The effects of quality improvement for depression in primary care at nine years: results from a randomized, controlled group-level trial

Abstract

Objective: To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.

Data sources: Depressed primary care patients from six U.S. health care organizations.

Study design: Group-level, randomized controlled trial.

Data collection: Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.

Principal findings: At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).

Conclusions: Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.

Figure 1

^*PIC Patient Screening, Enrollment, and 9-Year Follow-up ^*QI-meds indicates quality improvement plus medication management; QI-therapy, quality improvement plus psychotherapy.