Depression is expected to be the second leading cause of disability worldwide in the 21st century. Unfortunately, treatment of depression in primary care practices often fails to meet treatment standards. Efforts are being made to employ quality improvement (QI) strategies to improve depression treatment.
Two recent studies, supported by the Agency for Healthcare Research and Quality and summarized here, reach different conclusions about the impact of QI programs on primary care for depression in managed care organizations (MCOs). The first study (HS08349) found that QI interventions improved use of medications and psychotherapy for depression, reduced symptoms, and increased employment retention of depressed MCO primary care patients. The second study (HS07649) concluded that QI teams alone were insufficient to improve depressive symptoms among primary care MCO patients with chronic depression.
Wells, K.B., Sherbourne, C., Schoenbaum, M., and others, "Impact of disseminating quality improvement programs for depression in managed care," January 12, 2000 Journal of the American Medical Association 283(2), pp. 212-220.
When primary care physicians in managed care practices in this study used QI interventions that improved resources for medication management or psychotherapy, their care became more appropriate. More of their patients received the appropriate, recommended antidepressants and counseling. What's more, their patients became less depressed and were more apt to remain at work.
The researchers conducted a 1-year study of 46 primary care clinics in 6 U.S. managed care organizations. They randomized matched clinics to usual care (mailing of depression care guidelines) or to one of two QI programs, which trained local experts and nurse specialists to provide clinician and patient education, identified a pool of potentially depressed patients, and provided nurses for medication followup or access to trained psychotherapists. At 6 months, 51 percent of QI patients versus 40 percent of controls (usual care) had counseling or used antidepressant medication at an appropriate dosage, with a similar pattern at 12 months (59 percent vs. 50 percent).
In practices receiving QI interventions, 30 percent more patients received counseling and 40 percent more were prescribed appropriate antidepressants in the first 6 months compared with practices not receiving QI interventions. Over the next 6 months, the numbers were 20 percent and 30 percent more, respectively, for counseling and appropriate antidepressants. Also, QI patients were 7 to 10 percentage points less likely to have probable depression at 6- and 12-month followup than usual care patients. Initially employed QI patients were more apt to remain working at 12 months than controls (90 vs. 85 percent).
Brown, J.B., Shye, D., McFarland, B.H., and others, "Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression," January 2000 Journal on Quality Improvement 26(1), pp. 39-54.
This study of two QI approaches to improving primary care for depression failed to show any difference between patients treated by QI-exposed clinicians and those of nonexposed clinicians in a large health maintenance organization. The HMO used an 11-member continuous quality improvement (CQI) team at certain HMO sites to develop depression solution tracks, for example, to promote patient awareness and reduce stigma, increase clinician willingness and ability to diagnose and treat depression, and provide system supports to enable better care. The results were not encouraging. Patients of CQI-exposed clinicians had no significant decrease in mean depression symptoms compared with patients seen by unexposed clinicians.
Most of the CQI team's recommendations were not implemented. The inability of the CQI team to get its recommended solution tracks staffed and funded, despite sincere promises of support from senior management and an organization-wide commitment to CQI, suggests that CQI teams cannot, by themselves, do the job. They cannot eliminate fundamental resource constraints, competing resource needs, decades-old barriers between primary and specialty care, or inefficiencies in organizational structures, conclude the researchers.
In the second QI approach, certain HMO clinicians were randomized to be exposed to academic detailing (AD). Trained pharmacists from the clinicians' own medical offices visited the doctors four times with handouts containing basic messages about the key role of the clinician in treating depression, the value of depression screening, and the message that depression can be treated. AD increased treatment rates, but it failed to improve symptoms and it reduced overall functional status of patients with chronic depression. This might have been due to the little information directly relevant to chronically depressed patients in the 1993 depression practice guideline sponsored by the Agency for Healthcare Research and Quality (then the Agency for Health Care Policy and Research), which the QI programs implemented. The researchers suggest that future depression guidelines should adopt an approach more tailored to chronic illness care, rather than focusing on acute depression.
An important difference in the QI approaches used by the two AHRQ-funded studies described here is the practice resources—such as nurse specialists and trained psychotherapists—available to support and implement treatment recommendations in the first study. Looking across the two studies, the researchers conclude that expert QI teams and trained clinicians alone may be insufficient; additional resources to support primary care practices in this role may be needed to affect patient outcomes.