Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial

JAMA. 2001 Sep 19;286(11):1325-30. doi: 10.1001/jama.286.11.1325.


Context: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.

Objective: To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.

Design: Group-level randomized controlled trial conducted June 1996 to July 1999.

Setting: Forty-six primary care clinics in 6 community-based managed care organizations.

Participants: One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.

Interventions: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.

Main outcome measures: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.

Results: Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.

Conclusions: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Cost of Illness
  • Cost-Benefit Analysis
  • Depressive Disorder / economics*
  • Depressive Disorder / therapy*
  • Employment
  • Family Practice / economics*
  • Family Practice / standards*
  • Health Care Costs / statistics & numerical data
  • Health Services Research / methods
  • Humans
  • Managed Care Programs / economics
  • Managed Care Programs / standards*
  • Mental Health Services / economics
  • Mental Health Services / standards*
  • Outcome and Process Assessment, Health Care
  • Primary Health Care / economics
  • Primary Health Care / standards*
  • Quality Assurance, Health Care / economics*
  • Quality-Adjusted Life Years
  • United States