Post-traumatic stress disorder (PTSD) is a mental health disorder that sometimes results when individuals are directly or indirectly exposed to actual or threat of death, serious injury, or sexual violence (American Psychiatric Association 2013). An estimated 6.8 percent of the United States population has PTSD, with women estimated to have higher prevalence than men (9.7 percent for women versus 3.6 percent for men) (Kessler et al. 2005a; Kessler et al. 2005b) and veterans having a higher prevalence than the general population (7-20 percent for veterans of the recent wars, and estimates of about 30 percent for all veterans of the Vietnam War) (VA National Center for PTSD 2007, 2014).
Most people who experience traumatic events have a brief adjustment period during which they successfully cope with the experience. For others, symptoms worsen over time and last for months or years, disrupting their ability to function in everyday life. The cost of PTSD care can be significant. Studies have found that individuals with PTSD have increased health care service utilization, as measured by number of physical and mental health appointments and hospitalizations (Tuerk et al. 2012). The prevalence of PTSD among women with public insurance is over three times as high as for women with private insurance (Seng et al. 2009). Given the relatively higher risk of exposure to violence among people with low income, the need for effective PTSD treatment among Medicaid recipients is likely to be sizeable.
In recent years, increased national attention has led to an improvement in the types and effectiveness of treatments for individuals diagnosed with PTSD. Particularly promising are a number of psychotherapy treatment approaches -- for example, exposure therapy and cognitive processing therapy (CPT) -- that have demonstrated slightly to significantly better treatment outcome for those diagnosed with PTSD, such as reduction of symptoms and improved mental health. Despite advances in the development of evidence-based treatment for adults with PTSD, the implementation of these treatments varies widely (Mellman et al. 2003), overall recovery rates remain low, and large disparities exist in the type and quality of mental health treatment across providers, patient populations, types of disorders, and even geographic regions. To enhance accountability, improve quality, and increase transparency for treatment of individuals with PTSD, the creation of quality measures is a first essential step. Well-constructed measures of evidence-based treatments could be used not only for overall quality improvement and monitoring purposes, but also for training and education and to determine the comparative effectiveness of treatments.
A. Project Purpose
In September 2011, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE), with support from the HHS National Institute of Mental Health (NIMH), contracted with Mathematica Policy Research and the National Committee for Quality Assurance (NCQA) to develop quality measures for treatment of adults with PTSD. The Veterans Affairs and Military Health System have already invested significant resources to improve the care of active and retired duty individuals with PTSD; ASPE and NIMH were interested in building upon this existing work to develop measures that could be used in civilian ambulatory treatment settings. The overall goal was to develop measures that could eventually be used to hold providers or organizations accountable for delivering high quality care; however, there was recognition that PTSD quality of care measures could also be used for training and education and by other researchers.
The first step in this 3.5-year project involved prioritizing important measure concepts. Identification of measure gaps and priorities was informed through an environmental scan and input from a technical advisory group (TAG). The process identified several potential measure concepts, including measures that screen for common co-occurring conditions, assess appropriate receipt of psychotherapy and pharmacotherapy, routinely assess and monitor PTSD symptoms, and measure patient outcomes. The measure concept "the delivery of evidence-based psychotherapy" was selected. We then identified common elements of psychotherapy for PTSD with support from a newly formed technical expert panel (TEP), developed measure specifications for a survey to assess the delivery of evidence-based psychotherapy for PTSD, and pre-tested the measure. The pre-testing involved quantitative data collection to examine the measure's preliminary psychometric properties and explore potential approaches to scoring, as well as qualitative data collection, including focus groups and site coordinator debriefings to gather information on the measure's feasibility, usefulness, and importance. Based on findings from the pre-testing, we recommended modifications to the measure specifications and additional testing of the measure to more fully understand its importance, scientific acceptability, usability, and feasibility as defined by the National Quality Forum (NQF).
B. Report Roadmap
This report summarizes the development and testing results of the quality measures for PTSD. Chapter II describes the process for selecting measure concepts. Chapter III explains the process for specifying the measures. Chapter IV describes the methods used to test the measure, and Chapters V summarizes the results. The final chapter offers conclusions and lessons learned from this project that may be applicable to future measure development and implementation efforts.