Treating depression in staff-model versus network-model managed care organizations

Prevention of Adolescent Depression in Primary Care: Barriers and Relational Work Solutions

BACKGROUND AND PURPOSE

Depression affects millions of adolescents in the United States each year. This population may benefit from targeted preventive interventions. We sought to understand the internal factors that affect the ability of healthcare organizations to implement an intervention that involves mental health screening and depression prevention treatment of at-risk adolescents in primary care settings.

METHODS

From November 2011 to July 2016 we conducted a study of the implementation of a multisite (N=30) phase 3 randomized clinical trial of an Internet-based depression prevention intervention program (CATCH-IT). We describe the prevalence of internal barriers on the screening and enrollment process by reporting REACH (the proportion of target audience exposed to the intervention).

RESULTS

A total of 369 adolescents were randomized into the intervention or control program. Mean REACH values for the study clinics were 0.216 for screening and 0.181 for enrollment to CATCH-IT. Mean REACH enrollment lost due to internal barriers was 0.233. This translated to 4,691 adolescents lost at screening and 2,443 adolescents lost at enrollment due to internal barriers.

CONCLUSION

We propose a model of the implementation process that emphasizes the importance of positive relational work that assists in overcoming internal barriers to REACH. We also provide implications for policy and practice.

Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: Survey results from a randomized evaluation

BACKGROUND

Primary care is the main point-of-entry for identifying and treating mental health problems. This research examines the effect of a new model of supporting primary care providers (PCPs) treating mental health disorders, the electronic consultation (eConsults), a standard process for communication between PCPs and psychiatrists through an electronic health records system.

METHODS

A cluster-randomized evaluation of the psychiatric eConsults model, as implemented in a large integrated delivery system. Web survey data before and after the implementation of psychiatric eConsults were collected on PCPs' perceptions of their capability and skill to deliver mental health services, and analyzed with linear regression models.

RESULTS

At baseline PCPs had mixed assessments of perceived support for delivering mental health services and of the availability of specialist consultations, but had relatively high perceived self-efficacy and skill for identifying, diagnosing and treating depression. PCPs in the Treatment group had statistically significant 18%, 13%, and 16% improvements in perceived support for diagnosing mental health problems, making treatment decisions, and changing treatment regimens, respectively; and 24% improved perceived ease of access to consultations for mental health, compared to the Control group. Evidence of effects on self-efficacy and perceived skill around depression was more limited.

CONCLUSIONS

The psychiatric eConsults model improved PCPs' perceptions of support for delivering mental health care and perceptions of access to specialist consultations.

IMPLICATIONS

Electronic consultations may be a promising approach to support the delivery of mental health services in primary care settings.

LEVEL OF EVIDENCE

Pre- and post-intervention web surveys from a cluster-randomized trial.

Complexity in Redesigning Depression Care: Comparing Intention Versus Implementation of an Automated Depression Screening and Monitoring Program

Health care technology promises to improve quality and decrease costs while improving the patient experience. A recent trial tested a novel health technology that sought to reduce barriers to guideline-recommended depression care by coupling automated telephonic patient assessment with provider notification and decision support. This study compares the intended effects and the end users' experience with using this technology. Responses to semi-structured interviews with the leadership and design team (the intention group) were compared with responses from health professionals in clinics using the technology (the implementation group). Qualitative methods were applied to compare perspectives on the role of technology in care delivery and on the technology's impact on barriers to providing guideline-recommended care. Four members of the intention group and 17 members of the implementation group were interviewed. The 2 groups had similar notions of technology's role in care delivery. The technology increased provider awareness, empowered midlevel providers, and facilitated collaboration among care team members. However, the implementation group identified gaps in care processes and in the informatics system that the technology did not address, and for which providers remained responsible. The 2 groups had comparable perspectives on the value and limits of technology in improving adherence to guideline-recommended care. However, the intention group did not discuss many of the shortcomings identified by the implementation group. Also, the interviews suggest that although some barriers persisted and a few new ones arose, the technology succeeded in reducing barriers to guideline-recommended care.

Primary care providers' initial treatment decisions and antidepressant prescribing for adolescent depression

OBJECTIVE

Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. This study examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network.

METHODS

A cross-sectional survey was administered to 58 PCPs within a large pediatric practice network. PCP reports of initial treatment decisions were compared in response to 2 vignettes describing depressed adolescents with either moderate or severe symptoms. PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics were measured.

RESULTS

Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (odds ratio [OR], 5.50; 95% confidence interval [CI], 2.47-12.2] p < .001). Depression severity did not affect the likelihood of antidepressant recommendation (OR, 1.58 [95% CI, 0.80-3.11] p = .19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR, 1.72 [95% CI, 1.14-2.59] p = .009) and access to an on-site mental health provider (OR, 5.13 [95% CI, 1.24-21.2] p = .02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR, 0.85 [95% CI, 0.75-0.98] p = .02).

CONCLUSION

PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs' antidepressant prescribing.

A preliminary study of aged care facility staff indicates limitations in awareness of the link between depression and physical morbidity

Background

It is important to understand the complex inter-relationship between depression and physical illness in order to plan and provide quality health care services for older persons and reduce suffering and early mortality. This study assessed the awareness and knowledge of age-care staff of the link between physical morbidity and depression.

Methods

One hundred and nineteen staff from both residential (high and low care) and community aged care facilities were surveyed on their awareness and knowledge of the relationship between physical morbidity and symptoms of depression. Predictors of levels of knowledge were assessed using multiple regression analysis.

Results

Awareness of the link between physical morbidity and symptoms of depression was generally high. However, while nearly eighty percent of respondents said they had had training in mental health, they were only able to answer an average of six out of ten of the knowledge questions correctly. Predictors of knowledge were: higher age, higher educational status and working in a high care facility.

Conclusions

Responses to the survey questions demonstrated gaps in knowledge about the relationship between depression and physical health. The need for regular ongoing training to improve knowledge and awareness of this relationship is indicated. Treatment of physical health issues which is essential in reducing the risk for depression in older persons in aged care environments could be optimized by improved staff training.

The development and first use of the QUEST measures to evaluate school nurses' knowledge and skills for depression recognition and management

BACKGROUND

Depression affects around 5% of adolescents and its identification and management is an important part of front-line professionals' roles. There are few validated measures of knowledge and skills in this area. We describe a multiple-choice question set to test nurses' depression knowledge and vignettes to examine case recognition skills.

METHODS

A 24-item knowledge test and 12 vignettes were developed based on relevant literature and expert panel review. Three rounds of panel review assessed face and content validity and expert agreement of vignette depression status. The measures were piloted with 26 school nurses. Following amendments, administered to 146 school nurses. A depression attitude scale was used concurrently so that associations among knowledge, attitudes, and condition recognition could be explored.

RESULTS

Readability for the knowledge test and vignettes was satisfactory. Item difficulty and discrimination indices for most knowledge questions were acceptable; overall, participants scored 50% correctly, with less than 5% unanswered. The panel reached 89% agreement about vignette depression status, and nurse participants' judgments of the vignettes achieved 65% sensitivity and 47% specificity.

CONCLUSION

The study produced psychometrically tested instruments for measuring depression recognition and knowledge. There was evidence for content validity, and limited evidence of convergent validity from associations among measures. Some of the items may be modified, and a smaller set of vignettes having the best expert agreement may be useful in future research.

Assessment of changes in confidence, attitude, and knowledge of non-psychiatric physicians undergoing a depression training program in Taiwan

OBJECTIVE

To assess whether non-psychiatric physicians would benefit from a national depression training program and explore associated factors.

METHOD

Attending physicians were asked to complete survey questionnaires of confidence, attitude, knowledge, and their willingness to implement new strategies to improve care, before and after training. Paired t-test and multiple regression analysis were used to determine the differences and explore factors associated with the domains of confidence, attitude, and knowledge. McNemar's test was used to compare the difference between the physicians' intention to change depression management before and after training.

RESULTS

Of 524 eligible physicians, 307 (59%) completed the pre- and post-program assessments. These physicians showed significantly increased knowledge score and willingness to implement new treatment strategies, as well as more positive attitude toward and confidence in treating depression. The lower corresponding baseline score was associated with greater improvement in domains ofknowledge, confidence, and attitude. Completion of the training was associated with an improvement in knowledge and becoming less helpless and avoidant attitude. Other factors including non-family-medicine physicians, post-graduate education, and female gender are associated with greater improvements in various domains.

CONCLUSIONS

Our study shows that even a brief educational program can positively influence the physicians' knowledge, attitudes, and confidence in treating depression. Further work is needed to monitor whether the effects of training are long-term, and can be translated into behavioral change in practice.

Association of general medical and psychiatric comorbidities with receipt of guideline-concordant care for depression

OBJECTIVE

This study described the association of general medical and psychiatric comorbidities with receipt of guideline-concordant depression care.

METHODS

Pharmacy, medical, and behavioral claims and enrollment data from OptumHealth in 2003-2006 were linked for 1,835 adults with a new depression diagnosis or a new antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, guideline-concordant psychotherapy, and any guideline-concordant therapy.

RESULTS

Eleven percent of patients received guideline-concordant psychotherapy; 23%, guideline-concordant pharmacotherapy; and 33%, any guideline-concordant therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; conversely, having a general medical but no psychiatric comorbidity was associated with lower rates of guideline-concordant psychotherapy. Comorbidities were associated with the probability of receiving any guideline-concordant therapy, but they were not associated with improved guideline concordance among patients already receiving therapy.

CONCLUSIONS

Patients with general medical comorbidities may not receive psychotherapy referrals, perhaps because of well-established relationships with their primary care providers.

Conditions that influence a primary care clinician's decision to refer patients for depression care

The objective of this study was to identify conditions that influence primary care clinicians' referral decisions related to depression care. Forty primary care clinicians (15 general internists, 10 nurse practitioners, and 15 family practice physicians) were included in this study. The clinicians participated in semistructured interviews and completed two quantitative instruments (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis revealed that several conditions influence a clinician's decision to refer a depressed patient to a mental health specialist: the patient's resources, the clinician's comfort in prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment. The decision to refer a patient with depression to a mental health specialist is a complex process involving the clinician, patient, and practice-related issues. Understanding these relationships may provide strategies to improve depression care management and lead to the design of depression care quality-improvement interventions that accommodate primary care practice context. The findings from this study suggest a need to increase mental health training opportunities for primary care clinicians to strengthen their skills and comfort level in managing depressed patients and encourage the development of relationships between primary care clinicians and mental health specialists to facilitate timely and accessible mental health care for patients.

Children's psychosocial problems presenting in a family medicine practice

Primary care physicians have an important role in identifying, treating, and referring children with psychosocial problems. However, there is a limited literature describing whether and how family physicians address psychosocial problems and why parents may not discuss children's problems with physicians. The current study examined how family physicians address psychosocial problems and reasons that parents do not discuss children's psychosocial problems with physicians. Results indicated that there are a variety of reasons involving parents, their perceptions of physicians, and the number of psychosocial problems reported, that may lead to fewer discussions of psychosocial problems.

Organizational factors and depression management in community-based primary care settings

BACKGROUND

Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework.

METHODS

We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance).

RESULTS

The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment.

CONCLUSIONS

The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.

Non-psychiatric physicians' knowledge, attitudes and behavior toward depression

BACKGROUND/PURPOSE

Depression is a major health concern, often treated by non-psychiatrists. This study assessed self-reported knowledge, attitudes and treatment practices of non-psychiatric physicians in the recognition and management of depression.

METHODS

Survey questionnaires were given to non-psychiatric physicians who attended a depression training program. We asked physicians about their current clinical practice, knowledge, confidence, attitudes and perceived barriers to care regarding recognition and management of patients with depression.

RESULTS

Of 524 eligible non-psychiatric physicians, 375 (72%) completed surveys. The majority of physicians held a strong sense of responsibility for managing depression, although they provided treatment to only a small proportion of depressed patients. Most of them were not confident treating depressed patients, and they reported that incomplete knowledge and training were major barriers that limited their involvement. The patient and organization barriers were not related to reported management, but the physician barriers (lack of skills and knowledge in managing depression) were related to reported rate of treatment. Age, prior depression training, and education were major contributing factors to domains of knowledge, attitude and behavior, in terms of the number of domains involved. Family physician orientation was associated with higher score on knowledge scale, but not with other variables of attitude and behavior.

CONCLUSION

Our study suggests that non-psychiatrists may also play a role in the care of depression, but identifying and managing depression can be a challenge to them. Attitudinal barriers, confidence, and knowledge of treatment may compromise the physicians ability to manage depression. Future interventions and educational efforts need to address each of these issues.

Effects on knowledge and attitudes of using stages of change to train general practitioners on management of depression: a randomized controlled study

OBJECTIVE

To assess the impact on knowledge and attitudes of a tailored educational intervention on depression using a modified version of the Prochaska stages of change model, compared with standard continuing medical education, for general practitioners (GPs) in primary care in Iran.

METHOD

Using a randomized controlled trial, a total of 192 GPs were evenly randomized to intervention or control arm. The topic for the educational intervention was depressive disorders. The participants were divided in to small and large groups, depending on their initial stage of change. The GPs' knowledge and skills regarding management of depressive disorders were assessed through a questionnaire with 7 multiple choice questions, 11 Likert statements, 3 case vignettes, and 1 essay question. Attitudes toward management of depressive disorders were also assessed. Both questionnaires were validated.

RESULTS

There was a significant improvement in knowledge mean scores regarding multiple choice and Likert questions (intervention effect 6%; P = 0.002), as well as for the case vignettes and essay question (intervention effect 12%; P = 0.011) in the intervention arm, in comparison with the control arm. There were significant changes in mean attitude scores in both study arms, but no difference between them.

CONCLUSIONS

A theoretical model of medical learning and behavioural change can be used to devise educational formats that suit different stages of learning. Such tailored educational formats can improve GPs' knowledge and skills regarding management of depressive disorders.

Clinical inertia in depression treatment

OBJECTIVE

To explore reasons for clinical inertia in the management of persistent depression symptoms.

RESEARCH DESIGN

We characterized patterns of treatment adjustment in primary care and their relation to the patient's clinical condition by modeling transition to a given treatment "state" conditional on the current state of treatment. We assessed associations of patient, clinician, and practice barriers with adjustment decisions.

SUBJECTS

Survey data on patients in active care for major depression were collected at 6-month intervals over a 2-year period for the quality improvement for depression (QID) studies.

MEASURES

Patient and clinician characteristics were collected at baseline. Depression severity and treatment were measured at each interval.

RESULTS

Approximately, one-third of the observation periods ending with less than a full response resulted in an adjustment recommendation. Clinicians often respond correctly to the combination of severe depression symptoms and less than maximal treatment by changing the treatment. Appropriate adjustment is less common, however, in management of less severely depressed patients who do not improve after starting treatment, particularly if their care already meets minimal treatment intensity guidelines.

CONCLUSIONS

Our findings suggest that quality improvement efforts should focus on promoting appropriate adjustments for patients with persistent depression symptoms, particularly those with less severe depression.

System factors affect the recognition and management of posttraumatic stress disorder by primary care clinicians

BACKGROUND

Posttraumatic stress disorder (PTSD) is common with an estimated prevalence of 8% in the general population and up to 17% in primary care patients. Yet, little is known about what determines primary care clinician's (PCC's) provision of PTSD care.

OBJECTIVE

To describe PCC's reported recognition and management of PTSD and identify how system factors affect the likelihood of performing clinical actions with regard to patients with PTSD or "PTSD treatment proclivity."

DESIGN

Linked cross-sectional surveys of medical directors and PCCs.

PARTICIPANTS

Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey.

MEASUREMENTS

Two system factors (degree of integration between primary care and mental health services, and existence of linkages with other community, social, and legal services) as reported by medical directors, and PCC reports of self-confidence, perceived barriers, and PTSD treatment proclivity.

RESULTS

Surveys from 47 (of 58) medical directors (81% response rate) and 154 PCCs (86% response rate). PCCs from CHCs with better mental health integration reported greater confidence, fewer barriers, and higher PTSD treatment proclivity (all P < 0.05). The PCCs in CHCs with better community linkages reported greater confidence, fewer barriers, higher PTSD treatment proclivity, and lower proclivity to refer patients to mental health specialists or to use a "watch and wait" approach (all P < 0.05).

CONCLUSIONS

System factors play an important role in PCC PTSD management. Interventions are needed that restructure primary care practices by making mental health services more integrated and community linkages stronger.

Comorbid chronic illness and the diagnosis and treatment of depression in safety net primary care settings

OBJECTIVE

To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings.

DESIGN

This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI).

RESULTS

Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment.

CONCLUSION

Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.

Clinic-level process of care for depression in primary care settings

Multi-component models for improving depression care target primary care (PC) clinics, yet few studies document usual clinic-level care. This case comparison assessed usual processes for depression management at 10 PC clinics. Although general similarities existed across sites, clinics varied on specific processes, barriers, and adherence to practice guidelines. Screening for depression conformed to guidelines. Processes for assessment, diagnosis, treatment, and follow-up varied to different degrees in different clinics. This individuality of usual care should be defined prior to quality improvement interventions, and may provide insights for introducing or tailoring changes, as well as improving interpretation of evaluation results.

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity

BACKGROUND

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

OBJECTIVE

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

DESIGN

Secondary analysis from the Quality Improvement in Depression Study dataset.

PARTICIPANTS

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

MEASUREMENTS

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

RESULTS

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

CONCLUSIONS

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

Physician attitude toward depression care interventions: implications for implementation of quality improvement initiatives

Background

Few individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM) have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation.

Methods

We conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach.

Results

Six barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions.

Conclusion

CCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is needed to overcome all barriers to care.

Virtual standardized patients: an interactive method to examine variation in depression care among primary care physicians

BACKGROUND: Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581-90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested. AIM AND METHOD: The primary aim of this methods-focused paper was to review the extent to which our study method - an interactive CD-ROM patient vignette methodology - was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data? FINDINGS: Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology - combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol - generated valid explanations for variations in primary care physician practice patterns related to depression care.

Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research

The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process-including contextual factors, adoption, implementation, and sustainment of interventions-showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.

Primary care visit length, quality, and satisfaction for standardized patients with depression

BACKGROUND

The contribution of physician and organizational factors to visit length, quality, and satisfaction remains uncertain, in part, because of confounding by patient presentation.

OBJECTIVE

To determine associations among visit length, quality, and satisfaction when patient presentation is controlled.

DESIGN

A factorial experiment using standardized patients to make primary care visits presenting with either major depression or adjustment disorder, and a musculoskeletal complaint.

PARTICIPANTS

One hundred fifty-two primary care physicians, each seeing 2 standardized patients.

MEASUREMENTS

Visit length was determined from surreptitiously obtained audiorecordings. Other key measures were derived from physician and standardized patient report.

RESULTS

Mean visit length for 294 completed encounters was 22.3 minutes (range = 5.8-72.2, SD = 9.4). Key factors associated with visit length were: physician style (rho = 0.68 and 0.54 after multivariate adjustment), nonprofessional experience with depression (11% longer, 95% CI = 0-23%), practicing within an HMO (26% shorter, 95% CI = 61-90%), and greater practice volume (those working >9 half-day clinic sessions/week had 15% shorter visits than those working fewer than 6, 95% CI = 0-27%, and those seeing >12 patients/half-day had 27% shorter visits than those seeing <10 patients/half-day, 95% CI = 13-39%). Suicidal inquiry (a process-based quality-of-care measure for depression) was not associated with adjusted visit length. Satisfaction was linearly associated with visit length but not with suicide inquiry or follow-up interval.

CONCLUSIONS

Despite experimental control for clinical presentation, wide variation in visit length persists, largely reflecting individual physician styles. Visit length is a significant determinant of standardized patient satisfaction.

Systematic review of multifaceted interventions to improve depression care

OBJECTIVE

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

METHOD

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

RESULTS

Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

CONCLUSION

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Project CHAT: a brief motivational substance abuse intervention for teens in primary care

Many adolescents use alcohol and drugs (AODs); however, most do not seek help because of stigma or confidentiality concerns. Providing services in settings that teens frequent may decrease barriers. We examined the feasibility of adapting a brief motivational intervention (MI) for high-risk adolescents (age 12-18 years) in a primary care (PC) setting by conducting small feedback sessions with adolescents, parents, and clinic staff, and pilot testing the MI with adolescents. Findings from feedback sessions indicated that clinic staff thought teens would not talk about AOD use. In contrast, adolescents reported that they would talk about their AOD use; however, they were afraid of being judged. Parents were also concerned that the PC provider might be judgmental. Feedback from the MI pilot indicated that teens were willing to talk about their AOD use and indicated readiness to change. Findings suggest that providing a brief MI in a PC setting is a viable approach for working with high-risk youth.

Impacts of evidence-based quality improvement on depression in primary care: a randomized experiment

CONTEXT

Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process.

OBJECTIVE

Evaluate impacts of EBQI on practice-wide depression care and outcomes.

DESIGN

Practice-level randomized experiment comparing EBQI with usual care.

SETTING

Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients.

INTERVENTION

Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools. EVALUATION PARTICIPANTS: Five hundred and sixty-seven representative patients with major depression.

MAIN OUTCOME MEASURES

Appropriate treatment, depression, functional status, and satisfaction.

RESULTS

Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months, P = .07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome, P = .18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months, P = .02); physical functioning did not.

CONCLUSION

Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.

Management of mental disorders in VA primary care practices

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.

Models of integrated care

This article describes the range of options for integrating medicine and psychiatry, with a focus on the advantages and limitations of each model. The models were developed in different countries with specific health care cultures. This article illustrates the range of in- and outpatient options as currently practiced, with case reports from practitioners when possible, and describes qualifications for practicing in each model, the settings, the patient populations, the relevant financial issues, and the advantages and disadvantages of practicing in each model. It closes with comments on the next steps for advancing integrated care and the barriers to be overcome.

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms

BACKGROUND

Referral from primary care to the mental health specialty sector is important but poorly understood.

OBJECTIVE

Identify physician characteristics influencing mental health referral.

DESIGN

Randomized controlled trial using Standardized Patients (SPs).

SETTING

Offices of primary care physicians in 3 cities.

PARTICIPANTS

One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.

INTERVENTION

Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.

MEASUREMENTS

Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.

RESULTS

Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).

LIMITATION

The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.

CONCLUSIONS

Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.

Primary care patients' involvement in decision-making is associated with improvement in depression

BACKGROUND

Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes.

OBJECTIVE

The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms.

DESIGN

Prospective cohort study.

SETTING

Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care.

SUBJECTS

Primary care patients with current symptoms and probable depressive disorder.

MEASUREMENTS

Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors.

RESULTS

For each 1-point increase in IDM ratings, the probability of patients' report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004).

CONCLUSIONS

Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.

Primary care provider attitudes are associated with smoking cessation counseling and referral

OBJECTIVE

Most primary care providers (PCPs) endorse the importance of smoking cessation, but counseling rates are low. We evaluated the consistency of PCP's attitudes toward smoking cessation counseling and corresponding smoking-cessation behaviors.

DESIGN

This was a postintervention analysis of a population-based sample from a group randomized controlled trial to improve adherence to smoking cessation guidelines.

SETTING

A total of 18 VA sites in Southwestern and Western United States participated.

PARTICIPANTS

A total of 280 PCPs completed a survey at 12 months after the implementation of a smoking-cessation quality improvement (QI) program. Their patients also completed 12- (n = 1080) and 18-month (n = 924) follow-up surveys.

INTERVENTION

The quality improvement intervention included local priority setting, quality improvement plan development, implementation, and monitoring.

MEASUREMENTS AND MAIN RESULTS

PCPs at intervention sites were more likely to report counseling patients about smoking cessation (P = 0.04) but not referral. PCP attitude toward smoking-cessation counseling was strongly associated with reported counseling (P < 0.001) and with referral (P = 0.01). Other associations with counseling were the perceived barrier "patients are not interested in quitting" (P = 0.01) and fewer years in practice (P = 0.03); other associations with referral were specialty consultation (P < 0.0001) and the perceived barrier "referral not convenient" (P = 0.001) (negative association). PCP attitudes were associated with higher rates of counseling, referral, and program attendance.

CONCLUSIONS

PCPs, regardless of intervention participation, had attitudes consistent with their reported smoking-cessation behaviors and more favorable attitudes were associated with higher rates of patient-reported smoking cessation behavior. Findings suggest that PCPs who endorse smoking-cessation counseling and referral may provide more treatment recommendations and have higher patient quit rates.

Physician conceptions of responsibility to individual patients and distributive justice in health care

PURPOSE

Physicians' values may be shifting under managed care, but there have been no empirical data to support this claim. We describe physician conceptions of responsibility to individual patients and distributive justice in health care, and explore whether these values are associated with type of managed care practice and professional satisfaction.

METHODS

We mailed a questionnaire to 500 primary care physicians from 80 out-patient clinics in 11 managed care organizations (MCOs) who were participating in 4 studies designed to improve the quality of depression care in primary care.

RESULTS

We received 414 responses (response rate 83%). Twenty-eight percent of physicians strongly agreed that their main responsibility was to the individual patient rather than to society (strong sense of responsibility to individual patients). Physicians with a strong sense of responsibility to individual patients were older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, P = .009) and tended to practice in network- rather than staff-model MCOs (33% of physicians in network-model MCOs reported a strong sense of responsibility to individual patients compared with 24% in staff-model MCOs, P = .077). Scores on a scale measuring egalitarian conceptions of distributive justice within the health care system were similar for physicians regardless of whether they reported a strong sense of responsibility to individual patients. When we controlled for physician and practice characteristics, physicians with a strong sense of responsibility to individual patients and physicians with higher scores on an egalitarian scale were more likely to be very satisfied overall with their practices (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI], 1.11-4.49, and AOR = 1.18, 95% CI, 1.09-1.29, respectively).

CONCLUSIONS

Physicians with a strong sense of responsibility to individual patients are older and less likely to practice in staff-model MCOs. Stronger commitment to an egalitarian health care system and a strong sense of responsibility to individual patients are independently associated with greater practice satisfaction among physicians. The impact of these values on patient care should be a priority for future research and the subject of professional education and debate.

Variations in nurse practitioner use in Veterans Affairs primary care practices

BACKGROUND

Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers.

OBJECTIVES

To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use.

STUDY DESIGN

We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996.

PRINCIPAL FINDINGS

From 1996-1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care.

CONCLUSIONS

Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.

Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e)

BACKGROUND

Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions.

METHOD

The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site.

RESULTS

Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care.

CONCLUSIONS

Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.

Detection of postpartum depression and anxiety in a large health plan

To determine the prevalence of diagnosed and/or treated postpartum depression and anxiety, records were extracted for 1 year after delivery from databases of outpatient diagnoses and prescriptions, for women in a health maintenance organization who had delivered a child from July 1997 through June 1998. For comparison, telephone interviews were conducted 5 to 9 months after delivery with random samples of women who delivered at 2 facilities from June 1998 through January 1999. Of the women interviewed, 11% met criteria for major depression during the first 4 months postpartum, and an additional 13% met criteria for probable depression at 5 to 9 months postpartum. In contrast 7.0% of the large cohort had a visit or prescription for depression. The 1-year prevalence rate for diagnosed and/or treated anxiety without depression was 3.8%; the rate at time of interview was 14.7%. Overall, less than 33% of women with substantial depression or anxiety symptoms were detected.

Depression management in medical clinics: does healthcare sector make a difference?

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

Disparities in care for depression among primary care patients

CONTEXT

Ethnic minorities traditionally receive less care for depression than do white populations; we examine ethnic minority care for depression in a large cross-national primary care sample.

DESIGN

This is a cross-sectional study of identification and treatment of depression among diverse primary care patients, using self-report of symptoms and care.

SUBJECTS

One thousand four hundred and ninety-eight depressed primary care patients participating in four large studies of quality improvement for depression care are examined at baseline.

RESULTS

Primary care providers recommend depression treatments for Latino and African-American patients as frequently as they do for white patients. However, Latino and African-American patients are less likely to take antidepressant medications (adjusted odds ratio [OR], 0.30; 95% confidence interval [CI], 0.21 to 0.42 and adjusted OR, 0.56; 95% CI, 0.36 to 0.87, respectively) and Latinos are less likely to obtain specialty mental health care (adjusted OR, 0.50; 95% CI, 0.36 to 0.75).

CONCLUSIONS

Primary care providers are now able to recognize depression and recommend treatment for Latino and African-American patients, with this care recommended at equal rates to that of white patients. However, Latino and African-American patients remain less likely to obtain appropriate care, such as antidepressant medications or specialty care. New approaches to improving access to appropriate care for Latino and African-American primary care patients are needed.

Referral gridlock: primary care physicians and mental health services

BACKGROUND

Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations.

OBJECTIVE

To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services.

DESIGN

Cross-sectional analysis using nationally representative survey data from the 1998 to 1999 Community Tracking Study physician survey. The overall survey response rate was 61%.

PARTICIPANTS

A 1998 to 1999 telephone survey of 6586 primary care physicians.

MEASUREMENTS

Primary care physicians' report of whether they could obtain medically necessary referrals to high-quality mental health specialists or psychiatric admissions.

RESULTS

Overall, 54% of primary care physicians reported problems obtaining psychiatric hospital admissions, and 54% reported problems arranging outpatient mental health referrals. Primary care physicians practicing in staff and group model HMOs were much less apt to report difficulties than physicians in solo and small-group practices (P <.001). Reports of inadequate time with patients (P <.001) and smaller numbers of psychiatrists in a market area (P <.01) also were associated with problems obtaining mental health referrals. Pediatricians were more apt to report problems than general internists (P <.001).

CONCLUSIONS

Primary care physicians face greater hurdles obtaining mental health services than other medical services. Primary care is an important entry point for mental health services, yet inadequate referral systems between medical and mental health services may be hampering access.

The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients

BACKGROUND

Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment.

METHODS

A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling.

RESULTS

African Americans (adjusted OR, 0.30; 95% CI 0.19-0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26-0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35-1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08-9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression.

CONCLUSIONS

African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Do family physicians and internists differ in knowledge, attitudes, and self-reported approaches for depression?

OBJECTIVES

The purpose of this investigation was to assess the relationship of primary care specialty training with self-assessed skill, knowledge, attitudes, and behavior toward depression recognition and management.

METHOD

A baseline self-report questionnaire was administered to 184 internists and 138 family physicians participating in a multisite depression intervention study.

RESULTS

There were no marked differences in knowledge of internists and family physicians regarding depression, in attitudes about the effectiveness of specific therapies, or in barriers to providing optimum treatment for depression. However, compared to internists, family physicians rated themselves as more skilled in the management of depression. When considering management of patients with moderate to severe depression, family physicians were more likely to report that they prescribed a selective serotonin-reuptake inhibitor (relative odds (RO) = 3.51, 95 percent Confidence interval (CI) [2.19, 5.60] and to personally counsel patients (RO = 1.97, 95 percent CI [1.16, 3.38]) more than half the patients, but were less likely to refer to a specialist in mental health (RO = 0.52, 95 percent CI [0.33, 0.82]) than were internists. Additional potentially influential characteristics did not wholly account for the reported differences in practice according to specialty. Physicians of both specialties expressed considerable uncertainty in their knowledge of psychotherapy and in their evaluation of the effectiveness of other strategies for the prevention of recurrence of depression.

CONCLUSION

Strategies to improve mental health care should account for the orientation of primary care physicians to mental health issues.

Depression in primary care: linking clinical and systems strategies

Depression is a serious, often chronic disease that can be managed effectively with a chronic care model in primary care settings. Depressed persons are likely to be seen by a primary care physician, but their condition often goes unrecognized and untreated. There are effective treatment models that consist of efficacious psychotherapeutic and pharmacological interventions, use of evidence-based guidelines for primary care treatment of depression, development of explicit plans and protocols, reorganization of practice, longitudinal follow-up, patient self-management, decision-making support, access to community resources and leadership commitment. Moving these models into everyday practice requires overcoming both clinical and system barriers. Barriers consist of issues surrounding patients, providers, practices, plans, and purchasers. An understanding of these barriers at each level helps to provide a framework for the changes required to overcome them. The Robert Wood Johnson Foundation National Program on Depression in Primary Care will seek to apply simultaneously both clinical and system strategies in a new five-year initiative to overcome these barriers.

Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study

BACKGROUND

Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care.

METHODS

We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994-95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care.

RESULTS

On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34-38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14-26 percentage points).

CONCLUSION

According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.

Identifying physicians likely to benefit from depression education: a challenge for health care organizations

BACKGROUND

Few methods exist to identify physicians who might benefit from depression education.

OBJECTIVES

To develop a measure of physicians' confidence or self-efficacy in caring for depressed patients and assess it's reliability and validity.

RESEARCH DESIGN

A national sample of primary care physicians were surveyed and exploratory factor analysis (EFA) was used to identify factors underlying physicians' responses to 26 items. We named the factors, selected items with factor loadings > or = 0.50 for final scales, and tested a priori hypotheses about self-efficacy.

SUBJECTS

1) Random cross-sectional sample of family physicians, internists, obstetrician-gynecologists, and pediatricians (n = 5,369) and 2) 49 general internists and family physicians participating in a prepost evaluation of a depression workshop.

RESULTS

In the national sample, 3,712 physicians were eligible and 2,104 responded. Forty-six percent were female, and 51% were family physicians and general internists. EFA identified 5 factors, the first of which was called Self-Efficacy (4 items, alpha = 0.86). More family physicians (64%) had confidence (self-efficacy) in caring for depressed patients compared with general internists (33%), obstetrician-gynecologists (16%), and pediatricians (6%) (P < 0.001). Few physicians intended to change their care of depressed patients (10%) or take CME on depression (24%). Of the 49 physicians attending a depression workshop, 76% reported high self-efficacy after the workshop versus 50% before it (P = 0.013).

CONCLUSIONS

This study supports the reliability and validity of the Self-Efficacy scale as one method to identify physicians who might benefit from interventions. New approaches are needed because physicians are unlikely to change.

Counseling for depression by primary care providers

OBJECTIVE

Primary care providers (PCPs) deliver a significant amount of depression care, yet little is known about the content of clinical encounters with depressed patients. We describe the extent to which PCP's encounters with depressed and non-depressed patients involve psychotherapeutic counseling relative to other types of counseling during primary care visits.

METHOD

Cross-sectional evaluation of audiotaped office visits between October 1997 and September 1998 with 154 patients of 27 PCPs at three Veterans' Health Administration clinics in California. Using the Roter Interaction Analysis System, we coded conversation into mutually exclusive talk categories and developed specific measures of depression counseling coded for sequences of depression talk. Analysis of variance and covariance was used to evaluate differences in counseling by depression type adjusted for encounter length, previous depression treatment, patient characteristics, and provider clustering.

RESULTS

PCPs delivered significantly more depression care (assessed using coded audiotapes of patient visits) to their patients with major depression compared with patients who had no depression or symptoms but no disorder. However, counseling using psychotherapeutic techniques did not differ by depression level and was equivalent for patients with major depression and subthreshold relative to non-depressed. Encounters with patients who had major depression included more talk about depression, devoted more time to discussing depression, and included more depression talk per minute. PCP encounters with depressed patients also included less biomedical talk compared to other groups.

CONCLUSIONS

Findings suggest that PCPs do provide depression counseling to their patients who need it the most. Whether counseling is associated with appropriate treatment and subsequent outcomes will require additional research.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians

OBJECTIVE

We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians' knowledge about treatment.

DESIGN AND METHODS

Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians' knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design.

PARTICIPANTS

One hundred eighty-one primary care clinicians.

INTERVENTIONS

The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy).

RESULTS

Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P =.04 and by 33% for QI-therapy, P =.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P =.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components.

CONCLUSIONS

Dissemination of QI programs for depression in managed, primary care practices improved clinicians' treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists.

Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service

Our objective was to identify patient characteristics associated with inappropriate hospital days in a cohort of elderly medical inpatients. This prospective cohort study included a total of 196 patients aged 75 years and older, who were consecutively admitted over eight months to the internal medicine service of a regional, non-academic public hospital located in a rural area of Western Switzerland. Patients with severe cognitive impairment, terminal disease, or previously living in a nursing home were excluded. Data on demographics, medical, physical, social and mental status were collected at admission. A blinded hospitalization review was performed concurrently using a modified version of the Appropriateness Evaluation Protocol (AEP). Subjects' mean age was 82.4 years; 63.3% were women. Median length of stay was 8 days. Overall, 68 patients (34.7%) had at least one inappropriate day during their stay, including 18 patients (9.2%) whose hospital admission and entire stay were considered inappropriate. Most inappropriate days were due to discharge delays (87.10%), primarily to nursing homes (59.30%). Univariate analysis showed that subjects with inappropriate days were more likely to be living alone (69.1 vs 48.4%, p=0.006), and receiving formal in-home help (48.5 vs 32.8%, p=0.031). In addition, they were more impaired in basic and instrumental activities of daily living (BADLs, and IADLs, p<0.001 and p=0.015, respectively), and more frequently had a depressed mood [29.4 vs 10.9%, p=0.001 with a score > 6 at the Geriatric Depression Scale (GDS), short form]. Using multivariate analysis, independent associations remained for patients living alone (OR 2.6, 95%CI 1.2-5.8, p=0.016), those with a depressed mood (OR 2.8, 95%CI 1.1-7.3, p=0.032), with BADL dependencies (OR 1.5, 95%CI 1.2-1.8, p=0.001), and IADL dependencies (OR 1.3, 95%CI 1.0-1.6, p=0.032). Cardiovascular (OR 0.2, 95%CI 0.1-0.7, p=0.008) and pulmonary admission diagnoses (OR 0.1, 95%CI 0.0-0.7, p=0.022) were inversely associated with inappropriate hospital days. In conclusion, patients living alone, functionally impaired and showing depressive symptoms were at increased risk for inappropriate hospital days. These characteristics might permit better targeting for early discharge planning in these at-risk subjects, and contribute to avoiding premature discharge of other vulnerable elderly patients. Whether these interventions for at-risk patients will also result in prevention of hospitalization hazards, such as deconditioning and related functional decline, will require further study.