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## Complete Summary

#### TITLE

Bipolar disorder: percentage of patients with Bipolar I Disorder with
depressive symptoms and behaviors who have evidence of use of a mood
stabilizing or antimanic agent during the first 12 weeks of
pharmacotherapy treatment.

#### SOURCE(S)

STABLE (STAndards for BipoLar Excellence) performance measures. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. various p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Process

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of patients with Bipolar I
Disorder with depressive symptoms and behaviors who have evidence of use
of a mood stabilizing or antimanic agent during the first 12 weeks of
pharmacotherapy treatment.

#### RATIONALE

**Goals of Acute Treatment: Bipolar Disorder Depressive Episodes**

-   Remission of symptoms with a full return to usual levels of
    psychosocial functioning.

-   Avoid mood destabilization and precipitating a manic or hypomanic
    episode.

**Initial Treatment Considerations**

-   Treatment selection is dependent on illness severity, associated
    clinical features and patient preference.

-   Treatment choice should also consider patient history, potential
    side effects and individual therapeutic response to specific
    pharmacotherapy agents.

**Initial Treatment Recommendations**

-   Guidelines suggest lithium or lamotrigine alone or for patients
    refractory to monotherapy in combination with an atypical
    antipsychotic or lithium or lamotrigine alone or in combination,
    simultaneously, with an antidepressant.

-   For patients refractory to the combinations above, guideline
    recommendations include the use of additional antimanic and
    antipsychotic agents.

-   The use of antidepressants even in combination with a mood
    stabilizing or antimanic agent has been associated with some
    controversy over their potential to induce a mood switch.

#### PRIMARY CLINICAL COMPONENT

Bipolar I Disorder; depression; mood stabilizing agent; antimanic agent

#### DENOMINATOR DESCRIPTION

Patients with Bipolar I Disorder with symptoms or episodes that involve
depression (see the related \"Denominator Inclusions/Exclusions\" field
in the Complete Summary)

#### NUMERATOR DESCRIPTION

Patients with evidence of use of a mood stabilizing or antimanic agent
during the first 12 weeks of pharmacotherapy treatment (see the related
\"Numerator Inclusions/Exclusions\" field in the Complete Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Unspecified

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Behavioral Health Care\
Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

Age greater than or equal to 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Unspecified

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

See the \"Rationale\" field.

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

Patients with diagnosis of Bipolar I Disorder with depression:
International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) or Diagnostic and Statistical Manual of Mental
Disorders, Fourth Revision, Text Revision (DSM-IV-TR): 296.5x

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Patients 18 years of age or older with an initial diagnosis or new
presentation/episode of bipolar disorder

AND

Documentation of Bipolar I Disorder with depressive symptoms, behaviors
or episodes; to include at least one of the following:

-   Code 296.5x documented in body of chart, such as a pre-printed form
    completed by a clinician and/or codes documented in chart
    notes/forms

-   Diagnosis or impression documented in chart indicating Bipolar I
    Disorder with current depressive symptoms, behaviors or episodes

**Exclusions**\
Exclude case from denominator population if numerator-required
pharmacotherapy is not prescribed and the reason(s) for not prescribing
is documented in chart, such as, not clinically indicated; not
prescribed for related medical reasons (allergy, drug interaction); or
not prescribed for patient reasons (patient refusal), etc.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Encounter

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Documented treatment with at least one pharmacotherapy agent with mood
stabilizing or antimanic properties (Refer to the \"Data Dictionary
Reference\" in the original measure documentation for specified
medications.)

AND

Timeframe:\
Documentation of the stated pharmacotherapy must be within the first 12
weeks of treatment.

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Fixed time period

#### DATA SOURCE

Administrative data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a higher score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

-   The STABLE measures were developed using the RAND Appropriateness
    Method and have been shown to have content validity and face
    validity.

-   Data feasibility testing was performed to determine the availability
    of the data elements required in the measure numerator and
    denominator specifications.

-   Inter-abstractor reliability testing was performed to assess the
    data collection strategy. The data collection strategy included data
    collection forms; data dictionary references and abstractor
    instructions.

-   A field study was conducted to determine measure conformance in an
    appropriate convenience sample.

Refer to the references listed below for further information.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

STABLE performance measures: data feasibility testing & results. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. 2 p.

STABLE performance measures: development process & validity ratings.
Boston (MA): Center for Quality Assessment and Improvement in Mental
Health; 2007. 3 p.

STABLE performance measures: field study process & conformance findings.
Boston (MA): Center for Quality Assessment and Improvement in Mental
Health; 2007. 3 p.

STABLE performance measures: inter-abstractor reliability testing &
results. Boston (MA): Center for Quality Assessment and Improvement in
Mental Health; 2007. 2 p.

### Identifying Information

#### ORIGINAL TITLE

Bipolar disorder: use of mood stabilizing or antimanic agent in BD I
with depression.

#### MEASURE COLLECTION

[Standards for Bipolar Excellence (STABLE) Performance
Measures](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1995&doc=11485)

#### SUBMITTER

Center for Quality Assessment and Improvement in Mental Health

#### DEVELOPER

STABLE Project National Coordinating Council

#### FUNDING SOURCE(S)

AstraZeneca LLP, Wilmington, Delaware, provided financial sponsorship
for the STABLE Project. They did not otherwise participate in the
development of either the measures or toolkit.

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

The STABLE [National Coordinating Council
(NCC)](http://www.cqaimh.org/members.html) was comprised of national
experts in bipolar disorder, psychiatry, primary care, and performance
improvement. The NCC guided and directed the STABLE Project. NCC members
agreed to serve with the understanding that the STABLE Performance
Measures and Resource Toolkit would be fully transparent and available
without cost in the public domain.

[EPI-Q, Inc.](http://www.epi-q.com/index.html), is a consulting company
providing practice-based outcomes research, pharmacoeconomic studies,
and quality improvement services. EPI-Q managed the STABLE Project.

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

Unspecified

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2007 Jan

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

STABLE (STAndards for BipoLar Excellence) performance measures. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. various p.

#### MEASURE AVAILABILITY

The individual measure, \"Bipolar Disorder: Use of Mood Stabilizing or
Antimanic Agent in BD I with Depression,\" is published in \"STABLE
(STAndards for BipoLar Excellence) Performance Measures.\" This document
is available in Portable Document Format (PDF) from the [Center for
Quality Assessment and Improvement in Mental Health (CQAIMH) Web
site](http://www.cqaimh.org/stable.html).

#### COMPANION DOCUMENTS

The following is available:

-   STABLE National Coordinating Council Resource Toolkit Workgroup.
    STABLE resource toolkit. Boston (MA): Center for Quality Assessment
    and Improvement in Mental Health; 2007 Mar. 67 p. This document is
    available in Portable Document Format (PDF) from the [Center for
    Quality Assessment and Improvement in Mental Health (CQAIMH) Web
    site](http://www.cqaimh.org/stable.html).

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on January 10, 2008.
The information was verified by the measure developer on April 14, 2008.

#### COPYRIGHT STATEMENT

The STABLE materials published on this Web site are copyrighted by
CQAIMH. They may be used for research, teaching, and quality
measurement/improvement activities -- provided the following:

-   The materials are not sold, distributed or licensed for commercial
    purposes.

-   CQAIMH\'s copyright is acknowledged in reproductions of these
    materials.

-   Modifications to the materials are not made without CQAIMH\'s
    permission.

### Disclaimer

#### NQMC DISCLAIMER

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developers, and are screened solely to determine that they meet the NQMC
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<http://www.qualitymeasures.ahrq.gov/about/inclusion.aspx>.

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Readers with questions regarding measure content are directed to contact
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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008