BACKGROUND/RATIONALE:
In spite of the impact on veteran’s health status and treatment cost, depression is under-diagnosed and under-treated. The goal of this study is to learn how to implement a previously tested, effective collaborative care model for improving the quality of depression care across multiple Veterans Integrated Service Networks (VISNs). To achieve this goal, we are conducting a randomized controlled trial of evidence-based quality improvement (EBQI), a dissemination method that relies on expert design and local implementation of evidence-based practice interventions. We hypothesize that EBQI will result in increased rates of assessment and appropriate management of depression. Results will be useful in designing realistic chronic care programs and performance measures for continuing care improvement.
OBJECTIVE(S):
Our primary objective is to evaluate whether collaborative care EBQI results in increased rates of assessment and appropriate management of depression and decreased depressive symptomatology for veterans. Our secondary objective is to evaluate the effect of EBQI on organizational outcomes.
METHODS:
Three VISNs, 10, 16 and 23, are participating. Three primary care clinics within each VISN are randomized, two to the intervention and one to usual care, for a total of nine study sites. In the intervention clinics, VA leadership, assisted by study staff, tailor and implement a depression care program for patient assessment, patient self-management support, provider education, primary and mental health collaboration, and care management. The usual care clinics participate only in the evaluation. Patient recruitment is through a telephone interview. Patients who are at risk for major depression are recruited, 67 from each site. Patient outcomes including depression symptom severity on the PHQ-9 and the VA SF-12 have been assessed by telephone at six months post enrollment. Other outcome variables are adequacy of antidepressant trials, psychotherapy and specialty care visits, and treatment adherence. A utilization and cost analysis will be conducted. VISN and VAMC leadership are surveyed to assess organizational outcomes. Data is being collected through VA administrative databases, patient and staff interviews, and study records. Power calculations and data analysis planning reflect the clustered sample design.
FINDINGS/RESULTS:
Initial analysis of VISN and VAMC leadership surveys suggest that organizational support at all levels; central, VISN, VAMC, clinic, and provider is necessary to implement collaborative care for depression and that specifics of implementation need to be individualized for the specific clinic environment. Initial analysis of baseline survey results show that patients who have a history of comanagement by primary care and mental health specialty clinics have more severe psychological symptomatology than those not referred to mental health.
IMPACT:
Initial VISN and VAMC leadership surveys documented facilitating factors and barriers that helped to design additional MH QUERI studies of implementation of collaborative care for depression. A paper addressing aspects of patient safety in collaborative care telephone interventions with patients who present with suicidality risk has been published in an AHRQ compendium. A paper presenting issues in forming and sustaining primary care-mental health collaboration has been accepted. Expert panel, provider education and informatics papers are in preparation as are papers on the treatment outcome, the impact of co-occurring PTSD on depression treatment and influence of social support and patient expectations. This and the related projects have formed the basis for articles by the investigators on collaborative care for depression in Practice Matters, the QUERI Quarterly and the SGIM Forum and presentations to VA HSR&D, MIRECC, AHRQ, Academy Health and other professional organizations.
PUBLICATIONS:
Journal Articles
- Fortney JC, Steffick DE, Burgess JF, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Services Research. 2005; 40(5 Pt 1): 1422-42.
- Felker BL, Barnes RF, Greenberg DM, Chaney EF, Shores MM, Gillespie-Gateley L, Buike MK, Morton CE. Preliminary outcomes from an integrated mental health primary care team. Psychiatric Services. 2004; 55(4): 442-4.
