Effect of Improved Primary Care Access on Quality of Depression Care

PURPOSE We wanted to determine whether a major improvement in access to primary care during 2000 was associated with changes in the quality of care for patients with depression. METHODS Health plan administrative data were analyzed by multilevel regression to compare the quality of care received by patients with depression between 1999 and 2001, a time without major changes in depression care guidelines. Approximately 6,000 patients with depression who received all care in a large multispecialty medical group during any single year were subjects for this study. Thirteen different quality measures assessed process quality under the dimensions of effectiveness, timeliness, safety, and patient-centeredness. RESULTS The largest change was a reduction in the proportion of depressed patients with no follow-up visit in primary care after starting a new antidepressant medication: from 33.0% before a change in access to care to 15.4% afterward, P =.001. During the same period, continuity of care in primary care improved (>50% of primary care visits to 1 doctor increased from 67.3% to 74.0%, P = <.001), as did persistence of 6-month antidepressant medication (from 46.2% to 50.8%, P = <.001). Further analyses found that the latter change was primarily associated with the change in continuity of care. Measures of subspecialty mental health care worsened during this time. CONCLUSION Marked improvement in access to primary care for 1 year was associated with some improvement in primary care for patients with depression, but the mechanism appeared to be improved continuity. Those planning to implement advanced access to care need to do so in such a way that continuity of care is enhanced rather than harmed by the change.

[1]  Bradley N. Doebbeling,et al.  Does patient-centered care improve provision of preventive services? , 2004, Journal of General Internal Medicine.

[2]  N. Duan,et al.  Improving depression outcomes in community primary care practice , 2001, Journal of General Internal Medicine.

[3]  A. Stewart,et al.  Primary care and receipt of preventive services , 1996, Journal of General Internal Medicine.

[4]  J. Saultz,et al.  Interpersonal Continuity of Care and Care Outcomes: A Critical Review , 2005, The Annals of Family Medicine.

[5]  Patrick J O'Connor,et al.  Does improved access to care affect utilization and costs for patients with chronic conditions? , 2004, The American journal of managed care.

[6]  Sam Weir,et al.  A controlled trial of an advanced access appointment system in a residency family medicine center. , 2004, Family medicine.

[7]  C. Salisbury.  Does advanced access work for patients and practices? , 2004, The British journal of general practice : the journal of the Royal College of General Practitioners.

[8]  S. Dixon,et al.  Evaluation of advanced access in the national primary care collaborative. , 2004, The British journal of general practice : the journal of the Royal College of General Practitioners.

[9]  E. Fernández,et al.  An adaptation of Charlson comorbidity index predicted subsequent mortality in a health survey. , 2004, Journal of clinical epidemiology.

[10]  Patrick J O'Connor,et al.  Key issues in transforming health care organizations for quality: the case of advanced access. , 2004, Joint Commission journal on quality and safety.

[11]  D. Berwick,et al.  Advanced access: reducing waiting and delays in primary care. , 2003, JAMA.

[12]  T. Bodenheimer,et al.  Improving timely access to primary care: case studies of the advanced access model. , 2003, JAMA.

[13]  W. Rush,et al.  When depression is the diagnosis, what happens to patients and are they satisfied? , 2003, The American journal of managed care.

[14]  J. Corrigan,et al.  COMMITTEE ON IDENTIFYING PRIORITY AREAS FOR QUALITY IMPROVEMENT , 2003 .

[15]  P. Nutting,et al.  Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care , 2002, BMJ : British Medical Journal.

[16]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[17]  H. Pincus,et al.  Depression in primary care: linking clinical and systems strategies. , 2001, General hospital psychiatry.

[18]  D. Yue,et al.  Continuity of care in diabetes: to whom does it matter? , 2001, Diabetes research and clinical practice.

[19]  J. Takala,et al.  Good continuity of care may improve quality of life in Type 2 diabetes. , 2001, Diabetes research and clinical practice.

[20]  W A Hargreaves,et al.  Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. , 2000, Archives of family medicine.

[21]  A G Mainous,et al.  The effect of continuity of care on emergency department use. , 2000, Archives of family medicine.

[22]  Michael VonKorff,et al.  Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care , 2000, BMJ : British Medical Journal.

[23]  C. Sherbourne,et al.  Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. , 2000, JAMA.

[24]  T. Oxman,et al.  The need for a system in the care of depression. , 1999, The Journal of family practice.

[25]  K. Wells,et al.  Evidence-based care for depression in managed primary care practices. , 1999, Health affairs.

[26]  S. Pearson,et al.  Discontinuity of care: urgent care utilization within a health maintenance organization. , 1998, The American journal of managed care.

[27]  Jay R. Desai,et al.  Is having a regular provider of diabetes care related to intensity of care and glycemic control? , 1998, The Journal of family practice.

[28]  A G Mainous,et al.  The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? , 1998, American journal of public health.