ACP Committee Identifies Just One of Eight Performance Measures as Valid for Major Depressive Disorder

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ACP Performance Measurement Committee works to ensure performance measures are clinically sound, evidence-based and tested appropriately

March 22, 2024 (ACP) -- As part of its commitment to relieve burden on physicians in meeting requirements for unnecessary performance measures, the American College of Physicians Performance Measurement Committee recently reviewed measures that seek to evaluate quality of care for people with major depressive disorder.

The committee is charged with assessing the validity of performance measures used in Centers for Medicare & Medicaid Services (CMS) programs. To be supported by ACP, a performance measure must be clinically sound, evidence-based and tested appropriately with valid and reliable results. In a paper published in the Annals of Internal Medicine, the committee concluded that just one of eight measures that seek to evaluate screening, diagnosis and treatment of major depressive disorder ticks all of these boxes.

A measure looking at preventive care and screening for depression incorporates follow-up, and while this seems important at face value, nuances exist, explained Dr. Rebecca Andrews, vice chair of the ACP Performance Measurement Committee and chair elect of the ACP Board of Regents.

"What if it was a mild case of depression, and there was no follow-up because it was secondary to an acute life event?" said Andrews, who is set to serve as committee chair next year. "There is no way to pull that patient out of the measure and say we don't need follow-up."

Additionally, the committee reviewed outcome measures evaluating remission. The time periods for remission cited in the performance measures are arbitrary, she noted. "There is no data that supports the six- to 12-month time frames for remission from major depressive disorder," she said.

There are also other gaps in these measures. "If a patient presents and scores a 17 on the Depression Utilization of the PHQ-9 (Patient Health Questionnaire-9) tool and I get that score down to a 6, that is significant, but it doesn't meet the metric of remission, which is set at 5," she said.

One of the current evidence-based treatments for major depression is psychotherapy; however, this does not typically require a referral. Patients may find therapists anywhere, even online. "They may be getting adequate treatment, but there is no way to capture it with a measure," Andrews said.

The sole performance measure that passed muster in the new assessment focused on suicide risk assessment. "It is based on a methodology that we can support, is scientifically sound, highly clinically relevant and has a standardized code that says, 'I have done this,' which can be captured by an electronic medical record with no increased burden for physicians," she said.

The committee recently published a similar report on osteoporosis performance measures and has plans to take on several more conditions down the road. "We hope that organizations like CMS and others will read these papers and understand why these measures aren't working," Andrews said.

She added: "Performance measures are great ways to identify how we can provide better care, but they must be steeped in evidence-based medicine and can't be burdensome to the doctor. It's not that we shouldn't measure performance; it's that we have to do better at creating measures that have really good evidence and aren't burdensome to physicians."

Her message to internal medicine physicians is that "we hear you, and we know how much you are already doing, and we know how burdensome measures can be," she said. "Help us advocate. Read the papers, talk to insurance companies and explain what ACP is doing to your colleagues."

More Information

The position paper, "Quality Indicators for Major Depressive Disorder in Adults: A Review of Performance Measures by the American College of Physicians," is available on the Annals of Internal Medicine website.

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