Bipolar Disorder in Later Life

11 Specialized Care Delivery for the Older Adult: Quality of Care

chapter eleven Specialized Care Delivery for the Older Adult Quality of Care amy m. kilbourne, ph.d., m.p.h., and harold a. pincus, m.d. Despite the existence of clinical practice guidelines, the quality of care and subsequent outcomes for older persons with bipolar disorder remain suboptimal (Bauer et al. 2002; Kilbourne 2005a). Moreover, patients with bipolar disorder are more likely to have medical comorbidities than the general patient population (Kilbourne et al. 2004a), and subsequent medical and preventive care may be lacking as well (Druss et al. 2001). In this chapter we review the current knowledge on the quality of psychiatric care for older patients with bipolar disorder. We then propose a new paradigm in thinking about the quality of care and quality improvement for these older patients. This new approach involves (1) assessing the quality of care, using performance measures; (2) adapting guideline-based treatment models designed to reduce system-level barriers to appropriate care; and (3) translating and implementing such models into “real-world” settings. Ultimately, measuring quality is the foundation for improving quality, as the monitoring of performance is a key tool in evaluating quality improvement initiatives. Performance measures also provide the means by which good quality of care for older patients with bipolar disorder can be “indexed ” as an important benchmark for which health care providers and other administrators can strive. quality of care for older persons with bipolar disorder: current evidence Outcomes for older persons with bipolar disorder remain suboptimal (Bauer et al. 2001a), even with the availability of efficacious pharmacotherapy (Suppes et al. 2001; Wyatt et al. 2001) and practice guidelines (American Psychiatric Association 1994, 2002; Bauer et al. 1999; Goodwin 2003; Suppes et al. 2001). Without adequate treatment, a 25-year-old person with bipolar disorder can expect to lose 14 years of major effective activity and 9 years of life (Bauer et al. 2002; U.S. Department of Health, Education, and Welfare 1979). The Donabedian quality-of-care model describes a framework in which health care structural, or system, factors influence the processes of care (which typically constitute measures of “quality of care”), which, in turn, influence patients’ health outcomes (Donabedian et al. 1982). Hence, improving quality, especially processes of care, for older individuals with bipolar disorder should be a key focus of treatment. In the findings described below, “older age” was defined as 50 years or older, in part because of the potential years of life lost resulting from the destructive effects (e.g., suicide) of inadequately treated bipolar disorder (Bauer et al. 2002; Kilbourne et al. 2004a). Quality of Care Is Suboptimal Recent evidence suggests that older patients with bipolar disorder are less likely than younger patients to receive adequate quality of care. In a recently completed study of Department of Veterans Affairs (VA) patients from the mid-Atlantic region, the quality of care for older versus younger patients with bipolar disorder was evaluated using indicators of the minimum necessary standard of care (Kilbourne 2005a). These quality indicators included adequate pharmacotherapy (i.e., prescription of a mood stabilizer within the same year as the bipolar disorder diagnosis), outpatient follow-up care (receipt of an outpatient visit ⱕ490 days from a previous visit), and adequate post-hospitalization care (receipt of an outpatient follow-up visit ⱕ430 days after discharge), all of which represent appropriate care based on American Psychiatric Association and VA practice guidelines for the vast majority of patients diagnosed with bipolar disorder, regardless of current mood state (American Psychiatric Association 1994, 2002; Bauer et al. 1999). Overall, of 2,958 patients in the VA sample , 70.9% received a first-line mood stabilizer (lithium, divalproex / valproic acid, carbamazepine, or lamotrigine) and 65.8% received an outpatient mental health visit within 90 days. Of the 2,958 patients, 629 had a psychiatric hospitalization, and 196 s p e c i a l i z e d c a r e d e l i v e r y a n d r e s e a r c h of those, 53.1% received an outpatient visit on or within 30 days of discharge. Older patients (=50 years) were less likely than their younger counterparts to receive a mood stabilizer and less likely to receive outpatient care within 90 days, after controlling for patient factors and comorbidity. There was no difference in post-hospitalization follow-up care by age. Nonetheless, these results...