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Researchers weigh benefits and costs of QI programs to enhance treatment of depression in primary care

Effective medications and psychotherapies are available for depressed patients who visit primary care doctors. Most of these patients want to be treated for their depression, but many do not receive adequate treatment. Moreover, patients who are not offered the treatments they prefer are less likely to get treatment of any kind. A new study shows that quality improvement (QI) programs that support treatment choices of depressed patients can improve the likelihood they will be treated and receive preferred treatments. A second study finds that the cost-effectiveness of these QI programs is comparable to that of accepted medical interventions.

Both studies are from Partners in Care, a dissemination trial of two QI interventions for depression. For the studies, 46 primary care clinics in 6 managed care organizations were randomized to a medication QI program (QI-Meds), a psychotherapy QI program (QI-Therapy), or usual depression care (UC). In QI-Meds, nurse specialists were trained to provide monthly followup assessments and support medication adherence for 6 to 12 months. In QI-Therapy, local psychotherapists were trained to provide individual and group cognitive behavior therapy for 12 to 16 sessions; reduced psychotherapy copays matched primary care visit copays. UC clinics were provided with depression care guidelines. The studies, which are described here, were supported in part by the Agency for Healthcare Research and Quality (HS08349, principal investigator Kenneth B. Wells, M.D., M.P.H., of the University of California, Los Angeles).

Dwight-Johnson, M., Unutzer, J., Sherbourne, C., and others. (2001, September). "Can quality improvement programs for depression in primary care address patient preferences for treatment?" Medical Care 39(9), pp. 934-944.

In this study, depressed patients were encouraged to express treatment preferences to their primary care providers who, in turn, were encouraged to elicit treatment preferences. Patients and providers were free to select either antidepressant medication, psychotherapy, or no treatment. Clinics were randomly assigned to UC, QI-Meds, or QI-Therapy. Over half of patients in UC clinics who wanted treatment for depression did not get the treatment they preferred. Those who were not receiving their preferred treatment at baseline—either counseling or medication—were especially unlikely to get their preferred treatment in UC. In fact, those who preferred counseling but did not get it were likely to go without treatment.

Overall, 54 percent of patients in the QI-Meds group and 51 percent in the QI-Therapy group compared with 41 percent in the UC group received the depression treatment they preferred. Also, 45 percent of those in the QI-Meds group and 44 percent of those in the QI-Therapy group who preferred counseling received it, compared with 30 percent in UC. Finally, 47 percent of those in the QI-Meds group and 17 percent of those in the QI-Therapy group—who were not in treatment at baseline and who preferred medication—actually received medication, compared with only 9 percent in the UC group.

Schoenbaum, M., Unutzer, J., Sherbourne, C., and others. (2001, September). "Cost-effectiveness of practice-initiated quality improvement for depression." Journal of the American Medical Association 286(11), pp. 1325-1330.

Diverse managed primary care practices can implement QI programs to improve treatment of depressed patients that are as cost effective as accepted medical interventions, conclude these researchers. They randomly assigned clinics to UC, QI-Meds, or QI-Therapy and compared the cost-effectiveness of the QI and UC programs and their impact on employment of 1,356 depressed patients. Relative to usual care, average health care costs over the 2-year study period increased $419 (11 percent) in QI-Meds and $485 (13 percent) in QI-Therapy, but neither cost increase was statistically significant.

Estimated costs per quality-adjusted life year (QALY) gained were between $15,331 and $36,467 for QI-Meds and between $9,478 and $21,478 for QI-Therapy. Finally, compared with UC patients, QI patients from both groups had 25 fewer days with depression burden and QI-Meds and QI-Therapy patients were employed an average of 18 and 21 more days, respectively, during the 2-year study period. The QI programs did not influence the number of sick days for those who were employed.

The researchers conclude that practice-initiated, locally implemented programs that encourage guideline-concordant care for depression can substantially reduce the individual suffering and economic consequences of depression. The incremental costs per QALY of the QI programs relative to usual care were within the range of many accepted medical interventions and substantially below the estimated value of a year of life. The findings suggest that QI-Therapy may be even more cost effective than QI-Meds, underscoring the value of improving access of depressed primary care patients to structured psychotherapy, such as cognitive behavioral therapy.

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