Rebecca Andrews, MD: MDD Performance Measures Review Highlight Need for Tweaking

After reviewing major depressive disorder (MDD) performance measures, the American College of Physicians found only 1 valid measure based on quality indicators—suicide risk assessment.

The organization reviewed 8 performance measures in September 2022. The committee members of the American College of Physicians—all internal medicine physicians working in community and academic settings or various practices.

Members voted on 8 performance measures using a modified RAND/UCLA method. The following measures were:

1. Preventative Care and Screening for Depression and Follow-up
2. Adult Major Depressive Disorder Suicide Risk Assessment
3. Depression Utilization of the PHQ-9 Tool
4. Antidepressant Medication Management
5. Depression Response at 6 Months—Progress Towards Remission
6. Depression Response at 12 Months—Progress Towards Remission
7. Depression Remission at 6 Months
8. Depression Remission at 12 Months.

The members reviewed and analyzed the measures for quality indicators of importance, appropriate care, clinical evidence base, measure specifications, and feasibility or applicability. During 2 rounds, 11 members voted anonymously on the quality indicators on a 9-point scale for 3 levels of attribution: individual physician, group practice, and health plan level.

If an attribution had no available data, the member could not vote on the measure and was denoted as, “Do Not Support—Performance Measure Is Not Tested at This Level of Attribution.” One committee member did not vote as they served as the moderator, leading the discussion.

“One of the reasons I really enjoy being a part of this committee is the work that we're doing,” Rebecca Andrews, MD, MS, FACP from the University of Connecticut and vice chair of the Performance Measurement Committee, told HCPLive. “I think physicians are used to taking tasks or having to meet metrics to indicate that they're up to date and providing good care, but there's a lot of frustration in imperfect measures, or measures that are sort of taken out of convenience that don't really highlight the quality of the care that's given.”

Andrews hopes the paper will help organizations create new measures that improve validity, and physicians can have new metrics to meet that they can trust to be accurate. The paper can also assist physicians in acknowledging where their performance gaps are to improve patient care.

The suicide risk assessment received the highest score of 7 for individual physicians and 8 for group practice; the quality indicators of importance and appropriate use received a top score of 9. The other domains—clinical evidence base, measure specifications, and feasibility/applicability—scored a 7.

Performance measures that received the lowest scores were Depression Response at 6 Months—Progress Towards Remission, as well as Antidepressant Medication Management, both having a median overall rating of 4.

“There is no data that supports that six or 12 months are these magic numbers that say a patient should reach remission,” Andrews said.

Andrews also does not believe creating a follow-up plan for patients who screened for depression is necessary, since the metric may not “capture what you’re looking for.” She provided the example of a new mom taking care of her newborn and screening for depression at her physical.

“So the screening questions might be positive that I'm tired, and I don't really have interest in doing my normal activities, say painting or running or seeing my friends, because I'm really just all incorporated with a new baby at home, that won't need a specific follow up per se, other than touching base with my patient to make sure they're doing well, versus someone who has depression,” Andrews said.

Additionally, psychotherapy or talk therapy does not require a referral from a doctor, so a patient can find someone online who takes their insurance.

“There’s no check-the-box mechanism for [an] insurance company or your organization to say, ‘Okay, we hit this, you provided good care, they wouldn't have to read your notes,’” Andrews said. “And that's a cumbersome metric to ask a physician to report on; they would have to go through their notes and prove that for their patients.”

Antidepressant Medication Management was unsupported because they only included study data on health plans—not individual physician and group practice. Depression Remission at 12 Months also received a “do not support” score since this measure did not have data on individual physicians but only on group practice.

“The other thing I think I would like the physician audience to take away from this is that they could use these published articles that we hope to create with the performance measures committee, take them back, and use them to advocate with insurance companies, state agencies, their organization…as a guide to say we're not against performance measures in general, we just want them to measure what they're supposed to measure in a valid and accurate way,” Andrews said. “This almost provides a blueprint for how to do that, and a primer, if you will. We walk you through why certain of the performance measures we looked at were not valid and why we could not support them.”

Relevant disclosures for Andrews include Medtronic Vascular, Inc.

References

Qaseem A, Andrews RA, Campos K, et al. Quality Indicators for Major Depressive Disorder in Adults: A Review of Performance Measures by the American College of Physicians. Ann Intern Med. Published online March 5, 2024. doi:10.7326/M23-3077