Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial
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《英国医生杂志》
1 Dartmouth Medical School, HB 7250, Hanover, NH 03755, USA, 2 Center for Health Services Research. Durham Veterans Affairs Medical Center, Durham, NC 27705, USA, 3 Weill Medical College of Cornell University, White Plains, NY 10605, USA, 4 University of Colorado Health Sciences Center, UCHSC at Fitzsimmons, Aurora, CO 80010, USA, 5 Regenstrief Institute, Indianapolis, IN 46202-2859, USA, 6 Portland Veterans Administration Medical Center, Portland, OR 97207-1034, USA, 7 Center for Research Strategies, Denver, CO 80203-1694, USA
Correspondence to: A J Dietrich allen.j.dietrich@dartmouth.edu
Abstract
Depression is frequently treated in primary care,1 yet there are barriers to its effective management.2 3 Recent randomised controlled trials in primary care showed benefits for patients with depression from increased telephone support, better cooperation between primary care and mental health professionals, and more systematic follow up.4-6 Some of these changes are costly, however, and their implementation has required intensive support from research teams. Changes have also proved difficult to sustain outside externally funded research.7
To disseminate these models widely, strategies are needed to support their implementation and maintenance in community settings. To be practical, these strategies should be based on available resources. Our project, the re-engineering systems for primary care treatment of depression, relied on established quality improvement programmes. In the United States these programmes are typically part of the infrastructure of large medical groups. Their charge includes the collection of data on performance quality, the provision of these data to clinicians and administrators, and assistance for clinicians and practices to meet targets through educational support, additional resources, and changes in practice organisation. Similar resources could be developed through national health programmes and professional organisations.8 9
We developed and tested a model of evidence based management of depression that could be widely disseminated. We hypothesised that implementation would improve targeted processes for management of depression and improve outcomes at six months.
Methods
The characteristics of the practices and patients were well balanced (tables 1 and 2). The mean depression score on the Hopkins symptom checklist-20 for the total sample was 2.01, which is consistent with moderate to severe symptoms. According to the mental disorders patient health questionnaire,21 47% of usual care patients and 51% of intervention patients (P = 0.42) had generalised anxiety, panic disorder, or both.
Table 1 Characteristics of practices randomised to manage patients with depression using evidence based model or usual care. Values are numbers (percentages) unless stated otherwise
Table 2 Baseline characteristics of patients being managed for depression with evidence based model or usual care. Values are numbers (percentages) unless stated otherwise
Table 3 describes the process of care. Compared with the usual care clinicians the intervention clinicians more often asked patients about suicidal thoughts, offered educational materials, and assisted in setting self management goals. Intervention patients also received more follow up contact by visits or telephone and were significantly more likely at both three and six months to report receiving good or excellent care. We found no differences between the groups for frequency with which clinicians presented patients with treatment options or elicited their preferences. The patterns of management (drugs alone, counselling alone, or both) did not differ significantly. No adverse events were reported.
Table 3 Process of care for patients being managed for depression with evidence based model or usual care. Values are percentages (numbers/total numbers)
Table 4 presents depression scores, response, and remission based on intention to treat. Intervention patients had better outcomes on all measures at both follow up intervals. Although mean depression scores declined among patients in both groups, the decline was significantly greater in intervention patients: the intervention effect size on the Hopkins symptom checklist-20 was 0.23 at three months and 0.29 at six months.
Table 4 Clinical outcomes for patients being managed for depression with evidence based model or usual care. Values are percentages (number of patients/total number) unless stated otherwise
Log books completed by the care managers indicated that a mean of 20 minutes was expended for each telephone call, including record keeping. The psychiatrists had infrequent contact with the clinicians (< 5% of patients). The clinicians reported negligible time demands from the model aside from administrative duties such as obtaining consent.
Now that our trial is complete, the leaders of the organisations have sustained the model and disseminated it further with local resources. As of March 31, 2004 an additional 139 practices have been supported to implement the model.
Discussion
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50: 85-94.
Ford DE. Managing patients with depression: is primary care up to the challenge? J Gen Intern Med 2000;15: 344-5.
Nutting PA, Rost K, Dickinson M, Werner JJ, Dickinson P, Smith JL, et al. Barriers to initiating depression treatment in primary care practice. J Gen Intern Med 2002;17: 103-11.
Von Korff M, Goldberg D. Improving outcomes in depression. BMJ 2001;323: 948-9.
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. J Gen Intern Med 2001;16: 644-5.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289: 3145-51.
Lin EH, Simon GE, Katon WJ, Russo JE, Von Korff M, Bush TM, et al. Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry 1999;156: 643-5.
Leatherman S, Sutherland K. Quality of care in the NHS of England. BMJ 2004;328: 288-90.
Lewis R, Dixon J. Rethinking management of chronic diseases. BMJ 2004;328: 220-2.
Dietrich AJ, Oxman TE, Williams JW, Kroenke K, Schulberg HC, Bruce M, et al. Going to scale: re-engineering systems for primary care treatment of depression. Annals Fam Med 2004;2: 301-4.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders patient health questionnaire. JAMA 1999;282: 1737-44.
Lipman RS, Covi L, Shapiro AK. The Hopkins symptom checklist (HSCL)—factors derived from the HSCL-90. J Affect Disord 1979;1: 9-24.
Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics 2002;43: 441-50.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16: 606-13.
Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Annals 2002;32: 509-21.
Raudenbush S, Bryk A. Hierarchical linear models. 2nd ed. New York: Sage, 2002.
Verbeke G, Molenberghs G. Linear mixed models in practice: a SAS-oriented approach. New York: Springer, 1997: 222-33.
Diggle P, Liang K, Zeger S. Analysis of longitudinal data. New York: Oxford University Press, 1994.
Hsieh FY. Sample size formulae for intervention studies with the cluster as unit of randomization. Stat Med 1988;7: 1195-201.
Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unutzer J, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283: 212-20.
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272: 1749-56.
Badamgarav E, Weingarten S, Henning J, Knight K, Hasselblad V, Gano A, et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003;160: 2080-90.
Unutzer J, Katon W, Callahan CM, Williams JW Jr., Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288: 2836-45.
Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA 2000;284: 2100-7.
Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz I, Schulberg HC, Mulsant BH, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004;291: 1081-91.
Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. BMJ 2002;325: 934.
Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273: 1026-31.
Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999;56: 1109-15.
Simon GE, Von Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320: 550-4.
Hunkeler E, Meresman J, Hargreaves W, Fireman B, Berman W, Kirsch A, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9: 700-8.
Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, et al. Effectiveness of collaborative care depression treatment in veterans' affairs primary care. J Gen Intern Med 2003;18: 9-16.
Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet 2000;355: 185-91.
Moynihan R. FDA advisory panel calls for suicide warnings over new antidepressants. BMJ 2004;328: 303.
Smith R. Quality improvement reports: a new kind of article . BMJ 2000;321: 1428.(Allen J Dietrich, profess)
Correspondence to: A J Dietrich allen.j.dietrich@dartmouth.edu
Abstract
Depression is frequently treated in primary care,1 yet there are barriers to its effective management.2 3 Recent randomised controlled trials in primary care showed benefits for patients with depression from increased telephone support, better cooperation between primary care and mental health professionals, and more systematic follow up.4-6 Some of these changes are costly, however, and their implementation has required intensive support from research teams. Changes have also proved difficult to sustain outside externally funded research.7
To disseminate these models widely, strategies are needed to support their implementation and maintenance in community settings. To be practical, these strategies should be based on available resources. Our project, the re-engineering systems for primary care treatment of depression, relied on established quality improvement programmes. In the United States these programmes are typically part of the infrastructure of large medical groups. Their charge includes the collection of data on performance quality, the provision of these data to clinicians and administrators, and assistance for clinicians and practices to meet targets through educational support, additional resources, and changes in practice organisation. Similar resources could be developed through national health programmes and professional organisations.8 9
We developed and tested a model of evidence based management of depression that could be widely disseminated. We hypothesised that implementation would improve targeted processes for management of depression and improve outcomes at six months.
Methods
The characteristics of the practices and patients were well balanced (tables 1 and 2). The mean depression score on the Hopkins symptom checklist-20 for the total sample was 2.01, which is consistent with moderate to severe symptoms. According to the mental disorders patient health questionnaire,21 47% of usual care patients and 51% of intervention patients (P = 0.42) had generalised anxiety, panic disorder, or both.
Table 1 Characteristics of practices randomised to manage patients with depression using evidence based model or usual care. Values are numbers (percentages) unless stated otherwise
Table 2 Baseline characteristics of patients being managed for depression with evidence based model or usual care. Values are numbers (percentages) unless stated otherwise
Table 3 describes the process of care. Compared with the usual care clinicians the intervention clinicians more often asked patients about suicidal thoughts, offered educational materials, and assisted in setting self management goals. Intervention patients also received more follow up contact by visits or telephone and were significantly more likely at both three and six months to report receiving good or excellent care. We found no differences between the groups for frequency with which clinicians presented patients with treatment options or elicited their preferences. The patterns of management (drugs alone, counselling alone, or both) did not differ significantly. No adverse events were reported.
Table 3 Process of care for patients being managed for depression with evidence based model or usual care. Values are percentages (numbers/total numbers)
Table 4 presents depression scores, response, and remission based on intention to treat. Intervention patients had better outcomes on all measures at both follow up intervals. Although mean depression scores declined among patients in both groups, the decline was significantly greater in intervention patients: the intervention effect size on the Hopkins symptom checklist-20 was 0.23 at three months and 0.29 at six months.
Table 4 Clinical outcomes for patients being managed for depression with evidence based model or usual care. Values are percentages (number of patients/total number) unless stated otherwise
Log books completed by the care managers indicated that a mean of 20 minutes was expended for each telephone call, including record keeping. The psychiatrists had infrequent contact with the clinicians (< 5% of patients). The clinicians reported negligible time demands from the model aside from administrative duties such as obtaining consent.
Now that our trial is complete, the leaders of the organisations have sustained the model and disseminated it further with local resources. As of March 31, 2004 an additional 139 practices have been supported to implement the model.
Discussion
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50: 85-94.
Ford DE. Managing patients with depression: is primary care up to the challenge? J Gen Intern Med 2000;15: 344-5.
Nutting PA, Rost K, Dickinson M, Werner JJ, Dickinson P, Smith JL, et al. Barriers to initiating depression treatment in primary care practice. J Gen Intern Med 2002;17: 103-11.
Von Korff M, Goldberg D. Improving outcomes in depression. BMJ 2001;323: 948-9.
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. J Gen Intern Med 2001;16: 644-5.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003;289: 3145-51.
Lin EH, Simon GE, Katon WJ, Russo JE, Von Korff M, Bush TM, et al. Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry 1999;156: 643-5.
Leatherman S, Sutherland K. Quality of care in the NHS of England. BMJ 2004;328: 288-90.
Lewis R, Dixon J. Rethinking management of chronic diseases. BMJ 2004;328: 220-2.
Dietrich AJ, Oxman TE, Williams JW, Kroenke K, Schulberg HC, Bruce M, et al. Going to scale: re-engineering systems for primary care treatment of depression. Annals Fam Med 2004;2: 301-4.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders patient health questionnaire. JAMA 1999;282: 1737-44.
Lipman RS, Covi L, Shapiro AK. The Hopkins symptom checklist (HSCL)—factors derived from the HSCL-90. J Affect Disord 1979;1: 9-24.
Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics 2002;43: 441-50.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16: 606-13.
Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Annals 2002;32: 509-21.
Raudenbush S, Bryk A. Hierarchical linear models. 2nd ed. New York: Sage, 2002.
Verbeke G, Molenberghs G. Linear mixed models in practice: a SAS-oriented approach. New York: Springer, 1997: 222-33.
Diggle P, Liang K, Zeger S. Analysis of longitudinal data. New York: Oxford University Press, 1994.
Hsieh FY. Sample size formulae for intervention studies with the cluster as unit of randomization. Stat Med 1988;7: 1195-201.
Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unutzer J, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283: 212-20.
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272: 1749-56.
Badamgarav E, Weingarten S, Henning J, Knight K, Hasselblad V, Gano A, et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003;160: 2080-90.
Unutzer J, Katon W, Callahan CM, Williams JW Jr., Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288: 2836-45.
Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA 2000;284: 2100-7.
Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz I, Schulberg HC, Mulsant BH, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004;291: 1081-91.
Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. BMJ 2002;325: 934.
Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273: 1026-31.
Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999;56: 1109-15.
Simon GE, Von Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320: 550-4.
Hunkeler E, Meresman J, Hargreaves W, Fireman B, Berman W, Kirsch A, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9: 700-8.
Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, et al. Effectiveness of collaborative care depression treatment in veterans' affairs primary care. J Gen Intern Med 2003;18: 9-16.
Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet 2000;355: 185-91.
Moynihan R. FDA advisory panel calls for suicide warnings over new antidepressants. BMJ 2004;328: 303.
Smith R. Quality improvement reports: a new kind of article . BMJ 2000;321: 1428.(Allen J Dietrich, profess)