The pilot study of a telephone disease management program for depression

Abstract

Most depressed patients are seen and treated exclusively by primary care clinicians. However, primary care patients with depression are often not adequately treated. The aims of this pilot study were to measure the impact of a telephone disease management program on patient outcome and clinician adherence to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes. Thirty-five primary care practices in the University of Pennsylvania Health System were randomized to telephone disease management (TDM) or “usual care” (UC). All patients received a baseline and a 16-week follow-up clinical evaluation performed over the telephone. Those from TDM practices also received follow-up contact at least every 3 weeks, with formal evaluations at weeks 6 and 12. These interval contacts were designed to facilitate patient and clinician adherence to a treatment algorithm based on the Agency for Health Research and Quality (AHRQ) practice guidelines. Depressive symptoms evaluated with the Community Epidemiologic Survey of Depression (CES-D) scale as well as guideline adherence were the primary outcome measures. Sixty-one patients were enrolled in this pilot project. The overall effect for CES-D scores over time was significant, (P < .001), indicating that those participating in the trial (both TDM and UC groups) showed significant improvement. The interaction between intervention condition and time was also significant (P < .05), indicating that TDM patients improved significantly more over time than did UC patients. A greater proportion of TDM patients had CES-D scores <16 by Week 16 (66.7 versus 33.3%; χ², P < .05). The improvement in depression outcome for the TDM group was related to its impact on improving clinician adherence to depression treatment algorithms. The TDM pilot did not show a statistically significant effect on improving patient adherence to clinician recommendations, however. This preliminary data suggests that TDM for depression improves both clinician guideline adherence and patient outcomes in the acute phase of depression. The effect on patient outcome is at least partially explained by the effect of TDM on clinician adherence to depression treatment algorithms.

Introduction

Depression in primary care is a pressing public health problem [1]. Depression is highly prevalent in primary care settings, and more depressed patients of all ages are seen by primary care clinicians than by specialty mental health providers [2], [3]. A number of efficacious treatments are available to alleviate much of the symptoms, distress, and impairment associated with depression [4]. Still, many of the depressed patients detected in primary care are not adequately treated [5], [6]. Although the Agency for Health Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), has established treatment guidelines for depression in primary care based on current knowledge [7], these guidelines are seldom followed in usual practice [6], [8]. Thus, even those primary care patients identified by clinicians as depressed seldom experience better outcomes than do participants in clinical trials assigned to a placebo control group [9], [10]. Possible limitations to the implementation of practice guidelines for depression were discussed by Cabana et al. [11]. These included lack of awareness of and familiarity with the guidelines, lack of agreement with the recommendations, inertia of previous practice, as well as external variables such as insufficient time and reimbursement.

Disease management (DM) strategies have evolved as a means of overcoming barriers to the delivery of guideline adherent care. In this model, a DM specialist (typically a nurse, social worker, or psychologist) works with the patient to educate them about depression while monitoring their symptoms, treatment adherence, and side effects. In addition, the DM specialist provides feedback to the primary care clinician to assist in treatment planning. The DM model of care has been successfully applied to a number of chronic diseases, including diabetes, asthma, and hypertension [12] and seems an especially promising approach to the treatment of depression, especially given its nature as a chronic illness. Early work using this model with the treatment of depression in primary care has been encouraging and indicates that DM may work at least in part through its impact on patient and clinician adherence [13]. A well-implemented DM program could address many of the barriers to effective care for patients treated in primary care, even for high utilizers of nonpsychiatric health care services, [14], [15], [16], [17], [18].

A key feature of the depression DM program is the incorporation of the AHRQ guidelines [7]. For the acute phase of depression treatment, practitioners should prescribe an antidepressant and/or therapy, followed by weekly or biweekly contact for at least the first 6–8 weeks of treatment. Only when depressive symptoms have significantly improved is it recommended that the frequency of follow-up be reduced. The acute-phase treatment guidelines refer to treatment goals of 50% improvement by 6 weeks and remission of depressive symptoms by 12 weeks. Suggested modifications to treatment when these goals are not met include medication change or augmentation, addition of psychotherapy, or referral to a mental health provider. The AHRQ guidelines and DM can also be applied for the continuation and maintenance phases of depression treatment, where the focus is the prevention of relapse or recurrence of depression. However, it is important to note that adherence to AHRQ guidelines represents only 1 step in improving the outcomes of depressed patients in primary care. A recent review by Bauer [19] reports that only 6 of 13 studies that investigated adherence to practice guidelines and patient outcome found greater rates of adherence to be associated with better patient outcomes. For these purposes, information on patient as well as clinician adherence was analyzed with outcome data in order to better understand the benefits that can be derived from the implementation of depression practice guidelines.

Until the end of 1999, the University of Pennsylvania Health System (UPHS) conducted a series of DM programs to support the activities of the 285 clinicians in its 90 primary care practices. The early experience of this health system was in utilizing a face-to-face depression DM program in which the DM nurse was physically located in the primary care practices at specified times during the week. Our preliminary results were clinical observations without a control group, but it appeared that adherence to practice guidelines by the clinician and the patient had a positive effect on depression outcome [13]. One limitation of this face-to-face model was the difficulty in access for smaller primary care clinics, practitioners in rural settings, or when logistic issues prevent frequent clinical visits.

To address the issue of limited access, attention has turned to delivering DM programs by way of telephone assessments and management. The use of telephone DM (TDM) increases the flexibility of scheduling visits and allows for cost sharing between several clinics for a DM specialist. The use of telephone-based interventions has been shown in randomized trials to be more effective than usual care (UC) alone in the treatment of depression in primary care [14], [18], [20]. However, there is loss of face-to-face contact by the DM nurse, which may limit rapport building with the patient. As well, not having a presence in the clinician’s office may limit how much the clinical practice team sees the DM program as an integrated piece of the service they deliver, and this may limit clinician referrals. For the DM nurse, the clinical practice staff may not be as available in the TDM format to add additional context to the patient’s current distress. On the other hand, some patients may welcome the anonymity and feel less vulnerable talking to the DM nurse over the telephone compared with in person.

For this pilot project, we modified the existing face-to-face model of care into a telephone-based DM program. In this program, telephone contact between patients and a specially trained nurse was used to support the primary care clinician in treating depression. In order to evaluate the effectiveness of the program, we compared the TDM model of care to the UC of depression. However, as a result of the early termination of the TDM program due to financial exigencies in this health system, the program enrollment was limited. The aims of this pilot study were to measure the impact of TDM on patient outcome and clinician adherence (active and passive defined later) to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes. In order to measure the acute effects of TDM, the pilot study focused on the acute-phase (16-week) outcomes of patients who had significant depressive symptoms (Community Epidemiologic Survey of Depression, CES-D, score at least 16) at the time of referral to the study.

The aims of this pilot were to measure the impact of TDM on patient outcome and clinician adherence (active and passive defined later) to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes.