remained the same over the 2-year period, whereas the number of FTEs per institution increased from 5.11 to 5.35. The physician/FTE ratio remained unchanged.