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Risk Assessment of People with Common Mental Disorders with a Focus on Depression

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 was developed to provide information on the proportion of patients with a diagnosis of a depression that have been assessed for risk of self harm or suicide. It is intended to facilitate discussion about the feasibility of undertaking self harm and suicide risk assessment of patients with CMD, as recommended by best practice guidelines and to identify any related professional and technical issues. This measure is part of a suite of five WSoM mental health indicators (common mental disorders and depression).

Rationale for selection

Patients presenting with depression have a risk of self-harm. Best practice involves quantifying that risk and managing the risk appropriately. The appropriate identification of common mental disorders (CMD) and management of depression in primary health care is a current national priority . These disorders have been the subject of a recent national guideline which supports risk assessment[3]

Type of measure

Process

Domain(s) of quality

Effectiveness, Equity and access, Safety

Application and interpretation of the measure

Stated intent of the measure

The intent of the measure is to follow best practice guidelines and ensure that patients presenting with common mental disorders have a suicide risk assessment; and to identify those at greater risk of suicide.

Caveats - Considerations

Risk assessment can be complex and the use of a standardised method is not always possible and it does not always ensure risk has been adequately assessed. Risk assessment can be recorded by a variety of methods and data extraction can be problematic, particularly if recording through free-text clinical notes. Risk is often coded as free text and therefore standard instruments may not pick up the recorded risk assessments. Furthermore, data may not be recorded at the patient’s request because of potential insurance or legal issues. Data from this measure is, therefore not expected to provide robust data on levels of risk assessments at a practice level. If a consistent approach to coding is used within a practice, data can be more easily extracted and used for a practice to reflect upon best practice for risk management. Therefore, for this measure to be useful it is highly recommended that practices have an explicit and standardised approach to READ coding common mental disorders, as well as to recording risk assessments.

Links to other measures

Prevalence of common mental disorders in (i) adults and (ii) children Prescription of selective serotonin re-uptake inhibitors for the management of common mental disorders Follow up of patients with common mental disorders

Level of health care delivery/setting

A single primary care facility

Target population

Adults – over the age of 18 years

Stratification by vulnerable populations

Stratification by ethnicity and socio-economic status may be of interest, particularly if as the domain of quality suggest, this measure is addressing equity and access issues.

Associated incentives

Use of this measure is linked to: • MOPS • Cornerstone

Possible sources of bias or confounding

It is clear there is wide variation in both the use of particular READ codes and also how commonly READ coding occurs at all. Common mental health disorders are often identified in consultations where some other issue is more likely to be coded e.g. chronic pain, terminal illness, and chronic illness. The extent to which multiple READ codes are attached to a single person or a patient encounter will affect this measure. Screening for risk can occur and be recorded in a variety of manners. Risk assessment can be recorded as free text, as a READ code or as a screening term – or by the use of a standardised instrument such as the K10 or PHQ9.

Calculation of the measure

Output of calculation

Percentage of patients with a diagnosis of a depression with a recorded risk assessment.

Numerator description

Patients with a suicide risk recorded

Numerator exclusions

When an active decision is made, either as a result of patient request or health professional choice, not to record a diagnosis of CMD in the patient record.

Denominator description

Funded patients with a depression READ code recorded

Denominator exclusions

Non-funded patients. When an active decision is made, either as a result of patient request or health professional choice, not to record a diagnosis of CMD in the patient record.

Time period

One year

Criteria/standard for optimal performance

All patients diagnosed with a new depressive disorder should have an associated assessment of risk. Ideally this should be noted in their patient record. Data source Primary care electronic practice management systems.

Method of extraction

Depression: The codes identified below are those which encompass the term depression. 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.

Risk assessment can be recorded as a READ code. If the risk assessment is recorded in the free text, data extraction becomes problematic. READ Codes associated with risk assessment:

146A.00,1B19.11,1BD3.00,TK.15,TK60.00,U2.14,U2.15,146A.00,1B19.11,1BD3.00,1BD4.00,TK.00,TK.14,TK.15,TK60.00,U2.14

Screening terms may also be associated with risk assessment:

DEPR  ,Depression, EPDS ,  Edinburgh Postnatal Depression, POST,	EPNDS, GAD7,GAD-7, Questionnaire KES10,  Kes10 Questionnaire, KDS,	Kessler Distress, MTS	Mental Test Score

Key issues and challenges for data management

Risk assessment can be recorded as a READ code. If the risk assessment is recorded in the free text, data extraction becomes problematic. General Practice sporadically records the presence of suicide risk in patients using a number of different READ codes. At present, within most Practice Management Systems there is no apparent code that can be used to identify the absence of a suicide risk, or that risk has been assessed but is insignificant. This makes it difficult to introduce any READ code based process for identifying when a patient without risk as been assessed. The long term nature of common mental disorders makes it difficult to identify ‘episodes’. It is therefore suggested to assume that any patient that had a depression related READ code recorded within the twelve month period had a new episode. For some patients this will be counting episodes that had begun in a previous period, and for others, this will be some that have depression marked as long term, but have a recurrence of active management by general practice.

Appraisal of the measure

Availability of evidence to support application of the measure

Measure is formulated on and underpinned by evidence from a published systematic review, meta-analysis, or other peer-reviewed synthesis of clinical evidence relating to the area of focus., The measure has been reviewed using the Sieve Tool and a report is available.

Evidence of feasibility and reliability of implementation

Validity - The measure has been demonstrated to be valid (i.e. it measures what it purports to).

Development approach

Measure defined and feasibility of implementation has been tested. This measure is part of a suite of 11 measures the WSoM developed[1]. 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 four practices[2].

Other items

Links to educational activities

WSM, BMJ, BPAC, RNZCGP

Owner details

Reference number

1826

Date of entry to library

2012-07-30 11:22:58

Owner (Organisation name)

Royal New Zealand College of General Practitioners

Owner (Email contact)

jane.o’hallahan@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