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.
To assess how QI for depression affects health outcomes, quality of
care, and health outcome disparities at 57-month follow-up.
A group-level randomized controlled trial.
Forty-six primary care practices in 6 managed care organizations.
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.
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.
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).
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.