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Long-term Effectiveness of Disseminating Quality Improvement for Depression in Primary Care
Cathy D. Sherbourne, PhD;
Kenneth B. Wells, MD,MPH;
Naihua Duan, PhD;
Jeanne Miranda, PhD;
Jürgen Unützer, MD,MPH;
Lisa Jaycox, PhD;
Michael Schoenbaum, PhD;
Lisa S. Meredith, PhD;
Lisa V. Rubenstein, MD,MPH
Arch Gen Psychiatry. 2001;58:696-703.
Background This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC).
Methods The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years.
Results For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively).
Conclusions While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.
From the Health Program, RAND, Santa Monica, Calif (Drs Sherbourne, Wells, Duan, Jaycox, Schoenbaum, Meredith, and Rubenstein); the Neuropsychiatric Institute and Department of Biobehavioral Services, University of California, Los Angeles (Drs Wells, Duan, and Unützer); the Department of Psychiatry, Georgetown University Medical Center, Washington, DC (Dr Miranda); and the Department of Medicine, VA Greater Los Angeles Healthcare System, Sepulveda, Calif (Dr Rubenstein).
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