A fidelity measure for integrated management of depression in primary care

Med Care. 2006 Nov;44(11):1030-7. doi: 10.1097/01.mlr.0000233683.82254.63.

Abstract

Background: Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure.

Objectives: We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model.

Methods: Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months.

Results: 3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity.

Conclusions: Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

Publication types

  • Comparative Study
  • Evaluation Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Chi-Square Distribution
  • Depressive Disorder / diagnosis
  • Depressive Disorder / therapy*
  • Depressive Disorder, Major / diagnosis
  • Depressive Disorder, Major / therapy
  • Dysthymic Disorder / diagnosis
  • Dysthymic Disorder / therapy
  • Female
  • Follow-Up Studies
  • Humans
  • Logistic Models
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Monitoring, Physiologic
  • Patient Care Team*
  • Patient Compliance
  • Patient Education as Topic
  • Patients
  • Primary Health Care
  • Program Evaluation
  • Psychiatric Status Rating Scales
  • Psychiatry
  • Remission Induction
  • Time Factors
  • Treatment Outcome