Jump to: navigation, search

Follow Up of Patients with Common Mental Disorders

Basic Facts

Stage of development


Potential or current usage

Data extracts have been carried out in 4 practices in relation to this measure, using a query designed by Compass.

Brief overview of the measure

General description

This measure is part of a suite of 11 mental health indicators (common mental disorders and depression). This is a ‘pre-cursor’ for advanced indicators relating to the appropriate follow up of patients with CMD in primary care. It is envisaged that future indicators will specifically address processes and times frames for follow up. In order to apply an indicator that addresses time-frames, practices need to first have a follow up system in place.

Type of measure


Domain(s) of quality

Effectiveness, Efficiency, Equity and access, People-centred, Safety

Application and interpretation of the measure

Stated intent of the measure

Ensuring appropriate follow-up of patients with CMD through establishing practice systems for maintaining regular, on-going contact with patients with common mental disorders. Once these systems are in place, more advanced indicators relating to the appropriate follow up of patients with CMD in primary care can then be developed.

Caveats - Considerations

Very limited insight as to if/ how patients with recorded CMD are followed up Feasibility testing revealed there are currently no automated recall systems in general practices and there were no significant results in terms of recalls for patients with CMD. Where recall records were identified (in 1 out of 4 practices where the measure was tested) only 1 out of 13 recalls resulted in patients contact- even when there was a recorded attempt to follow up, patient response is very low. This measure does not necessarily provide information on how many patients respond to the practice follow up . Assumption CMD is consistently and appropriately recorded In order for a practice to recall patients effectively, it is necessary to first identify and consistently record CMD (i.e. indicator 1).

Links to other measures

WSoM Indicator 1: Prevalence of common mental disorders in (i) adults and (ii) children WSoM Indicator 2: Risk assessment of people with common mental disorders with a focus on depression WSoM Indicator 4: Prescription of selective serotonin re-uptake inhibitors for the management of common mental disorders

Level of health care delivery/setting

General practices within a PHO Secondary care settings may also find this measure useful (MH KPIs have a similar measure)

Target population

All funded patients with recorded CMD.

Stratification by vulnerable populations

If proxy available (i.e. query by quintile), then stratification by ethnicity or socio economic status may be of interest.

Associated incentives

Use of this measure is linked to: MOPS Cornerstone

Possible sources of bias or confounding

As the feasibility testing findings show, practices do not seem to have consistent and automated recall systems in place and may not record follow up of patients in their practice management systems. As a result, data extracts will not necessarily provide accurate information as to whether patients are being followed up or not- there may be an under estimation of follow up.

Calculation of the measure

Output of calculation

Percentage of patients with CMD followed up over 2 years

Numerator description

Number of recalls recorded

Numerator exclusions


Denominator description

Patients with a common mental disorder (CMD) READ code recorded. Patients= unique funded adults (18-65 years) within the current practice within the current quarter. Funded’ is an enrolled patient who has been identified in the current quarter as being uniquely funded in a given practice. The patient is capitated at that practice. Denominator exclusions None

Time period

2 years

Criteria/standard for optimal performance

Every practice within a PHO should have a process in place for maintaining regular, on-going contact with patients with common mental disorders.

Data source

Primary care electronic practice management systems.

Method of extraction

To identify how many patients with CMD are provided follow up, recall records need to be extracted. Feasibility testing of this measure only identified the PHQ-9 questionnaire as a recall record that was directly related to a CMD.

Key issues and challenges for data management

Practice activity/systems for regular follow up Patient response to follow up Availability of services/providers; coordination of services for patient follow up.

Appraisal of the measure

Development approach

Measure defined and feasibility of implementation has been tested. This measure is part of a suite of 11 measures the WSoM developed. The process followed to develop this set of measures is summarized below: Priority areas for measure development were identified in consultation with the College, MoH, PPP and the wider primary health care sector. A measure development template was devised, based on a measure appraisal tool (the sieve). The template was populated and specifications for each measure were refined through discussions. Generic implementation plans were developed. Compass field tested indicator on a sample of 5 practices.

Other items

Owner details

Reference number


Date of entry to library

2012-05-29 11:43:27

Owner (Organisation name)

Royal New Zealand College of General Practitioners

Owner (Email contact)


Creator (Organisation name)

Primary Health Care Quality Research Unit, Wellington School of Medicine and Health Sciences, University of Otago

Creator (Email contact)