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Not-so-Universal Screening for Depression in the United States

by Mike Rondinaro, Contributor

How often does your doctor ask you if you smoke? For most of us, this happens every time we visit their office.

Now, how often does your doctor ask if you’ve been feeling down, not sleeping properly, or had trouble concentrating over the last two weeks?

National guidelines indicate that doctors should be doing both of these to help keep our population healthier[1,2].Over 8% of Americans have had a major depressive episode within the past year, and yet depression still is not treated with the level of attention necessary to get help to many people in need[3].

Using data from the Medicare & Medicaid Physician Quality Reporting System (PQRS), we first take a look at how often medical practitioners report their rate of depression screening, and then dive into the screening rates themselves. The most recent data set is from 2014, and is available for download here: https://data.medicare.gov/data/physician-compare. For details on how we prepared the data, see the appendix.

PQRS is what’s known as a “pay-for-performance” program, which incentivizes individual medical professionals and group practices to report on their quality of care to the Centers for Medicare and Medicaid Services (CMS). In other words, not reporting data through PQRS means that the medical group will have to pay penalties to the government. In the PQRS guidelines, it is explained that participants are not expected to report on all measures. The measures they choose to report on are expected to reflect typical treatments with regard to their clinical setting and goals. Considering how common depression is in America, we’d like to see depression screening rates being reported to PQRS as frequently as other common health screenings (think tobacco use), and the screening rate itself to be similarly close. In order to understand the importance of both reporting and screening rates, consider this simplified example:

· Physician A reported to PQRS that she screened 100% of her patients for tobacco use and 0% of her patients for depression in 2014

· Physician B didn’t report any information to PQRS about tobacco screening, and reported screening 20% of his patients for depression in 2014

What does this data tell us about how depression and tobacco use are approached by this group of medical professionals? Physicians A + B both report data on screening for depression, making the reporting rate on screening for depression 100%. The reporting rate for screening for tobacco use is 50% (A reports, B does not). The average screening rate for depression is 10%, because Physician A screens 0% of the time, and Physician B screens 20% of the time. The average screening rate for tobacco use is 100%, as Physician A’s screening rate is the only data available. As you can see, both reporting and screening rates are important for understanding how medical professionals prioritize different conditions. While we can’t assume the reasons why a doctor may choose to report data on tobacco screening but not depression screening, keep in mind that the PQRS guidelines encourage participants to report on the conditions they consider relevant. Depression is a widely experienced condition that should be prioritized across a wide range of practices, and not restricted to mental health treatment facilities alone.

We used the approach outlined above to look at the actual figures from the 2014 PQRS dataset.

Reporting Rates

Medical professionals reported depression screening at an alarmingly low rate compared to other health screenings. The U.S. maps below show the percent of participants that report data on screening for four major health concerns using PQRS, and can give you an idea of how medical professionals in your state report on different health indicators.

The U.S. reporting rates were as follows:

· Screening for depression: 5%

· Screening for tobacco use: 68%

· Screening for unhealthy body weight: 45%

· Screening for high blood pressure: 13%

Screening Rates

Reporting is the first step toward making a change for the better in all health treatments. Without sufficient amounts of data, it is difficult to assess how medical professionals are performing across different health indicators. However, we can still utilize the data that was reported to look further into screening rates. Similar to the trend in reporting rates, the average screening rates for depression lagged behind the screening rates of other health concerns.

Of those practitioners who did indeed report, the average screening rates were as follows:

· Screening for depression: 51% (95% CI [49.3, 53.4])

· Screening for tobacco use: 95% (95% CI [95.3, 95.6])

· Screening for unhealthy body weight: 77% (95% CI [76.1, 76.9])

· Screening for high blood pressure: 83% (95% CI [82.2, 83.7])

New York: 2014 PQRS Reporting Numbers

In New York State, there were 3,815 individual practitioners enrolled with PQRS. Of these, only three percent, or 116 practitioners, reported back data on depression screening (compare that with 79%, or 3,014 practitioners, reporting data on tobacco usage screening). Of those 116 that reported, the average depression screening rate was 79%, meaning that four out of every five patients was screened.

Where Do We Go From Here?

Depression is a condition that may not always appear clearly on the surface, but that affects many people throughout the U.S. As understood by the practices highlighted above, understanding and actively working to prevent depression can be the difference maker for a patient learning to regain motor skills, recover from surgery, or manage persistent pain.

The first step toward improving mental health treatment in America is to report. As we move forward, more medical professionals can contribute data to expand on what was collected in the 2014 PQRS. With increased awareness and engagement toward mental health, there is no reason why depression screening and reporting can’t parallel other common screenings as a consistently included factor in proactive health management. A ten-question depression screening questionnaire is available through Spring at https://www.spring.care/depression-screening.

1. Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: US preventive services task force recommendation statement. JAMA. 2016;315(4):380–387. doi: 10.1001/jama.2015.18392 [doi].

2. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. preventive services task force reaffirmation recommendation statement. Ann Intern Med. 2009;150(8):551–555. Accessed 3/20/2017 8:41:10 PM. doi: 150/8/551 [pii].

3. Kessler RC, Bromet EJ. The epidemiology of depression across cultures. Annu Rev Public Health. 2013;34:119–138. doi: 10.1146/annurev-publhealth-031912–114409 [doi].



The data is packaged into four files:

· National Downloadable File: general information on practitioners, including demographics, associated practices, etc.

· Individual Eligible Professional (EP) Public Reporting — Clinical Quality of Care: information on six indicators of healthcare quality

· Group Practice Public Reporting — Clinical Quality of Care: information on fourteen indicators of healthcare quality

· Group Practice Public Reporting — Patient Experience: information on how patients rate the healthcare organization’s performance

We constructed a base dataset by joining the first and second files mentioned above. While the third and fourth datasets included valuable information not available elsewhere, they had more limited participation. While participation by group practices was lower than individual professionals in 2014, we were able to produce group-level information by combining information on individual practitioners’ screening rates (available in the Individual EP file) with their associated practices (available in the National Downloadable file). After preparing the data, we examined how often screening was reported via PQRS for four important healthcare concerns: depression, tobacco use, unhealthy body weight, and high blood pressure. These reporting rates were grouped by state and mapped onto the continental U.S. For the screening that was reported, we calculated the average screening rate for each condition. Finally, we isolated the data for New York to look closely at the rates of reporting and screening for depression.

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