Measuring antidepressant prescribing practice in a health care system using administrative data: implications for quality measurement and improvement.

BACKGROUND: Up to one in eight Americans experiences an episode of depression that requires treatment in his or her lifetime. The direct and indirect costs associated with major depression are high but may be reduced with appropriate treatment. To decrease the probability of relapse, guidelines specify that treatment with antidepressant medications should continue for at least 4 months after symptom remission and that adequate doses of antidepressants be used. A study was conducted in 1997-1999 to examine how different specifications in the construction of quality of care measures for depression treatment influence conclusions about the adequacy of antidepressant prescribing practices. METHODS: Subjects were all adult members of two United Healthcare plans who each had at least one outpatient or inpatient claim with a diagnosis of depression during the years 1993-1995 and were continuously enrolled for 12 months. Pharmacy claims data were used to construct measures of duration of treatment, dose, and type of antidepressant. The effects of two different definitions of a new episode (4-month versus 9-month clean period) and two different ways of identifying an episode of depression (one visit versus two visits with a code for depression) were examined on conclusions about adequacy of antidepressant prescribing practices (dose and duration). Whether antidepressant type was related to the likelihood that antidepressants were prescribed at therapeutic doses was also examined. RESULTS: Patients with two or more visits with depression diagnosis codes were significantly more likely to receive antidepressants than those with only one visit, and were more likely to receive therapeutic doses at each time period (1-5 months). The duration of the clean period was not related to conclusions about therapeutic dosing. Among persons receiving antidepressants, those receiving selective serotonin reuptake inhibitors (SSRIs) were more likely to receive therapeutic doses and to continue treatment for at least 5 months than were those prescribed other classes of antidepressants. In multivariate analysis, being prescribed an SSRI versus another class of antidepressants was significantly associated with receiving both 1 month (OR = 7.3 [5.7-9.3]) and 5 months (OR = 2.0 [1.6-2.5]) of therapeutic treatment. DISCUSSION: Conclusions regarding the appropriateness of antidepressant prescribing can vary markedly, depending on how the quality measure is specified. Given that administrative data are and will continue to be used for both monitoring and quality improvement purposes in the short run, it is critical that we understand how variations in measurement specifications influence the conclusions that are drawn about treatment of depression in health plans.

A retrospective evaluation of stifle osteoarthritis in dogs with bilateral medial patellar luxation and unilateral surgical repair.

The effects of surgical and nonsurgical therapy on the development of osteoarthritis were compared in 12 dogs with bilateral medial patellar luxation and unilateral surgical repair. Evaluations included severity of lameness and patellar luxation, ligamentous stability, range of motion, and radiographic evidence of osteoarthritis before surgery and at a mean of 33 months after surgery. Stifles without surgical treatment served as controls for the contralateral stifles with surgery. All stifles treated surgically had reduced patellofemoral joints, normal range of motion, and improved limb use. Osteoarthritis progressed significantly and comparably in both groups of stifles. Progression of osteoarthritis was not correlated with luxation grade, body weight, or interval from surgery to follow-up. Age at surgery was correlated positively with severity of osteoarthritis in the stifles treated surgically.

Clinical evaluation of cats with lower urinary tract disease.

In a prospective study, 141 cats with hematuria, dysuria, urethral obstruction, or combinations of these signs were evaluated by contemporary diagnostic methods and compared with 26 clinically normal cats (controls). Specific diagnosis was established in 45% (64/141) of cats affected with lower urinary tract disease (LUTD). Crystalline matrix plug-induced urethral obstruction was diagnosed in 21% (30/141) of affected cats, uroliths were identified in 21% (30/141) of affected cats, uroliths with concomitant bacterial urinary tract infection (UTI) were identified in less than 2% (2/141) of affected cats, and bacterial UTI alone was identified in less than 2% (2/141) of cats with LUTD. Viruses, mycoplasmas, and ureaplasmas were not isolated from urine samples collected from affected or control cats. Bovine herpesvirus 4 (BHV-4)-neutralizing antibodies were not detected in any serum sample obtained from cats with LUTD or from control cats. In contrast, BHV-4 antibodies were detected by an indirect immunofluorescent antibody (IFA) test in sera obtained from 31% (44/141) of cats with LUTD and 23% (6/26) of control cats. The prevalence of positive BHV-4 IFA test results in affected cats was not significantly different from that observed in control cats. Significant association was not apparent between positive BHV-4 IFA test results and clinical diagnosis, abnormal laboratory findings, or cat age. However, the number of male cats with BHV-4 IFA titer was significantly (P less than 0.02, chi 2 test) greater than that of female cats. Detection of BHV-4 antibodies in approximately 30% of affected and control cats indicates prior virus exposure. Further investigations are warranted to clarify the specific role of BHV-4 in cats with naturally acquired LUTD.