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Quality improvement programs improve primary care clinician knowledge about depression treatment over 18 months

Clinician education is usually a component of quality improvement programs for chronic diseases, but it is unclear whether such programs can lead to sustained gains in knowledge about treatment. A new study supported in part by the Agency for Healthcare Research and Quality (HS08349) suggests that in the case of depression, gains in knowledge can be both substantial and sustained beyond the period of active clinician education, even when clinician participation in education activity is voluntary.

Researchers led by Kenneth B. Wells, M.D., M.P.H., of RAND and the University of California, Los Angeles, School of Medicine, randomized 46 matched primary care practices in 7 managed care organizations across the United States to usual care (mailed written practice guidelines only) or comprehensive, practice-initiated quality improvement (QI) programs for depression. The programs included institutional commitment to QI and training of local experts to implement the interventions. The experts provided education opportunities to local practice clinicians over a 6-month period, through a mixture of lectures, academic detailing, and/or audit and feedback. In addition, intervention practices had nurse depression specialists trained by the study who were available to help with patient assessment, education, and referral to care. Further, practices had supplemental resources—either continuing availability of the nurse specialist for 6 or 12 months to support medication compliance or lower copayments during the first 6 months for patients to visit local therapists trained in an efficacious form of psychotherapy for depression.

Clinician and patient participation in all intervention activities was voluntary; 161 of 181 enrolled primary care clinicians completed mailed surveys at baseline and at 18-month followup. The surveys included a true-false test about appropriate treatment with antidepressant medications or with psychotherapy, based on points covered in the clinician training materials and practice guidelines.

At baseline, primary care clinicians had higher knowledge scores about medication management than about efficacious psychotherapy. Only the QI clinicians had greater treatment knowledge at 18-month followup; usual care clinicians did not improve appreciably or significantly in knowledge. The knowledge gain for QI clinicians was chiefly in the area of efficacious psychotherapy. In contrast, medication knowledge scores changed little for any group. These knowledge gains from QI are of longer duration than have been reported by other studies of implementation of QI programs.

More details are in "Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians," Lisa S. Meredith, Ph.D., Maga Jackson-Triche, M.D., M.S.H.S., Naihua Duan, Ph.D., and others, in the December 2000 Journal of General Internal Medicine 15, pp. 868-877.

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