1. Racial Differences in Quality of Care for Bipolar Disorder Center for Health Equity Research and Promotion Departments of Medicine and Psychiatry, University of Pittsburgh RAND-University of Pittsburgh Health Institute VA Providence Medical Center Amy M. Kilbourne, Gretchen L. Haas, Xiaoyan Han, Joseph Conigliaro, Patrick Elder, C. Bernie Good, Mark S. Bauer, Mujeeb Shad, Harold Alan Pincus

2. Background  Bipolar disorder is a chronic illness associated with functional impairment, costs  Despite practice guidelines, outcomes remain suboptimal  Potential disparities in guideline-based quality of care unexplored  Implementation of quality indicators- first step in quality improvement

3. Objective  Assess whether quality of care for bipolar I disorder differs by race, age, and other patient characteristics

4. Methods  Data source: VA National Patient Care Database »Retrospective analysis- FY 2001 »VISN 4 (10 medical centers) »FY 2001 (10/1/00-9/30/01)  Study population: bipolar I disorder diagnosis  Demographic and utilization data from NPCD  VA Pharmacy Benefits Management data

5. Quality Indicators 1.Current mood stabilizer prescription in 1 yr 2.Mental health outpatient contact <90 days* 3.Mental health outpatient contact <=30 days after psychiatric hospitalization discharge* *Two definitions: 1) outpatient visits only; 2) outpatient visits or telephone contact

6. Analyses  Excluded other race/ethnicity, nonveterans  Bivariate analyses  Multiple logistic regression »Controlled for patient demographics, comorbidities »Adjusted for facility as a fixed effect  Sensitivity analyses »Alternative definitions for outpatient, inpatient visits produced similar results

7. Results  2316 patients diagnosed with bipolar I disorder »Mean age = 52 »13% African-American »9% women »6% required to pay copayment (means test) »32% married  556 (24%) had psychiatric hospitalization

8. Quality Indicator Results: Bipolar I Disorder %

9. Quality Indicator Results by Race % * †p=.08, *p<.05 †

10. Quality Indicator Results by Age % *p<.05, **p<.001 **

11. Mood Stabilizer Prescription Multiple Logistic Regression* n=2316 OR 95% CI p African-American.64.45,.90.01 Age >60 Years.51.39,.66<.001 Female.84.58, 1.22.36 No Copayment.63.37, 1.10.10 Not Married.74.57,.95.02 # Comorbidities1.02.95, 1.09.61 Sub. Use Disorder1.20.91, 1.59.19 * Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility

12. Outpatient Visit <90 Days Multiple Logistic Regression* n=2316 OR 95% CI p African-American.68.51,.91.009 Age >60 Years.55.44,.69<.001 Female1.31.95, 1.80.10 No Copayment.71.48, 1.06.09 Not Married1.03.85, 1.26.76 # Comorbidities1.141.08, 1.21<.001 Sub. Use Disorder.87.70, 1.08.21 * Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility

13. Visit <30 Days Post-Discharge Multiple Logistic Regression* n=553 OR 95% CI p African-American.62.38, 1.00.05 Age >60 Years1.03.59, 1.78.93 Female2.561.30, 5.03.006 No Copayment.53.20, 1.36.19 Not Married.56.36,.86.008 # Comorbidities1.151.05, 1.31.006 Sub. Use Disorder.84.55, 1.26.39 * Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility

14. Visit or Tele. Contact <=30 Days Post-Discharge: Multiple Logistic Regression* n=553 OR 95% CI p African-American.98.56, 1.70.93 Age >60 Years.67.36, 1.26.21 Female1.92.79, 4.65.15 No Copayment.61.19, 4.65.15 Not Married.42.24,.73.002 # Comorbidities1.06.93, 1.20.40 Sub. Use Disorder.67.41, 1.10.11 * Adjusted for race, age, gender, means, mar. status, comorbidity, SUD, facility

15. Limitations  Secondary analyses of administrative data  Few women  Limited generalizability

16. Conclusions  Most patients with bipolar I disorder received guideline concordant pharmacotherapy  Many did not receive adequate outpatient care  Suboptimal care apparent for African-American and older patients

17. Implications  Further research- reasons for gaps in quality »Pharmacotherapy »Continuity of outpatient care  Telephone contacts might reduce quality gaps  Future quality improvement interventions should focus on older and minority patients

18. Acknowledgements  VA Health Services Research and Development Merit Review (IIR 02-283-2, A. Kilbourne, PI)  VA HSR&D MREP Career Dev. Award (Dr. Kilbourne)  VA Center for Health Equity Research and Promotion (M. Fine, MD MSc; PI)  VA Mental Illness Research Education and Clinical Center (G. Haas and I. Katz, Co-PIs)  Mental Health Intervention Research Center (MH30915, D. Kupfer, PI)