Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Objectives: Depression treatment requires close monitoring to achieve optimal, long-term control. Use of multiple sources of care may adversely affect coordination and continuity of depression treatment, and might also influence provider- and system-level performance measures as non-VA services may not be captured. The study has two objectives: 1) to examine utilization patterns of VA depressed primary care patients using data on VA and non-VA care to assess the potential impact of dual use on depression care and outcomes; and 2) to examine patient factors associated with use of non-VA care.

Methods: We used the baseline sample from a group randomized trial of depression collaborative care conducted in nine VA primary care practices in five states. We enrolled 760 randomly sampled depressed patients (Patient Health Questionnaire-9 >10) with at least one primary care visit in the previous 12 months. Utilization measures included VA and non-VA outpatient visits for physical and mental health problems in the prior 6 months. We used self-report measures from baseline computer-assisted telephone interviews.

Results: Overall, 45% of VA depressed primary care patients utilized non-VA care. Dual users had significantly more total outpatient visits for physical health than VA-only users (5.00 vs. 2.47, p <0.001), but similar numbers of visits in VA (2.14 vs. 2.47, p=0.307). Dual and VA-only users had similar numbers of outpatient mental health visits (1.42 vs 1.36, p=0.87), with majority of visits for dual users made in VA (1.30 visits). Factors associated with dual use were urban clinic location, having other insurance coverage, and dissatisfaction with care. Health status, medical comorbidity, depression PHQ-9 score, and alcohol use were not associated with dual use, with the exception that PTSD was a significant factor associated with use of non-VA outpatient care for mental health services.

Conclusions: Almost half of depressed primary care patients used non-VA care, with most of their non-VA use for physical rather than mental problems. Access to other health care resources and dissatisfaction of care are major factors associated with use of non-VA care. Non-VA use could potentially impact depression treatment in primary care and may have differential effects on care management for chronic disease and mental health care. Greater reliance on VA outpatient mental health services may reflect limited public and private coverage for these services outside VA. Inaccuracies in mental health performance measures are unlikely to be due to lack of capture of non-VA mental health care. Development of strategies for sharing information between VA and non-VA providers will improve care for all dual users.