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Five-Year Impact of Quality Improvement for Depression
Results of a Group-Level Randomized Controlled Trial
Kenneth Wells, MD, MPH;
Cathy Sherbourne, PhD;
Michael Schoenbaum, PhD;
Susan Ettner, PhD;
Naihua Duan, PhD;
Jeanne Miranda, PhD;
Jürgen Unützer, MD, MPH;
Lisa Rubenstein, MD, MSHS
Arch Gen Psychiatry. 2004;61:378-386.
Background Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown.
Objective To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up.
Design A group-level randomized controlled trial.
Setting Forty-six primary care practices in 6 managed care organizations.
Patients Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up.
Interventions Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months.
Main Outcome Measures Probable depressive disorder in the previous 6 months, mental health–related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care.
Results Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P = .04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P = .04 for QI-ethnicity interaction for probable depressive disorder).
Conclusions Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.
From the Health Program, RAND, Santa Monica, Calif (Drs Wells, Sherbourne, Schoenbaum, and Rubenstein); the Neuropsychiatric Institute (Drs Wells, Duan, Miranda, and Unützer), the Departments of Psychiatry and Biobehavioral Services (Drs Wells, Duan, Miranda, and Unützer) and Biostatistics (Dr Duan), the Health Services Research Center (Drs Wells, Duan, Miranda, and Unützer), and the Center for Community Health (Dr Duan), University of California at Los Angeles; University of California at Los Angeles Department of Medicine, Division of General Internal Medicine and Health Services Research (Drs Ettner and Rubenstein); and the Department of Medicine, VA Greater Los Angeles Healthcare System, Sepulveda, Calif (Dr Rubenstein).
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