Abstract
OBJECTIVE: We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians’ knowledge about treatment.
DESIGN AND METHODS: Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians’ knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design.
PARTICIPANTS: One hundred eighty-one primary care clinicians.
INTERVENTIONS: The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy).
RESULTS: Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P=.04 and by 33% for QI-therapy, P=.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P=.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components.
CONCLUSIONS: Dissemination of QI programs for depression in managed, primary care practices improved clinicians’ treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto U.S. mental and addictive disorder service system: Epidemiologic Catchment Area prospective one-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85–94.
Kessler RC, McGonagel KA, Shanzang Z, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.
Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405–18.
Wells KB, Sturm R, Sherbourne CD, Meredith LS. Caring for Depression. Cambridge, Mass: Harvard University Press; 1996.
Sturm R, Wells KB. How can care for depression become more cost-effective? JAMA. 1995;273:51–8.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–5.
Anderson SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians. Gen Hosp Psychiatry. 1990;12:177–90.
Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.
Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.
Lin E, Katon W, Simon G, et al. Achieving guidelines for the treatment of depression in primary care; Is physician education enough? Med Care. 1998;35:831–42.
Greco PJ, Eisenberg JM. Changing physicians’ behavior. New Eng J Med. 1993;329:1271–4.
Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullet: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153:1423–31.
Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA. 1998;279:358–63.
Soumerai SB, Avorn JA. Principles of education outreach (“academic detailing”) to improve clinical decision making. JAMA. 1990;263:549–56.
Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Med Care. 1986;24:659–66.
Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based decision support systems on physician performance and patient outcomes. JAMA. 1998;280:1339–46.
Rubenstein LV, Jackson-Triche M, Unützer J, et al. Evidence-based interventions for depression in managed primary care practices. Health Aff. 1999;18:89–105.
Wells KB. The design of Partners in Care: evaluating the cost-effectiveness of improving care for depression in primary care. Soc Psychiatry Psychiatr Epidemiol. 1999;34:20–9.
Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.
Wasserman S, Faust K. Social Network Analysis: Methods and Applications. Cambridge: Cambridge University Press; 1994.
Partners in Care. Improving Quality of Care for Depression in Primary Care. Santa Monica, Calif: RAND, MR-1198-AHRQ; 2000.
Clinician Guide to Depression Assessment and Management in Primary Care Settings. Santa Monica, Calif: RAND, MR-1198/1-AHRQ; 2000.
Munoz RF, Miranda J. Group Therapy Manual for Cognitive-Behavioral Treatment of Depression. Santa Monica, Calif: RAND, MR-1198/4-AHRQ; 2000.
Munoz RF, Miranda J. Individual Therapy Manual for Cognitive-Behavioral Treatment of Depression. Santa Monica, Calif: RAND, MR-1198/6-AHRQ; 2000.
Rubenstein LV, Jackson-Triche M, Unützer J, et al. Evidence-based interventions for depression in managed primary care practices. Health Affairs. 1999;18:89–105.
Meredith LS, Rubenstein LV, Rost KM, et al. Treating depression in staff model vs network model managed care organizations. J Gen Intern Med. 1999;14:39–48.
Bryk AS, Raudenbush SW. Hierarchical Linear Models: Applications and Data Analysis Methods. Newbury Park, Calif: Sage; 1992.
Kreft GG, De Leeuw J. Introducing Multilevel Modeling. Thousand Oaks, Calif: Sage; 1998.
Goldstein H. Multilevel Statistical Models, 2nd ed. New York: Halstead Press; 1995.
Littell RC, Milliken GA, Stroup WW, Wolfinger RD. SAS System for Mixed Models. Cary, NC: SAS Institute, Inc.; 1996.
Singer JD. Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. J Educ Behavioral Statistics. 1998;24:323–55.
Prochaska JO, DiClemente CC. Stages and processes of self-change in smoking: toward an integrative model of change. J Consulting Clin Psychology. 1983;51:390–5.
Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–65.
Wells KB, Sherbourne CD, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care. JAMA. 2000;283:212–20.
Author information
Authors and Affiliations
Corresponding author
Additional information
This research was supported by grants from the Agency for Health Care Policy and Research (R01-HS08349) and the National Institute of Mental Health (R29-MH55223-01).
Rights and permissions
About this article
Cite this article
Meredith, L.S., Jackson-Triche, M., Duan, N. et al. Quality improvement for depression enhances long-term treatment knowledge for primary care clinicians. J GEN INTERN MED 15, 868–877 (2000). https://doi.org/10.1046/j.1525-1497.2000.91149.x
Issue Date:
DOI: https://doi.org/10.1046/j.1525-1497.2000.91149.x