Association Between Quality Measures and Mortality in Individuals With Co-Occurring Mental Health and Substance Use Disorders

Posted on: November 21, 2016

Recently, a group of my colleagues and I completed an article for the Journal of Substance Abuse Treatment: “Association Between Quality Measures and Mortality in Individuals With Co-Occurring Mental Health and Substance Use Disorders.” We were concerned that individuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. In addition, the relationship between measures of treatment quality and mortality for these individuals is unknown. Our study led us to the following, as described in our article’s introduction:

“Mental and substance use disorders are leading causes of preventable deaths (Centers for Disease Control and Prevention, 2014; National Institute on Drug Abuse, 2012; Walker, McGee, & Druss, 2015). Compared to the general population, individuals with mental disorders, substance use disorders and co-occurring mental and substance use disorders have increased mortality rates, with the highest rates found in clinical samples and among individuals with co-occurring psychosis and substance use disorders (Degenhardt, Bucello, et al., 2011; Degenhardt, Singleton, et al., 2011; Dickey, Dembling, Azeni, & Normand, 2004; Mathers et al., 2013; Muhuri & Gfroerer, 2011; Roerecke & Rehm, 2013; Rosen, Kuhn, Greenbaum, & Drescher, 2008; Singleton et al., 2009; Walker et al., 2015). Reducing the premature mortality associated with mental and substance use disorders is an ongoing public health challenge and an important goal for health care systems. While health care systems have little influence over some causes of premature mortality, such as accidents and homicides, they do have control over the quality of the care they deliver, which may also influence mortality, through earlier recognition of worsening physical health symptoms or by influencing patients’ risk behaviors by providing effective treatment. If health care systems are to play a role in reducing premature deaths among persons with co-occurring disorders, then is important to know whether or not a relationship exists between quality of care and mortality. However, it is unknown whether and how the quality of healthcare impacts mortality for individuals with co-occurring disorders.

“Understanding the link between healthcare quality and mortality requires scientifically rigorous and valid measures. Valid measures are also essential for quality improvement efforts. Quality of care is typically measured using either measures of process, which assess what is happening in the healthcare setting, or outcomes, which assess the impact of the care on the patient’s symptoms or functioning. While improved patient outcomes is the gold standard for measuring quality, using outcome based quality measures is potentially problematic for at least three reasons.

“Obtaining outcome data can be expensive and difficult to collect; outcome data cannot be used to identify which care processes need to be improved, and outcome measures require risk adjustment for illness severity. Process-based measures, which can be operationalized using readily-available administrative data, are an important source of information about where performance falls short and quality improvement efforts should be targeted. Process-based measures can also be reported in real-time, allowing health care systems to take timely corrective action.

“There are no reliable and valid process-based, quality measures that have been developed and tested for individuals with co-occurring disorders (Dausey, Pincus, & Herrell, 2009). Thus, although care for individuals with mental and/or substance use disorders varies across treatment systems (Watkins, Pincus, et al., 2011; Watkins et al., 2015), and settings (Charbonneau et al., 2003; Harris et al., 2009; Kilbourne et al., 2010; Lee et al., 2014), differences in the process of care have not been linked to differences in patient outcomes, and there are no process-based quality measures that predict improved outcomes. Thus it is unknown whether improvements in treatment process would lead to improvements in patient outcomes. Existing process-based behavioral health quality measures focus on either mental or substance use disorders and have not been validated in a population with comorbid disorders (Harris, Gupta, et al., 2015). Unless process measures are associated with clinically meaningful outcomes, using them to monitor and improve performance will not result in the expected improvements in outcomes.

“Given the importance of mortality as a clinical outcome and the need for validated quality measures applicable to this population, we examined the association of 5 potential quality measures with one- and two-year mortality among persons with co-occurring disorders. If these process-based quality measures are associated with decreased mortality, it suggests that health care systems could devise specific strategies to improve performance on these measures and, by doing so, have some assurance that the care they are providing is linked to improvements in this essential patient outcome. It would also provide initial evidence for the predictive validity of the measures.

You may see an abstract of “Association Between Quality Measures and Mortality in Individuals With Co-Occurring Mental Health and Substance Use Disorders” here, where you will also be able to download a PDF of the full article (with a charge payable to the Journal of Substance Abuse Treatment).

Posted in: Co-Occurring Disorders