Impact of the QOF and the NICE guideline in the diagnosis and management of depression: a qualitative study

Assessing depression severity using the UK Quality and Outcomes Framework depression indicators: a systematic review

BACKGROUND

Depression is a major cause of chronic ill-health and is managed in primary care. Indicators on depression severity assessment were introduced into the UK Quality and Outcomes Framework (QOF) in 2006 and 2009. QOF is a pay-for-performance scheme and indicators should have evidence to support their use; potential unintended consequences should also have been considered.

AIM

To review the effectiveness of routine assessment of depression severity using structured tools in primary care, and to determine the views of GPs and patients regarding their use.

DESIGN

Systematic review.

METHOD

Studies were identified by searching electronic databases; study selection, data abstraction, and quality assessment were carried out by one reviewer, with checks from other authors and GRADE (grading of recommendations, assessment, development and evaluation) tables completed for included effectiveness studies.

RESULTS

Eight studies met the eligibility criteria. There was very low-quality evidence that assessing severity in a structured way at diagnosis using a validated tool led to interventions that were appropriate to the severity of depression. Patients and GPs had different perceptions of the assessment of depression at diagnosis, with patients being more positive. GPs highlighted unintended consequences. There was low-quality evidence that structured assessment at follow-up led to increased rates of remission and response, but changes to management were not seen. Patients used this assessment to measure their own response to treatment.

CONCLUSION

Any estimate of the effect of structured assessment of depression severity in UK general practice is uncertain. GPs consider routine use of questionnaires as incentivised by the QOF has unintended consequences, which could adversely affect patient care.

Stepped care for depression is easy to recommend, but harder to implement: results of an explorative study within primary care in the Netherlands

Background

Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care.

Methods

Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire.

Results

Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs.

Conclusions

The management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework

OBJECTIVES

To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system.

DESIGN

Retrospective longitudinal study.

SETTING

Data for 2007-2008 to 2010-2011, extracted from the clinical computer systems of general practices in England.

PARTICIPANTS

All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice.

MAIN OUTCOME MEASURES

Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement.

RESULTS

Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels).

CONCLUSIONS

Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system.

A qualitative study of primary care professionals' views of case finding for depression in patients with diabetes or coronary heart disease in the UK

BACKGROUND

Routinely conducting case finding (also commonly referred to as screening) in patients with chronic illness for depression in primary care appears to have little impact. We explored the views and experiences of primary care nurses, doctors and managers to understand how the implementation of case finding/screening might impact on its effectiveness.

METHODS

Two complementary qualitative focus group studies of primary care professionals including nurses, doctors and managers, in five primary care practices and five Community Health Partnerships, were conducted in Scotland.

RESULTS

We identified several features of the way case finding/screening was implemented that may lead to systematic under-detection of depression. These included obstacles to incorporating case finding/screening into a clinical review consultation; a perception of replacing individualised care with mechanistic assessment, and a disconnection for nurses between management of physical and mental health. Far from being a standardised process that encouraged detection of depression, participants described case finding/screening as being conducted in a way which biased it towards negative responses, and for nurses, it was an uncomfortable task for which they lacked the necessary skills to provide immediate support to patients at the time of diagnosis.

CONCLUSION

The introduction of case finding/screening for depression into routine chronic illness management is not straightforward. Routinized case finding/screening for depression can be implemented in ways that may be counterproductive to engagement (particularly by nurses), with the mental health needs of patients living with long term conditions. If case finding/screening or engagement with mental health problems is to be promoted, primary care nurses require more training to increase their confidence in raising and dealing with mental health issues and GPs and nurses need to work collectively to develop the relational work required to promote cognitive participation in case finding/screening.

Systematic depression screening in high-risk patients attending primary care: a pragmatic cluster-randomized trial

BACKGROUND

Systematic screening for depression in high-risk patients is recommended but remains controversial. The aim of this study was to assess the effectiveness of such screening in everyday clinical practice on depression recognition.

METHODS

A pragmatic, cluster randomized, controlled study that randomized primary care physicians (PCPs) in Spain either to an intervention or control group. The intervention group (35-PCPs) received training in depression screening and used depression screening routinely for at least 6 months. The control group (34-PCPs) managed depression in their usual manner. Adherence to (1-6; never-very frequently), feasibility (1-4; unfeasible-very feasible), and acceptance (1-5; very poor-very good) of the screening were evaluated. Underrecognition (primary outcome) and undertreatment rates of major depressive disorder (MDD) in the two groups were compared 6 months after randomization in a random sample of 3737 patients assigned to these PCPs using logistic regression adjusting for the clustering effect.

RESULTS

No significant differences were found for recognition rates (58.0% vs. 48.1% intervention vs. control; OR [95%CI] 1.40 [0.73-2.68], p = 0.309). The undertreatment rate did not differ significantly either (p = 0.390). The mean adherence to depression screening was 4.4 ± 1.0 ('occasionally'), the mean feasibility was 3.1 ± 0.5 ('moderately feasible'), and the mean acceptance was 4.2 ± 0.6 ('good').

CONCLUSIONS

This research was not able to show effectiveness of the systematic screening for MDD in high-risk patients on depression recognition in primary care. The poor adherence to screening implementation could partially explain the results. These reflect the difficulties of putting into practice the clinical guidelines usually based on interventional research.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01662817.

The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial

OBJECTIVES

To determine the effectiveness of collaborative care in reducing depression in primary care patients with diabetes or heart disease using practice nurses as case managers.

DESIGN

A two-arm open randomised cluster trial with wait-list control for 6 months. The intervention was followed over 12 months.

SETTING

Eleven Australian general practices, five randomly allocated to the intervention and six to the control.

PARTICIPANTS

400 primary care patients (206 intervention, 194 control) with depression and type 2 diabetes, coronary heart disease or both.

INTERVENTION

The practice nurse acted as a case manager identifying depression, reviewing pathology results, lifestyle risk factors and patient goals and priorities. Usual care continued in the controls.

MAIN OUTCOME MEASURE

A five-point reduction in depression scores for patients with moderate-to-severe depression. Secondary outcome was improvements in physiological measures.

RESULTS

Mean depression scores after 6 months of intervention for patients with moderate-to-severe depression decreased by 5.7±1.3 compared with 4.3±1.2 in control, a significant (p=0.012) difference. (The plus-minus is the 95% confidence range.) Intervention practices demonstrated adherence to treatment guidelines and intensification of treatment for depression, where exercise increased by 19%, referrals to exercise programmes by 16%, referrals to mental health workers (MHWs) by 7% and visits to MHWs by 17%. Control-practice exercise did not change, whereas referrals to exercise programmes dropped by 5% and visits to MHWs by 3%. Only referrals to MHW increased by 12%. Intervention improvements were sustained over 12 months, with a significant (p=0.015) decrease in 10-year cardiovascular disease risk from 27.4±3.4% to 24.8±3.8%. A review of patients indicated that the study's safety protocols were followed.

CONCLUSIONS

TrueBlue participants showed significantly improved depression and treatment intensification, sustained over 12 months of intervention and reduced 10-year cardiovascular disease risk. Collaborative care using practice nurses appears to be an effective primary care intervention.

TRIAL REGISTRATION

ACTRN12609000333213 (Australia and New Zealand Clinical Trials Registry).

Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study

BACKGROUND

Annual recording of the Royal College of Physicians three questions (RCP3Q) morbidity score is rewarded within the UK 'pay-for-performance' Quality and Outcomes Framework.

AIMS

To investigate the performance of the RCP3Qs for assessing control in real-life practice compared with the validated Asthma Control Questionnaire (ACQ) administered by self-completed questionnaire.

METHODS

We compared the RCP3Q score extracted from a patient's computerised medical record with the ACQ self-completed after the consultation. The anonymous data were paired by practice, age, sex, and dates of completion. We calculated the sensitivity and specificity of the RCP3Q scale compared with the threshold for good/poor asthma control (ACQ ≥1).

RESULTS

Of 291 ACQ questionnaires returned from 12 participating practices, 129 could be paired with complete RCP3Q data. Twenty-five of 27 patients who scored zero on the RCP3Q were well controlled (ACQ <1). An RCP3Q score ≥1 predicted inadequate control (ACQ ≥1) with a sensitivity of 0.96 and specificity of 0.34. Comparable values for RCP3Q≥2 were sensitivity 0.50 and specificity 0.94. The intraclass correlation coefficient of 0.13 indicated substantial variability between practices. Exacerbations and use of reliever inhalers were moderately correlated with ACQ (Spearman's rho 0.3 and 0.35) and may reflect different aspects of control.

CONCLUSIONS

In routine practice, an RCP3Q score of zero indicates good asthma control and a score of 2 or 3 indicates poor control. An RCP3Q score of 1 has good sensitivity but poor specificity for suboptimal control and should provoke further enquiry and consideration of other aspects of control such as exacerbations and use of reliever inhalers.

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

BACKGROUND

The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.

METHODS/DESIGN

A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6-22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.

DISCUSSION

The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.

Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II

BACKGROUND

The UK Quality and Outcomes Framework (QOF) rewards practices for measuring symptom severity in patients with depression, but the endorsed scales have not been comprehensively validated for this purpose.

AIM

To assess the discriminatory performance of the QOF depression severity measures.

DESIGN AND SETTING

Psychometric assessment in nine Scottish general practices.

METHOD

Adult primary care patients diagnosed with depression were invited to participate. The HADS-D, PHQ-9, and BDI-II were assessed against the HRSD-17 interview. Discriminatory performance was determined relative to the HRSD-17 cut-offs for symptoms of at least moderate severity, as per criteria set by the American Psychiatric Association (APA) and NICE. Receiver operating characteristic curves were plotted and area under the curve (AUC), sensitivity, specificity, and likelihood ratios (LRs) calculated.

RESULTS

A total of 267 were recruited per protocol, mean age = 49.8 years (standard deviation [SD] = 14.1), 70% female, mean HRSD-17=12.6 (SD = 7.62, range = 0-34). For APA criteria, AUCs were: HADS-D = 0.84; PHQ-9 = 0.90; and BDI-II = 0.86. Optimal sensitivity and specificity were reached where HADS-D ≥9 (74%, 76%); PHQ-9 ≥12 (77%, 79%), and BDI-II ≥23 (74%, 75%). For NICE criteria: HADS-D AUC = 0.89; PHQ-9 AUC = 0.93; and BDI-II AUC = 0.90. Optimal sensitivity and specificity were reached where HADS-D ≥10 (82%, 75%), PHQ-9 ≥15 (89%, 83%), and BDI-II ≥28 (83%, 80%). LRs did not provide evidence of sufficient accuracy for clinical use.

CONCLUSION

As selecting treatment according to depression severity is informed by an evidence base derived from trials using HRSD-17, and none of the measures tested aligned adequately with that tool, they are inappropriate for use.