Development of a Quality Measure for Adults with Post-Traumatic Stress Disorder. APPENDIX A: PTSD Tag1 Presentation


Development of Quality Measures for Post-Traumatic Stress Disorder Technical Advisory Group

March 1, 2012
Mathematica Policy Research
[text version of presentation slides]


  • Introductions
  • Conflict of Interest
  • Background Information
  • Measure Development Process
  • Measure Concepts
  • Wrap-Up
  • Next Steps

Project Overview

  • ASPE and NIMH are funding this project
  • Purpose is to develop quality measures of care provided to adults with PTSD treated in ambulatory settings
  • The focus is on care provided to adults diagnosed with PTSD treated outside of the VA
  • Mathematica is the prime contractor and has a subcontract with NCQA

Project Goals

  • Goals in the next year
    • Develop a foundation for measuring quality of PTSD treatment
  • Long term goals
    • Promote evidence-based treatment and quality improvement efforts for PTSD care
    • Develop a process to assess quality of psychosocial care
    • Develop measures that will be submitted for NQF endorsement

Project Timeline

March 1, 2012 TAG meeting
mid-March Finalize concepts for measure development
March 2012 thru August 2012 Develop measure specifications and testing protocols
July/August 2012 TAG meeting (teleconference)
September/October 2012 Conduct focus groups to assess feasibility and usability
November/December 2012 Draft report summarizing project activities

Role of Technical Advisory Group

  • Provide guidance on the prioritizaton of measure concepts
  • Provide guidance on mechanisms and feasibility for developing measure concepts
  • Review and provide feedback on the measure specifications
  • Provide feedback and guidance on the testing plan

Goals of Today's Meeting

  • Obtain guidance in identifying the most promising evidence-based measurement opportunities
  • Obtain guidance on the types of measures that should be prioritized for development
  • Obtain guidance on data sources for developing these measures

PTSD Overview

  • PTSD is an anxiety disorder that some people develop following exposure to a traumatic event
Population Prevalence
General Population 6.8%
   Women 10%
   Men 3.5%
Veterans 5% to 30%
  • PTSD commonly co-occurs with depression, substance use, traumatic brain injury, and metabolic conditions


Evidence for PTSD Treatment and Care

Evidence for PTSD Care

  • Psychotherapy
    • Cognitive Behavior Therapy (CBT)
      • Research and guidelines support the use of CBT
      • Most studies have examined exposure therapy (ET) and found it to be effective in reducing symptoms
    • Eye Movement Desensitization and Reprocessing
      • Different interpretations of research on effectiveness
  • Medication
    • SSRIs
      • Conflicting interpretations of the research of effectiveness of SSRIs
      • Guidelines support use of SSRIs but vary in recommending them as first or second line of treatment
  • Care coordination
    • Little research in PTSD; however, there is some evidence in the broader mental health field
  • Support services (housing, employment, peer support groups)
    • Little research available in PTSD; some guidelines recommend assessing need for and/or provision of support services
  • Consumer experience
    • Little research in PTSD, but evidence in broader mental health and health field supports measuring patient experience with care


Current PTSD Treatment and Care

PTSD Treatment Settings

  • In the general population, 57% of individuals with PTSD received mental health services within the past year
    • 23% psychiatrist
    • 26% non-psychiatrist in specialty mental health
    • 31% general medical provider
    • 11% human services professional
    • 13% complimentary alternative medicine

Prevalence of PTSD Treatments Provided

  • Among patients with PTSD in an urban primary care setting
    • 50% received mental health treatment
      • 35% received counseling and medication (SSRIs)
      • 29% received counseling only
      • 36% received medication only (SSRIs)
  • Among patients with PTSD in the VA
    • 64% received mental health treatment
      • 54% received medication
      • 39% received counseling


Existing Related Measures

Existing PTSD Measures

Measure Name Measure Developer
1. Number of evaluation and management visits with a prescribing provider following the start of a new treatment episode for patients undergoing pharmacotherapy Greenberg et al.
2. Complicated PTSD with a new treatment episode of PTSD with no care by a licensed mental health provider RAND/VA
3. Cognitive Behavior Therapy (CBT) for PTSD RAND/VA
4. Proportion of patients with PTSD diagnosis who are monitored regarding symptom severity RAND/VA
5. Proportion of patients with PTSD diagnosis receive an adequate trial of selective serotonin reuptake inhibitors (SSRIs) RAND/VA
6. Reassess severity of symptoms between the beginning of the second month and the end of the fourth month RAND/VA
7. Reduction in target symptoms during the new treatment episode RAND/VA
8. Comprehensive assessment: co-morbid psychiatric conditions, psychiatric history, and response to treatment RAND/VA
9. All patients diagnosed with co-occurring SUD who are in a new treatment episode for COD should receive appropriate treatment for both their substance use disorder and mental health disorder RAND/VA
10. Proportion of patients with co-occurring SUD and severe functional impairment that receive integrated SA and MH treatment RAND/VA
11. Patients with a new treatment episode in specialty care receive baseline assessment of needs in the following domains: housing, social supports, employment RAND/VA
12. Pateitns with identified need should be offered services for: social supports, housing, employment status RAND/VA
13. Percentage of patient charts that document assessment for suicide ideation RAND/VA
14. Family psychoeducation Nelson & Wright 1996


Measure Concepts & Points of Consideration

NQF Framework

Importance Extend to which measure concept is evidence-based, and for which there is variation in or less than optimal performance
Scientific Acceptability Extent to which the measure properties produce consistent (reliable) and credible (valid) results about the quality of care
Usability Extent to which intended users can understand the results of the measure and find them useful for decision making and quality improvement
Feasibility Extent to which the data are readily available or can be collected without undue burden and can be implemented for performance measurement

Measure Concept Domains

  • Psychotherapy
  • Pharmacotherapy
  • Assessing/monitoring/treatment for other commonly occurring behavioral and physical health conditions
  • Care coordination
  • Patient experience

Measurement Considerations

  • Level of specificity
    • Is a treatment provided? vs. Were the appropriate components of a treatment provided?
  • Assessing psychotherapy
    • Are there clearly defined treatment process elements?
    • Is there an established number of elements that must be provided in order for the treatment to be effective?
    • Are there feasible and reliable methods of measuring provision of treatment elements that don't involve direct observation?
    • Research on measuring CBT for depression via clinician and patient reported instruments could inform PTSD measure development
  • Data Sources
    • Claims data
      • Comparatively little burden for facilities to collect and report performance data using claims
      • Prior work at Mathematica suggests data on psychosocial treatment can not reliably be obtained in claims data
    • Surveys
      • Potential source for gathering information that may not be in charts
      • Feasibility of collecting and reporting survey data may concern providers
    • Chart abstracted/Electronic health records
      • Is provision of psychotherapy documented in a consistent way across providers?
      • What level of detail is provided (i.e., therapy vs. CBT vs. exposure therapy)?
      • How feasible is it to extract information on psychotherapy?
      • How feasible is it to measure fidelity to treatment implementation?

Measure Concept Domains

  • Psychotherapy
  • Pharmacotherapy
  • Assessing/monitoring/treatment for other commonly occurring behavioral and physical health conditions
  • Care coordination
  • Patient experience


  • What measure domains and concepts should be prioritized?
    • What measure concepts will advance quality of PTSD care?
    • What would be feasible to develop?
    • What level of specificity?


  • Confirm final list of promising concepts
  • Next TAG meeting (call) for July/August 2012