Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.

BACKGROUND Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN A group-level randomized controlled trial. SETTING Forty-six primary care practices in 6 managed care organizations. PATIENTS Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.

[1]  James Butler,et al.  Speaking of Health: Assessing Health Communication, Strategies for Diverse Populations , 2005 .

[2]  M. Weissman,et al.  Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. , 2003, JAMA.

[3]  N. Duan,et al.  Impact of a Primary Care Quality Improvement Intervention on Use of Psychotherapy for Depression , 2003, Mental health services research.

[4]  C. Sherbourne,et al.  Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial. , 2003, Health services research.

[5]  T. Peters,et al.  For Personal Use. Only Reproduce with Permission from the Lancet Publishing Group , 2022 .

[6]  Adrienne Y. Stith,et al.  PATIENT-PROVIDER COMMUNICATION: THE EFFECT OF RACE AND ETHNICITY ON PROCESS AND OUTCOMES OF HEALTHCARE , 2003 .

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

[8]  C. Sherbourne,et al.  The effects of primary care depression treatment on patients' clinical status and employment. , 2002, Health services research.

[9]  A. Haines,et al.  Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial , 2002, BMJ : British Medical Journal.

[10]  Daniel F. McCaffrey,et al.  Bias reduction in standard errors for linear regression with multi-stage samples , 2002 .

[11]  Adrienne Y. Stith,et al.  Unequal treatment: confronting racial and ethnic disparities in health care. , 2003 .

[12]  C. Sherbourne,et al.  Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. , 2001, The American journal of psychiatry.

[13]  N. Duan,et al.  Two-year effects of quality improvement programs on medication management for depression. , 2001, Archives of general psychiatry.

[14]  C. Sherbourne,et al.  Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. , 2001, JAMA.

[15]  M. Lillie-Blanton,et al.  Site of medical care: do racial and ethnic differences persist? , 2001, Yale journal of health policy, law, and ethics.

[16]  J. Stoddard,et al.  Minority physicians' experiences obtaining referrals to specialists and hospital admissions. , 2001, MedGenMed : Medscape general medicine.

[17]  C. Sherbourne,et al.  Long-term effectiveness of disseminating quality improvement for depression in primary care. , 2001, Archives of general psychiatry.

[18]  S. Abbuhl,et al.  Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers. , 2001, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[19]  M. Tai-Seale,et al.  Racial Disparities in Service Use among Medicaid Beneficiaries after Mandatory Enrollment in Managed Care: A Difference-in-Differences Approach , 2001, Inquiry : a journal of medical care organization, provision and financing.

[20]  W. Manning,et al.  Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. , 2001, Archives of general psychiatry.

[21]  David Satcher,et al.  Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General , 2001 .

[22]  C. Sherbourne,et al.  The quality of care for depressive and anxiety disorders in the United States. , 2001, Archives of general psychiatry.

[23]  T. Laveist,et al.  Attitudes about Racism, Medical Mistrust, and Satisfaction with Care among African American and White Cardiac Patients , 2000, Medical care research and review : MCRR.

[24]  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.

[25]  K. Weinfurt,et al.  The effects of patient sex and race on medical students' ratings of quality of life. , 2000, The American journal of medicine.

[26]  David E. Booth,et al.  Analysis of Incomplete Multivariate Data , 2000, Technometrics.

[27]  M. van Ryn,et al.  The effect of patient race and socio-economic status on physicians' perceptions of patients. , 2000, Social science & medicine.

[28]  Michael J. Campbell,et al.  Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial , 2000, The Lancet.

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

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

[31]  N. Powe,et al.  Race, gender, and partnership in the patient-physician relationship. , 1999, JAMA.

[32]  J M Abreu,et al.  Conscious and nonconscious African American stereotypes: impact on first impression and diagnostic ratings by therapists. , 1999, Journal of consulting and clinical psychology.

[33]  T. Koepsell,et al.  Patient-physician racial concordance and the perceived quality and use of health care. , 1999, Archives of internal medicine.

[34]  L. Leape,et al.  Underuse of Cardiac Procedures: Do Women, Ethnic Minorities, and the Uninsured Fail To Receive Needed Revascularization? , 1999, Annals of Internal Medicine.

[35]  Samin K. Sharma,et al.  Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. , 1999, Medical care.

[36]  K. Wells.  The design of Partners in Care: evaluating the cost-effectiveness of improving care for depression in primary care , 1999, Social Psychiatry and Psychiatric Epidemiology.

[37]  M. Rhee,et al.  The impact of language as a barrier to effective health care in an underserved urban Hispanic community. , 1998, The Mount Sinai journal of medicine, New York.

[38]  David M. Murray,et al.  Design and Analysis of Group- Randomized Trials , 1998 .

[39]  W. Katon,et al.  Treatment Costs, Cost Offset, and Cost-Effectiveness of Collaborative Management of Depression , 1998, Psychosomatic medicine.

[40]  J. Schaefer,et al.  Collaborative Management of Chronic Illness , 1997, Annals of Internal Medicine.

[41]  R. Kravitz,et al.  Underuse of coronary revascularization procedures: application of a clinical method. , 1997, Journal of the American College of Cardiology.

[42]  Brian T. Austin,et al.  Organizing care for patients with chronic illness. , 1996, The Milbank quarterly.

[43]  D. Baker,et al.  Determinants of emergency department use: are race and ethnicity important? , 1996, Annals of emergency medicine.

[44]  W. Katon,et al.  A multifaceted intervention to improve treatment of depression in primary care. , 1996, Archives of general psychiatry.

[45]  L. Coffey.  Caring for depression. , 1996, Healthplan.

[46]  Alan D. Lopez,et al.  The global burden of disease: a comprehensive assessment of mortality and disability from diseases injuries and risk factors in 1990 and projected to 2020. , 1996 .

[47]  W. Katon,et al.  Collaborative management to achieve treatment guidelines. Impact on depression in primary care. , 1995, JAMA.

[48]  C. Sherbourne,et al.  Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. , 1995, Archives of general psychiatry.

[49]  E. Keeler,et al.  Health care for black and poor hospitalized Medicare patients. , 1994, JAMA.

[50]  R. Little.  Pattern-Mixture Models for Multivariate Incomplete Data , 1993 .

[51]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .