VA Health Care: Improvements Needed in Monitoring Antidepressant Use for Major Depressive Disorder and in Increasing Accuracy of Suicide Data
What GAO Found
GAO's analysis of Department of Veterans Affairs (VA) data for fiscal years 2009 through 2013 shows that about 10 percent of veterans who received VA health care services were diagnosed with major depressive disorder (MDD). MDD is characterized by depressed mood or loss of interest along with other symptoms for 2 weeks or more that represent a change in the way individuals function from their previous behaviors. Because GAO found diagnostic coding discrepancies in 11 of the 30 veterans' medical records it reviewed from six VA medical centers (VAMC), VA's data may understate the prevalence of MDD among veterans being treated through VA, to the extent that such discrepancies may permeate VA's data. One treatment for MDD is the use of medications such as antidepressants. According to GAO's analysis, 94 percent of veterans diagnosed with MDD were prescribed at least one antidepressant.
VA policy states that antidepressant treatment must be consistent with VA's current clinical practice guideline (CPG); however, GAO's review of 30 veterans' medical records identified deviations from selected MDD CPG recommendations for most veterans reviewed. For example, 26 of the 30 veterans were not assessed using a standardized assessment tool at 4 to 6 weeks after initiation of treatment, as recommended in the CPG. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. GAO found that VA does not have a system-wide process in place to identify and fully assess whether the care provided is consistent with the CPG. As a result, VA does not know the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG and whether appropriate actions are taken by VAMCs to mitigate potentially significant risks to veterans.
The demographic and clinical data that VA collects on veteran suicides were not always complete, accurate, or consistent. VA's Behavioral Health Autopsy Program (BHAP) is a quality initiative to improve VA's suicide prevention efforts by identifying information that VA can use to develop policy and procedures to help prevent future suicides. The BHAP templates are a mechanism by which VA collects suicide data from VAMC's review of veteran medical records. GAO's review of 63 BHAP templates at five VAMCs found that 40 of the templates that VAMCs submitted to VA Central Office had incomplete data. Also, GAO found that the BHAP templates VAMCs submitted contained inaccurate data. For example, 6 BHAP templates included a date of death that was incorrect based on information in the veteran's medical record, and 9 BHAP templates included an incorrect number of outpatient VA mental health visits in the last 30 days. Moreover, GAO found that VAMCs submitted inconsistent information because they interpreted VA's guidance on completing the BHAP templates differently. This situation was further exacerbated because BHAP templates prepared by VAMCs are generally not being reviewed at any level within the Department for completeness, accuracy, and consistency. Lack of complete, accurate, and consistent data and poor oversight can inhibit VA's ability to identify, evaluate, and improve ways to better inform its suicide prevention efforts.
Why GAO Did This Study
In 2013, VA estimated that about 1.5 million veterans required mental health care, including services for MDD. MDD is a debilitating mental illness related to reduced quality of life and productivity, and increased risk for suicide. VA also plays a role in suicide prevention. GAO was asked to review how VA tracks veterans prescribed antidepressants and what suicide data VA uses in its prevention efforts.
This report examines (1) VA's data on veterans with MDD, including those prescribed an antidepressant; (2) the extent that veterans with MDD who are prescribed antidepressants receive recommended care and the extent to which VA monitors such care; and (3) the quality of data VA requires VAMCs to collect on veteran suicides. GAO analyzed VA data, interviewed VA officials, and conducted site visits to six VAMCs selected based on geography and population served. From each of these six VAMCs, GAO also reviewed five randomly selected medical records for veterans diagnosed with MDD and prescribed an antidepressant in 2012, as well as all completed BHAP templates. The results cannot be generalized across VA but provide insights.
GAO recommends that VA identify and address MDD coding discrepancies; implement processes to review data and assess deviations from recommended care; and implement processes to improve completeness, accuracy, and consistency of veteran suicide data. VA concurred with GAO's recommendations and described its plans to implement them.
Recommendations for Executive Action
|Department of Veterans Affairs||To more accurately estimate the prevalence of MDD and identify enrolled veterans with MDD, the Secretary of Veterans Affairs should direct the Under Secretary for Health to determine and address the factor(s) contributing to the imprecise coding based on the results of those examinations. For example, feedback and additional training could be provided to clinicians regarding the importance of diagnostic code accuracy, or VA's medical record could be enhanced to facilitate the selection of a more accurate diagnostic code.||
In response to our recommendation, VA officials conducted chart reviews and expert panel meetings to analyze diagnostic coding among veterans with a new depression diagnosis and a concurrent new antidepressant medication start. The expert panel recommended, among other things, that VA enhance the system for entering depression diagnoses. In fiscal year 2016, VA transitioned to an updated diagnosis framework and examined the effect of the changes on the VA systems for entering depression diagnoses. VA determined the diagnosis patterns for depression could lead to a more accurate estimate of MDD.
|Department of Veterans Affairs||To more accurately estimate the prevalence of MDD and identify enrolled veterans with MDD, the Secretary of Veterans Affairs should direct the Under Secretary for Health to identify the extent to which there is imprecise diagnostic coding of MDD by further examining encounters with a diagnostic code of depression not otherwise specified, which could be incorporated into VAMCs' ongoing review of diagnostic coding accuracy.||
In response to our recommendation, VA examined diagnostic coding among veterans with a new depression diagnosis and a concurrent new antidepressant medication start by conducting chart reviews for a sample of veterans to examine the diagnosis in the veterans' medical record and the diagnostic code used for the encounter. VA also reviewed a sample of veterans' charts for those veterans that had a new antidepressant start, but did not have a depression diagnosis. Through this process, VA officials identified the number of veterans in the sample where the diagnosis in the veterans' medical chart did not match the diagnosis code used.
|Department of Veterans Affairs||To ensure that veterans are receiving care in accordance with the MDD CPG, the Secretary of Veterans Affairs should direct the Under Secretary for Health to implement processes to review data on veterans with MDD prescribed antidepressants to evaluate the level of risk of any deviations from recommended care and remedy those that could impede veterans' recovery.||
In response to our recommendation, VA officials reviewed the scores of Patient Health Questionnaire (PHQ-9) assessments for those veterans with MDD who had a PHQ-9 to determine associations between receipt of guideline concordant antidepressant care and changes in depression symptoms. VA officials found that PHQ-9 scores decreased compared to those veterans that did not receive guideline concordant care. VA officials also reviewed whether veterans were receiving Healthcare Effectiveness Data and Information Set consistent antidepressant care and conducts quarterly assessments. VA officials determined that about 90 percent of the veterans in their review received guideline concordant care.
|Department of Veterans Affairs||To improve VA's efforts to inform its suicide prevention activities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that VAMCs have a process in place to review data on veteran suicides for completeness, accuracy, and consistency before the data are submitted to VA Central Office.||
In response to our recommendation, VA created a checkbox in the BHAP template to indicate that the VAMC leadership has reviewed the template. This box must be checked in order for the template to be accepted. Officials reported that 72 percent of templates were reviewed by VAMC leadership. VA plans to continue to monitor progress.
|Department of Veterans Affairs||To improve VA's efforts to inform its suicide prevention activities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify guidance on how to complete BHAP templates to ensure that VAMCs are submitting consistent data on veteran suicides.||
In response to our recommendation, VA has issued clarifying guidance to suicide prevention coordinators. This guidance included entering information into the BHAP template for veterans who did not receive care at the VA, when to leave a field in the template blank, and how to correct any submitted information. According to VA officials, since the release of the new guidance, suicide prevention coordinators have reported being more comfortable using the BHAP templates and have had fewer questions about the submission of templates.
|Department of Veterans Affairs||To improve VA's efforts to inform its suicide prevention activities, the Secretary of Veterans Affairs should direct the Under Secretary for Health to implement processes to review data on veteran suicides submitted by VAMCs for accuracy and completeness.||
In response to our recommendation, VA has begun reviewing selected BHAP templates to identify any discrepancies in data entry or questions that arise during the review. These discrepancies could be due to data entry error or may lead to new information, which is then modified or added to the BHAP template. This process will help ensure that VA officials receive accurate and consistent suicide data from VAMCs.