VA Health Care: Improvements Needed to the Monitoring of Antidepressant Use for Major Depressive Disorder and the Accuracy of Suicide Data
Published: 2015-06-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2013, VA estimated that about 1.5 million veterans required mental health care, including for MDD. MDD is a debilitating mental illness related to reduced quality of life and increased risk for suicide. VA also plays a role in suicide risk assessment and prevention.
This testimony addresses the extent to which (1) veterans with MDD who are prescribed an antidepressant receive recommended care and (2) VAMCs are collecting information on veteran suicides as required by VA. The testimony is based on GAO's November 2014 report, VA Health Care: Improvements Needed in Monitoring Antidepressant Use for Major Depressive Disorder and in Increasing Accuracy of Suicide Data ( GAO-15-55 ). For that report GAO analyzed VA data, interviewed VA officials, and conducted site visits to six VAMCs selected based on geography and population served. GAO also reviewed randomly selected medical records for five veterans from each of the six VAMCs, for veterans diagnosed with MDD and prescribed an antidepressant in 2012, as well as all completed BHAP templates. The results cannot be generalized across VA. GAO followed up in May 2015 to determine the status of GAO's previous recommendations.
section_title: What GAO Found
paragraphs: Department of Veterans Affairs (VA) policy states that antidepressant treatment must be consistent with VA's current clinical practice guideline (CPG) for major depressive disorder (MDD); however, GAO's recent review of 30 veterans' medical records found that most contained deviations. For example, although the CPG recommends that veterans' depressive symptoms be assessed at 4-6 weeks after initiation of antidepressant treatment using a standardized assessment tool, 26 of the 30 veterans were not assessed in this manner within this time frame. Additionally, 10 veterans did not receive follow up within the time frame recommended in the CPG. GAO found that VA (1) does not have a system-wide process in place to identify and fully assess the extent to which veterans with MDD who have been prescribed antidepressants are receiving care as recommended in the CPG and (2) does not know whether appropriate actions are being taken by VA medical centers (VAMC) to mitigate potentially significant risks to veterans. GAO also found that VA's data may underestimate the prevalence of MDD among veterans being treated through VA as a result of imprecise coding by clinicians, further complicating VA's ability to know if veterans with MDD are receiving care consistent with the CPG.
GAO's recent work has found that the demographic and clinical data that VA collects on veteran suicides were not always complete, accurate, or consistent. VA's Behavioral Health Autopsy Program (BHAP) is a quality initiative to improve VA's suicide prevention efforts by identifying information that VA can use to develop policy to help prevent future suicides. The BHAP templates are a mechanism by which VA collects suicide data from VAMCs' review of veteran medical records. GAO's review of the 63 completed BHAP templates at five VAMCs found that (1) over half of the templates that VAMCs submitted to VA had incomplete or inaccurate data, and (2) VAMCs submitted inconsistent information because they interpreted VA's guidance differently. Lack of complete, accurate, and consistent data—coupled with GAO's finding of poor oversight of the review of BHAP templates—can inhibit VA's ability to identify, evaluate, and improve ways to better inform its suicide prevention efforts.
section_title: What GAO Recommends
paragraphs: GAO recommended that VA implement processes to assess deviations from recommended care; identify and address MDD coding issues; and implement processes to improve veteran suicide data. VA has made progress on these recommendations and has fully implemented one.

section_title: Letter
paragraphs: I am pleased to be here to discuss our recent work on the monitoring of  veterans with major depressive disorder (MDD) who were prescribed an  antidepressant and data collection efforts by the Department of Veterans  Affairs (VA) on veteran suicides. In 2013, VA estimated that about   1.5 million veterans required mental health services, including for MDD.  MDD is a particularly debilitating mental illness and is associated with  reduced quality of life, reduced productivity, and increased risk for  suicide. These negative effects underscore the importance for veterans  of timely, evidence-based assessment for and treatment of MDD, which  may include medications such as antidepressants, psychotherapy, or a  combination of both. Based on our previous analysis of VA data from  veterans’ medical records and administrative sources, 532,222 veterans  had a diagnosis of MDD from fiscal years 2009 through 2013, and among  those veterans, about 499,000 (94 percent) veterans were prescribed at  least one antidepressant by a VA provider. According to VA, the  prevalence of MDD among veterans being treated in VA primary care  settings is higher than that among the general population.
In addition to providing ongoing care to veterans with MDD, VA plays a  role in suicide risk assessment and prevention among veterans.  According to VA in a June 2013 report, about one-quarter of the 18 to   22 veterans who die by suicide each day were receiving care through  VA.veterans, which include substance use disorder, physical impairments,  previous suicide attempts, and depression. Additionally, life stressors,  such as marital or financial problems, contribute to a veteran’s risk of  suicide.
Research has identified numerous risk factors for suicide among  Given the debilitating effects that depression can have on veterans’  quality of life, VA’s monitoring of veterans with MDD is critical to ensuring  that they receive care that is associated with positive health care  outcomes. Additionally, the relatively high veteran suicide rate makes it  important that VA use data that it collects related to veteran suicides to  drive its prevention efforts. Today I will address two areas: the extent to  which (1) veterans with MDD who are prescribed an antidepressant  receive recommended care, and (2) VA medical centers (VAMC) are  collecting information on veteran suicides as required by VA.
My statement is based on a GAO report released in November 2014  examining VA’s monitoring of veterans with MDD who have been  prescribed an antidepressant and the use of suicide data within VA. For  our work examining the care received by veterans with MDD who are  prescribed an antidepressant, we reviewed VA policy documents and  interviewed VA Central Office officials responsible for developing and  implementing VA mental health policy. We also conducted site visits to six  VAMCs, which we selected for variation in complexity of health care  services offered, geographic location, and number of veterans using   We reviewed a random, nongeneralizeable  mental health services.sample of medical records for 5 veterans treated at each of the 6  VAMCs—for a total of 30 veterans—to assess the extent to which the  antidepressant treatment-related care VAMCs provided was consistent  with three evidence-based treatment recommendations included in VA  guidelines. Results from our medical record review cannot be  generalized to the VAMC or across VAMCs. For our work examining the  data that VA requires VAMCs to collect on veteran suicides, we reviewed  VA policies, guidance, and documents related to VA’s suicide prevention  efforts to identify the data collected by VA staff on veteran suicides. We  also interviewed VA Central Office and VAMC officials responsible for  VA’s suicide prevention program, obtained documents and interviewed  officials regarding the collection of veteran suicide data, and compared  data obtained from VAMCs to information included in the veterans’  medical records and information we obtained from VA Central Office.Results from our review of veteran suicide data can be generalized to the  VAMCs we visited, but cannot be generalized to other VAMCs. In May  2015, in preparation for this statement, we met with VA officials to discuss  the status of VA’s implementation of action plans to address the six  recommendations included in our November 2014 report.
The work on which this statement is based was conducted, with updates  in May 2015, in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives. Further details on our  scope and methodology are included in our report.
subsections: section_title: Background
paragraphs: VA provides care to veterans with mental health needs in VAMC primary  and specialty care clinics. The Uniform Mental Health Services in VA  Medical Centers and Clinics handbook (Handbook), which defines VA’s  minimum clinical requirements for mental health services, requires that  VA facilities provide evidence-based treatment through the administration  of medication, when indicated, consistent with the MDD clinical practice  guideline (CPG) recommendations. The CPG is guidance intended by  VA to reduce current practice variation between clinicians and provide  facilities with a structured framework to help improve patient outcomes,  but should not take the place of the clinician’s clinical judgment. The MDD  CPG includes approximately 200 evidence-based recommendations to  provide information and assist in decision making for clinicians who  provide care for adults with MDD. CPG recommendations describe, for  example, the use of standardized assessments of veterans’ depressive  symptoms as part of an evidence-based treatment plan.
The Handbook requires VAMCs to have a suicide prevention coordinator whose  responsibilities include establishing and maintaining a list of veterans assessed to be at  high risk for suicide; monitoring these veterans; responding to referrals from staff and the  Veterans Crisis Line; and collecting and reporting information on veterans who die by  suicide and who attempt suicide. intended to improve VA’s suicide prevention efforts by identifying  demographic, clinical, and other related information on veteran suicides  that VA Central Office can use to develop policy and procedures to help  prevent future veteran deaths. VA Central Office officials explained that  the BHAP initiative allows them to collect more systematic and  comprehensive information about suicides, including information gleaned  from interviews of family members of those veterans who die by suicide.  VA Central Office has provided suicide prevention coordinators with a  BHAP guide on how to complete the fields in the BHAP template.
section_title: Veterans in Our Review Often Did Not Receive Recommended Care, and VA Lacks Methods to Track Whether Recommended Care Is Provided
paragraphs: Our recent work, based on the three CPG recommendations we selected,  has found almost all of the 30 veterans with MDD in our review who had  been prescribed antidepressants received care that deviated from the  MDD CPG recommendations. For example, we found that although the  CPG recommends that veterans’ depressive symptoms be assessed at   4-6 weeks after initiation of antidepressant treatment using a standard  assessment tool to determine the efficacy of the treatment, 26 of the   30 veterans were not assessed using such a tool within this time frame.  Additionally, 10 veterans did not receive follow up within the time frame  recommended in the CPG. Table 1 below depicts the specific  recommendations we reviewed and the number of veterans that did not  receive care consistent with the corresponding CPG recommendation.
We also found that VA does not always know the extent to which  veterans with MDD who have been prescribed antidepressants are  receiving care as recommended in the CPG, and some clinicians at  VAMCs we visited described instances in which they generally do not  follow the CPG recommendations. For example, officials from two VAMCs  we visited explained that they do not routinely use the nine item Patient  Health Questionnaire (PHQ-9). According to officials at one of these  VAMCs, the standard of care is to conduct a clinical interview and  observation. However, the CPG recommendation states that the PHQ-9  combined with a clinical interview should be used to obtain the necessary  information about symptoms and symptom severity. It also states that the  PHQ-9 improves diagnostic accuracy and aids treatment decisions by  quantifying symptom severity. Additionally, we found that VA Central  Office has not developed a mechanism to determine the extent to which  mental health care delivery in VAMCs conforms to the recommendations  in the MDD CPG. While deviations from recommended practice may be  appropriate in many cases due to clinician discretion, VA has not fully  assessed whether these examples are acceptable deviations from the  CPG. VA Central Office and some VAMCs have implemented limited  methods to determine the extent to which veterans are receiving care that   However, without  is consistent with some of the CPG recommendations.a system-wide process in place to identify and fully assess whether the  care provided is consistent with the CPG, VA does not know the extent to  which veterans with MDD who have been prescribed antidepressants are  receiving care as recommended in the CPG and whether appropriate  actions are taken by VAMCs to mitigate potentially significant risks to  veterans. The CPG is intended to reduce practice variation and help  improve patient outcomes, but without an understanding of the extent to  which veterans are receiving care that is consistent with the CPG, we  concluded that VA may be unable to ensure that it meets the intent of the  CPG and improves veteran health outcomes.
To ensure that veterans are receiving care in accordance with the MDD  CPG, we recommended that VA implement processes to review data on  veterans with MDD who were prescribed antidepressants to evaluate the  level of risk of any deviations from recommended care and remedy those  that could impede veterans’ recovery. VA concurred with our  recommendations and stated that VA would examine associations  between treatment practices and indicators of veteran recovery or  adverse outcomes. VA Central Office officials reviewed whether a cohort  of veterans with MDD received treatment with an antidepressant that was  in line with MDD CPG recommendations. However, in choosing CPG  recommendations to review, VA officials told us that they chose the  recommendations for review based on the ease of obtaining the needed  data and because the antidepressant medication coverage measure is  nationally recognized, rather than based on a methodical review of all of  the CPG recommendations to identify those that may put veterans at risk  and could impede veterans’ recovery if not followed, as we recommended  in our November 2014 report. Therefore, it is not clear whether the CPG  recommendations that VA chose to review were among those that may  put veterans at risk and could impede recovery if not followed. Moreover,  VA has not indicated whether it has implemented a process that will  review CPG recommendations on an ongoing basis to identify deviations  that place veterans at risk and impede recovery. This recommendation  remains open pending further VA action.
Diagnostic coding discrepancies further complicate VA’s ability to know if  veterans with MDD are receiving care consistent with the CPG.  Specifically, we found that for 11 of the 30 veterans’ medical records we  reviewed the clinician coded the encounter as “depression not otherwise  specified,” a less specific code than MDD, even though the clinician  documented a diagnosis of MDD in the veteran’s medical record.  Therefore, VA’s data may not fully reflect the extent to which veterans  have MDD due to a lack of diagnostic coding precision by clinicians, or   As a  the extent to which such discrepancies may permeate VA data. result, VA’s ability to monitor veterans with MDD and assess its  performance in treating veterans as recommended in the MDD CPG and  measuring health outcomes for veterans is further limited because VA  may not be fully aware of the population of veterans with MDD.
VA’s data on the number of veterans with MDD are based on the diagnostic codes  associated with patient encounters.
To address this shortcoming, our report recommended that VA (1) identify  the extent to which there is imprecise diagnostic coding of MDD by  examining encounters with a diagnostic code of “depression not  otherwise specified” and (2) determine and address the factor(s)  contributing to imprecise coding. VA concurred with our recommendations  and stated that they would examine patterns of diagnostic coding among  veterans with new episodes of depression by evaluating diagnosis  patterns and treatment settings, as well as conduct chart reviews for a  sample of veterans to examine the diagnosis in the veteran’s medical  record and the diagnostic code used for the encounter. VA’s review of the  accuracy of diagnostic codes is ongoing. Additionally, during the course  of our review, VA Central Office officials reported that they had  discovered a software mapping error in VA’s medical record system  where selection of MDD as a diagnosis when using a keyword search  function may mistakenly result in the selection of the “depression not  otherwise specified” diagnostic code. While this error has been resolved,  according to VA officials the solution would only apply to encounters  going forward and would not retroactively correct any previous coding  discrepancies. As a result, any such instances would still be coded in  VA’s system as “depression not otherwise specified,” even though these  veterans were diagnosed with MDD, and therefore data VA collected prior  to resolving the software error may still not fully reflect the number of  veterans with MDD.
section_title: Data VA Collects on Veteran Suicides Were Not Always Complete, Accurate, or Consistent
paragraphs: Our recent work has found that demographic, clinical, and other data  submitted to VA Central Office on veteran suicides were not always  completely or correctly entered into the BHAP Post-Mortem Chart  Analysis templates (BHAP templates)—a mechanism by which VA  Central Office collects veteran suicide data from VAMCs’ review of  veterans’ medical records. We found that over half of the 63 BHAP  templates we examined had incomplete or inaccurate information (see   fig. 1).
It is important that VA have complete, accurate, and consistent data  because VA Central Office uses this information to compile internal  reports as part of VA’s quality improvement efforts for its suicide  prevention program, and unreliable data limits VA Central Office’s ability  to develop policy and procedures aimed at preventing veteran deaths.
VA Central Office used veteran enrollment information when compiling  the BHAP report in March 2014. Specifically, VA Central Office included  clinical data in the BHAP report only for veterans utilizing VA services.  However, we found that clinical data for 23 of the 63 BHAP templates we  reviewed would not be included in the report because of missing data,  such as not indicating whether the veteran was enrolled in VA health care  services, even though the veteran had a VA medical record.
Additionally, 40 of the 63 BHAP templates we reviewed included various  data fields where no response was provided, resulting in incomplete data.  For example, for 19 templates, VAMC staff did not enter requested data  as to whether the veteran had all or some of 15 active psychiatric  symptoms within 12 months prior to the veteran’s date of death. These  missing fields are counted as “no” in the report, meaning that the veteran  did not have these symptoms. For at least one BHAP template we  reviewed, the nonresponse for the question about the psychiatric  symptom of isolation would have counted as “no” in the report; however,  officials from the responsible VAMC told us that the veteran did have this  symptom. Furthermore, we found that VAMCs did not always submit  BHAP templates for all veteran suicides known to the facility, as required  by the BHAP guide, and VA Central Office does not have a process in  place to determine whether it is receiving the BHAP templates for all  known veteran suicides. For example, one VAMC had completed 13  BHAP templates at the time of our site visit but had not submitted them;  however, neither the VAMC nor VA Central Office were aware that these  templates had not been submitted until after we requested them from VA  Central Office.
We also found numerous instances of inaccurate data in the 63 BHAP  templates we reviewed. For example, we found 6 BHAP templates that  included a date of death that was incorrect based on information in the  veteran’s medical record. The difference in the dates of death in the  veterans’ medical records and the dates of death in the BHAP templates  ranged from 1 day to 1 year. The accuracy of the date of death recorded  in the BHAP template is important because it is used as a point of  reference to calculate other fields, such as the number of mental health  visits in the last 30 days. Without accurate information, VA cannot use  this information to determine whether policies or procedures need to be  changed to ensure that veterans at high risk for suicide are being seen  more frequently by a mental health provider to help prevent suicides in  the future.
We also found several situations where VAMCs interpreted and applied  instructions for completing the BHAP templates differently, resulting in  inconsistent data being reported across VAMCs. For example, one VAMC  included a visit to an immunization clinic as the veteran’s final visit, while  another VAMC did not include this type of visit, even though this was the  last time the veteran was seen in person. The BHAP guide indicates that  the final visit should be the last time the veteran had in-person contact  with any VAMC staff, but the BHAP guide does not identify the different  types of visits that should be counted. Additionally, VA policy and  guidance states that the BHAP template should be completed for all  suicides known to the facility, but at the five VAMCs we visited, these  data were not always being reported. VA policy and instructions do not  explicitly state that veterans not being seen by VA also should be  included, and in the absence of this declaration, some VAMCs interpreted  the instructions to mean that only veterans being seen by VA should be  included in the data submitted. Therefore, two VAMCs have submitted  data only for veterans being treated by VA, while the others include data  on all known veteran suicides—whether they have been treated by VA or  not. When VAMCs do not provide consistent data, VA Central Office will  receive and use inconsistent data in preparing its trend reports, such as  BHAP reports, which are intended to be used to improve suicide  prevention efforts.
Further, we found that VA did not have an established process for  reviewing the accuracy of BHAP templates, and for the sites we covered  in our review, BHAP templates were not being reviewed by VA officials at  any level for accuracy, completeness, and consistency. Therefore, our  findings at five VAMCs could be symptomatic of a nationwide problem,  and other VAMCs may also be submitting incomplete, inaccurate, or  inconsistent suicide-related information and VA may not be getting the  data it needs across the department to make appropriate resource  decisions and develop new policy. We also found that VA lacks sufficient  controls, such as automated data checks, to ensure the quality of the  existing BHAP data. Not reviewing the data is inconsistent with internal  control standards for the federal government, which state that agencies  should have controls over information processes, including procedures  and standards to ensure the completeness and accuracy of processed  data.
To improve VA’s efforts to inform its suicide prevention activities, we  made three recommendations in our November 2014 report that directed  VA to (1) clarify guidance on how to complete the BHAP templates to  ensure that VAMCs are submitting consistent data on veteran suicides,  (2) ensure that VAMCs have a process in place to review data on veteran  suicides for completeness, accuracy, and consistency before the data are  submitted to VA Central Office, and (3) implement processes to review  data on veteran suicides submitted by VAMCs for accuracy and  completeness. VA agreed with our recommendations and, to date, has  made some progress in addressing these recommendations.
VA has issued clarifying guidance to suicide prevention coordinators  and VA officials reported that suicide prevention coordinators  expressed being more comfortable with filling out the BHAP  templates. We closed the first recommendation as implemented.
The last two recommendations remain unimplemented pending VA’s  completion of planned actions.
To ensure that the BHAP data are accurate, complete, and  consistent, VA created a checkbox in the BHAP template to  indicate that the data were checked by VAMC leadership. VA’s  initial random checks indicate the checkbox is being used and  VAMC leadership is reviewing entries resulting in better  consistency of the data. VA plans to run monthly reviews to  determine compliance.
Additionally, VA created a software program to compare data from  the BHAP templates to the data entered into another suicide  prevention database maintained by VA. VA officials plan for this  review to become part of the quarterly routine review process and  information about missing cases will be sent back to the VAMCs  for correction on a quarterly basis.
Chairman Coffman, Ranking Member Kuster, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you might have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staff have any questions about this testimony, please  contact Randall B. Williamson, Director, Health Care at (202) 512-7114 or  williamsonr@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  statement. GAO staff who made key contributions to this testimony are  Marcia A. Mann, Assistant Director; Emily Binek; Cathleen Hamann;  Sarah Resavy; and Jennifer Whitworth.
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