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Prescription of Selective Serotonin Re-uptake Inhibitor (SSRI) for the Management of People with Common Mental Disorders

Basic Facts

Stage of development

Tested

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). The measure was developed to quantify the use of selective serotonin re-uptake inhibitor (SSRI) prescriptions in general practice across the spectrum of common mental disorders. This measure does not currently address the appropriateness of prescribing, although quantifying the use of SSRIs may be a step towards supporting its appropriate prescribing.

Rationale for selection

Recent national guidelines support appropriate pharmacological management of depression. SSRIs are commonly used in the treatment of common mental disorders. In order to reflect on their use within practice it is necessary to first quantify their use. The age range specified for use of this indicator reflects the issues regarding the use of SSRIs in younger people and children and the need for caution in their use in older adults

Type of measure

Outcomes

Domain(s) of quality

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

Application and interpretation of the measure

Stated intent of the measure

This is a quality improvement tool to enable practices to reflect on prescribing SSRIs within the practice and to align this with best practice.

Caveats - Considerations

Comparison between practices or practitioners not currently meaningful Due to wide variation in coding and in management patterns of common mental disorders, comparisons between practices or practitioners would not be meaningful at this time. Limited insights into how CMDs are currently managed This measure does not describe all the methods used to manage people with common mental disorders, e.g. other medication, psychotherapy, referral to secondary services etc., and therefore provides a very limited view of how common mental disorders are managed. It is therefore advisable that this measure is understood within its specific practice context. It is most useful for self-monitoring purposes. The difference between the number of SSRI prescriptions for funded patients and funded patients with a CMD recorded with an SSRI prescribed may be an interesting issue to explore.

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

Level of health care delivery/setting

Used at the practice individual practitioner levels.

Target population

Funded adults (18 – 65 yrs)

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

There are regional variations in prescribing which are not completely understood. Variations may be driven by local clinical leaders and may reflect local practice. Comparisons across regions may therefore be difficult. Patients who refuse or have contraindications for treatment with an SSRI should be excluded from the denominator, but it is not currently possible to identify these patients and therefore we understand the results will be biased.

Calculation of the measure

Output of calculation

Percentage of patients with a common mental disorder receiving an SSRI prescription.

Numerator description

Patients with a common mental disorder READ code recorded and prescribed a selective serotonin re-uptake inhibitor within the period.

Numerator exclusions

Non-funded patients.

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

Non-funded patients. Patients who refuse or have contraindications for treatment with an SSRI.

Time period

1 year.

Criteria/standard for optimal performance

Patients with READ codes for CMD should be considered for therapy with an SSRI. There is no known standard for prescribing of SSRIs in a primary care setting and therefore it is impossible to define optimal levels of care.

Data source

Primary care electronic practice management systems.

Method of extraction

Common mental disorders include a wide variety of conditions including anxiety, depression, substance use disorder and specific phobic disorders. Many of these common mental disorders may overlap with depression, and the denominator needs to be chosen carefully. Possible Read codes Common mental disorders: Common mental disorders include a wide variety of conditions including anxiety, depression, substance use disorder and specific phobic disorders. As these conditions span the whole of the mental disorders READ code hierarchy, high level codes (excluding the codes for ‘mental retardation’) are given below. Where a specified code is suffixed with the wild card symbol (*) all codes directly below that code in the hierarchy should also be included. E0013 E0021 E112* E113* E118. E11y2 E11z2 E130. E135. E2003 E291. E2B. E2B1. Eu204 Eu251 Eu32* Eu33* Eu341 Eu412 1287 1465 1B17.11 TJ90z.00 2257 6891 Patients on medication could have one or several prescriptions for SSRIs during the year. Not every patient will receive a prescription at every appointment, but some may receive a prescription more frequently than three monthly, especially when therapy is initiated. Prescription data Selective serotonin re-uptake inhibitors: Citalopram Escitalopram# Fluoxetine Paroxetine Sertraline#

Key issues and challenges for data management

Coding variability It is clear there is wide variation between practices in both the use of particular READ codes and also how commonly READ coding occurs at all. For practices to be able to undertake self-monitoring of the measure, an agreed common method of recording must be determined and implemented. This will allow them to run queries or use tools inside the PMS to generate the data. Common mental disorders are often identified in consultations where some other issue is more likely to be coded e.g. chronic pain, terminal illness, chronic illness. The extent to which multiple READ codes are attached to a single person or a patient encounter will affect this measure. Unclear correlation between data and medication use Data relating to prescribing may be incomplete, new medications can be introduced and affect prescribing patterns. Not all prescriptions written are collected, and not all prescriptions collected are taken. Often medication is not taken for the prescribed length of time or in the prescribed manner. Therefore, data from the PMS may be a measure of practitioner behaviour but will not accurately reflect with how those medications are actually used. Exclusion challenge Patients who refuse or have contraindications for treatment with an SSRI should be excluded from the denominator. However, it is not currently possible to identify these patients and therefore we understand the results will be biased. Long-term nature of common mental disorders Once a condition has been recorded as long term in the patient management system, it is uncommon for clinicians to classify consequent presentations as relating to that condition. It is therefore difficult to identify “episodes” for mental health conditions. Multiple conditions recorded Common mental disorders are often identified in consultations where some other issue is more likely to be coded e.g. chronic pain, terminal illness, chronic illness. The extent to which multiple READ codes are attached to a single person or a patient encounter will affect this measure. - See more at: https://www.hqmnz.org.nz/measures/mental-health/prescription-of-selective-serotonin-re-uptake-inhibitor-ssri-for-the-management-of-people-with-common-mental-disorders#sthash.Zy5uOmGT.dpuf

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: 1. Priority areas for measure development were identified in consultation with the College, MoH, PPP and the wider primary health care sector. 2. A measure development template was devised, based on a measure appraisal tool (the sieve). 3. The template was populated and specifications for each measure were refined through discussions. 4. Generic implementation plans were developed. Compass field tested indicator on a sample of 5 practices.

Other items

Owner details

Reference number

784

Date of entry to library

2012-05-31 09:55:03

Owner (Organisation name)

Royal New Zealand College of General Practitioners

Owner (Email contact)

quality@rnzcgp.org.nz

Creator (Organisation name)

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

Creator (Email contact)

roshan.perera@otago.ac.nz