Quality of Care for PTSD and Depression in the Military Health System: Final Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This study is a comprehensive assessment of the quality of care delivered by the MHS in 2013-2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012-2013 and 2013-2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

Quality of Care for PTSD and Depression in the Military Health System: Phase I Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Given the rates of posttraumatic stress disorder (PTSD) and depression among U.S. service members, attention has been directed to ensuring the quality and availability of programs and services targeting these and other psychological health (PH) conditions. Understanding the current quality of care for PTSD and depression is an important step toward improving care across the MHS. To help determine whether service members with PTSD or depression are receiving evidence-based care and whether there are disparities in care quality by branch of service, geographic region, and service member characteristics (e.g., gender, age, pay grade, race/ethnicity, deployment history), DoD's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to conduct a review of the administrative data of service members diagnosed with PTSD or depression and to recommend areas on which the MHS could focus its efforts to continuously improve the quality of care provided to all service members. This study characterizes care for service members seen by MHS for diagnoses of PTSD and/or depression and finds that while the MHS performs well in ensuring outpatient follow-up following psychiatric hospitalization, providing sufficient psychotherapy and medication management needs to be improved. Further, quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting the need to ensure that all service members receive high-quality care.

Symptom management after breast cancer treatment: is it influenced by patient characteristics?

PURPOSE: With improved patient survival from breast cancer, more interest has evolved regarding the symptoms women experience in association with breast cancer treatments. We studied the extent to which symptoms for women with incident breast cancer are addressed by their physicians and how symptom management varies with patient characteristics. METHODS: As part of the Los Angeles Women's (LAW) Study, we categorized women from a population-based study of incident breast cancer (n = 1,219) as having an unmet need if she had at least one severe symptom (any of the following: nausea/vomiting, arm problems, hot flashes, vaginal dryness, difficulty sleeping) for which she did not receive the help she wanted. Multivariable analyses predicted having any unmet need as a function of patient demographic and health characteristics. RESULTS: The prevalence of unmet need varied by the type of symptom with the highest proportion of women receiving help for nausea and vomiting (0.91) and the lowest for vaginal dryness (0.48). Black women (OR = 3.61, 95% CI: [1.57, 8.31]), and Spanish-speaking Hispanic women (OR = 2.69, 95% CI: [1.22, 5.94]) were significantly more likely than white women to report an unmet need. More black and Hispanic women compared to white women cited the doctor not thinking treatment would benefit her (P = 0.02), not appreciating how much the problem bothered her (P = 0.03), not knowing about treatments (P < 0.0001), or insurance/cost barriers (P = 0.009) as reasons for her unmet need. CONCLUSION: These results show the persistence of racial disparities in the receipt of appropriate care within the health care system.

Symptoms after breast cancer treatment: are they influenced by patient characteristics?

PURPOSE: This study examines the burden of symptoms by treatment type and patient characteristics in a population-based sample of newly diagnosed breast cancer patients. METHODS: Using the Los Angeles County SEER Registry Rapid Case Ascertainment, we identified a cohort of breast cancer patients in 2000 and conducted telephone surveys in English and Spanish among participants. RESULTS: We completed interviews of 1,219 breast cancer patients and found almost half (46%) had at least one severe symptom (any of the following: nausea/vomiting, arm problems, hot flashes, vaginal dryness, difficulty sleeping) that interfered with her daily functioning or mood. Multi-variate analysis controlling for patient characteristics and treatment showed that older (OR=0.90; P<0.000), black (OR=0.50; P<0.000), Hispanic Spanish-speaking (OR=0.37; P<0.000), widowed or never married (OR=0.68; P=0.049), and working (OR=0.72; P=0.024) women were less likely to report severe symptoms than other women. Number of comorbid conditions (OR=1.21; P<0.000) and receipt of chemotherapy (OR=1.48; P=0.040) were positively associated with reporting symptoms. CONCLUSION: These findings estimate the prevalence of several mutable symptoms in breast cancer patients that can be addressed by appropriate treatments. Comorbidity is a significant predictor of symptoms, especially amongst those receiving chemotherapy. Variation in symptom reporting occurred by race/ethnicity and other sociodemographic characteristics, raising questions of different thresholds for reporting symptoms or truly fewer symptoms for some sociodemographic groups. Population-based estimates of the probability of symptoms in women with incident breast cancer can be used to provide patient education about potential outcomes following the treatment of breast cancer.