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Measure Summary
Title
Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers the risk of suicide.
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
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percentage of patients diagnosed with unipolar depression, who receive an initial assessment that considers the risk or suicide. See the related National Quality Measures Clearinghouse (NQMC) summary of the STABLE Project National Coordinating Council measure Bipolar disorder: the percentage of patients diagnosed with bipolar disorder who receive an initial assessment that considers the risk of suicide.

Rationale

Bipolar Disorder and Risk of Suicide

  • Unipolar depression and bipolar disorder are associated with a significant risk of suicide. The risk of completed suicide is higher in bipolar disorder than in unipolar depression.
  • Patients with bipolar disorder are at high risk for suicide; rates as high as 80% of patients with bipolar disorder have been reported with either suicidal ideation or suicide attempts.
  • Suicide completion rates in patients with bipolar I disorder have been reported as high as 10-15% with some studies reporting higher rates in patients with bipolar II disorder.
  • Among the phases of bipolar disorder, depression is associated with the highest suicide risk, followed by mixed states and presence of psychotic symptoms with episodes of mania being least associated with suicide.
  • Data from a large study reporting systematic treatment enhancement program for bipolar disorder (STEP-BD) baseline data identified that of patients with bipolar disorder, 60% had a history of prior suicide attempts and that this finding was consistent with other large studies that show a strong association between prior history of suicide attempts and new attempts or completed suicide in patients with bipolar disorder.

Assessing Risk of Suicide

  • All patients should be asked about suicidal ideation, intention to act on these ideas, and extent of plans or preparation for suicide.
Evidence for Rationale
Marangell LB, Bauer MS, Dennehy EB, Wisniewski SR, Allen MH, Miklowitz DJ, Oquendo MA, Frank E, Perlis RH, Martinez JM, Fagiolini A, Otto MW, Chessick CA, Zboyan HA, Miyahara S, Sachs G, Thase ME. Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years. Bipolar Disord. 2006 Oct;8(5 Pt 2):566-75. PubMed External Web Site Policy

Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002 Apr;159(4 Suppl):1-50. [472 references] PubMed External Web Site Policy

Raja M, Azzoni A. Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk. J Affect Disord. 2004 Nov 1;82(3):437-42. PubMed External Web Site Policy

Valtonen H, Suominen K, Mantere O, Leppamaki S, Arvilommi P, Isometsa ET. Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry. 2005 Nov;66(11):1456-62. PubMed External Web Site Policy

Zalsman G, Braun M, Arendt M, Grunebaum MF, Sher L, Burke AK, Brent DA, Chaudhury SR, Mann JJ, Oquendo MA. A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders. Bipolar Disord. 2006 Oct;8(5 Pt 2):558-65. PubMed External Web Site Policy
Primary Health Components

Unipolar depression; suicide risk assessment

Denominator Description

Patients diagnosed with unipolar depression (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who receive an initial assessment for unipolar depression that includes an appraisal of the risk of suicide (see the related "Numerator Inclusions/Exclusions" field)

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure

Unspecified

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 Extent of Measure 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.

State of Use of the Measure

State of Use
Current routine use
Current Use
Internal quality improvement

Application of the Measure in its Current Use

Measurement Setting
Ambulatory/Office-based Care
Behavioral Health Care
Professionals Involved in Delivery of Health Services
Advanced Practice Nurses
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Least Aggregated Level of Services Delivery Addressed
Individual Clinicians or Public Health Professionals
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Age

Age greater than or equal to 18 years

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Data Collection for the Measure

Case Finding Period

Unspecified

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Clinical Condition
Diagnostic Evaluation
Encounter
Patient/Individual (Consumer) Characteristic
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
Patients 18 years of age or older with an initial diagnosis or new presentation/episode of depression

AND

Documentation of a diagnosis involving unipolar depression; to include at least one of the following:

  • Codes 296.2x; 296.3x. 300.4 or 311 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 "depression"
  • Use of a screening/assessment tool for depression with a documented score or conclusion that the patient is clinically depressed and that indication that this information is used to establish or substantiate the diagnosis

Exclusions
Unspecified

Exclusions/Exceptions
Unspecified
Numerator Inclusions/Exclusions

Inclusions
Documentation of an assessment for risk of suicide; to include at least one of the following:

  • Documented clinician evaluation of the presence or absence of suicidal ideation or intention
  • Documented reference to comments the patient made that relate to the presence or absence of thoughts of suicide/death
  • Documented reference to use, or presence in the chart of, a screening tool or patient assessment form that addresses suicide

AND

Timeframe:
Documentation of the assessment for risk of suicide must be present prior to, or concurrent with, the visit where the diagnosis and/or treatment plan is first documented.

Exclusions
Unspecified

Numerator Search Strategy
Encounter
Data Source
Administrative clinical data
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Bipolar disorder or depression: assessment for risk of suicide.

Submitter
Center for Quality Assessment and Improvement in Mental Health - Clinical Specialty Collaboration
Developer
STABLE Project National Coordinating Council - Clinical Specialty Collaboration
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) External Web Site Policy 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. External Web Site Policy, 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

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2007 Jan
Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in October 2013.

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 or Depression: Assessment for Risk of Suicide," 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 External Web Site Policy.

Companion Documents

The following is available:

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. This NQMC summary was retrofitted into the new template on June 27, 2011. The information was reaffirmed by the measure developer on October 7, 2013.

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