Quality Improvement Programs for Depression in Managed Primary Care
abstract & commentary
Source: Wells KB, et al. Impact of disseminating quality improvement programs for depression in managed primary care. JAMA 2000;283:212-220.
Regrettably, the quality of care for depression in managed primary care settings is moderate to poor with resultant poor outcomes.1 Since depression is expected to be the second leading cause of disability worldwide this century,2 improving care for patients with depression is essential. Wells and colleages undertook the first randomized study to assess quality improvement (QI) interventions in primary care by comparing the effect of QI dissemination vs. usual care for patients with depression currently, in the past 12 months, and/or recurrent during their lifetime. Health-related quality of life and use of services were also assessed. Managed care clinics (N = 46) were grouped into clusters based on patients, demographics, clinician specialty, and distance to mental health providers. Depressed, adult, English- and Spanish-speaking patients were eligible if they had insurance. The QI intervention included: 1) an institutional commitment to pay 50% of the cost to implement to program (between $30,000-$72,000 per site for one year); 2) training of local leaders, including a primary care physician (PCP), nursing supervisor, and a mental health specialist to implement interventions—the specialist did monthly lectures and provided feedback to PCPs by monthly chart audits; 3) training of local staff-nurses provided brief clinical assessments and headed patient education via pamphlets and videos; and 4) identification of current and/or past depression by the Center for Epidemiologic Studies Depression (CES-D) scale, with clinic (intervention) or patient notification (usual care). A cut-off score of 20 on the CES-D was used to identify depression. The Short-Form 12 (SF-12) was used to track health-related quality of life. Quality of care for medications was assessed according to appropriate national guidelines. The enrolled sample included 443 usual care and 913 intervention patients. The sample had a mean age of 44 years, was 71% women, 57% non-Hispanic white, and 30% Hispanic. About 50% had depression in the past 12 months and 75% had a previous episode over their lifetime. Adherence rates for QI interventions were as follows: 100% of the psychiatrist leaders were trained, 100% of the clinic staff were trained, 80% of PCPs attended one or more lectures, 60% of primary care physicians received feedback from expert chart audits, 73% of patients visited a nurse specialist for education and follow-up assessment of depression, and only 40% of therapy patients received cognitive-behavioral therapy. At six months, 50.9% of QI patients and 39.7% of usual care patients had counseling or used medication according to guidelines, with a similarly significant difference at 12 months (59.2% vs 50.1%). Intervention patients were about 10% less likely to be depressed and had improved health-related quality of life at six- and 12-month follow-up. For those in remission, the intervention decreased the likelihood of depression occurring by 10% in the first six months and by 19% in the second six months. In a secondary analysis, the medication subgroup had more pronounced and sustained effects than the therapy intervention. Overall, medical visits (to PCPs) did not increase for intervention patients, but these patients were also 30% more likely to have a mental health specialist visit during the study. All data analysis used an intent-to-treat analysis, and controlled for age, sex, education, and 19 chronic medical conditions.
Comment by Donald m. Hilty, MD
This is an ideal trial for the treatment of depression in primary care because of the naturalistic conditions, practical interventions, and the competence in which the study was carried out. The sample had high rates of depression over the past 12 months and overall, for lifetime episodes—this is probably due the high prevalence of depression and the duration of episodes, which are not uncommonly extended in settings without ideal treatment. Limitations include a potential bias toward worse outcomes for intervention patients because of design and analytic methods, which probably understated the benefits of the intervention. It would have also been useful to follow these patients longer, because an even greater intervention effect would be seen. Cost-effectiveness analyses are now needed for clinics to decide whether to implement such QI programs for depression and other medical disorders. Physicians in a primary care may want to consider implementation of depression QI programs. A focus on medication interventions, which are available and easier to standardize than therapy interventions, may be an appropriate first step.
1. Wells KB, et al. Quality of care for primary care patients with depression in managed care. Arch Fam Med 1999;8:529-536.
2. Murray CJ, et al. The global burden of disease: A comprehensive assessment of mortality and disability From disease, injuries, and risk factors in 1990 and projected to 2020. Boston, Mass: The Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996.