INTRODUCTION

Depression is a common, disabling, and costly condition that is often chronic or recurrent1. Over 35 randomized controlled trials have proven that practice system changes in primary care can greatly improve response and remission rates while improving work productivity and long-term health care costs2–5. These practice system changes include a care manager to coordinate care, scheduled consultation of the primary care team with mental health specialists, treatment intensification when depression does not improve, relapse prevention, and systematic evaluation, monitoring, and follow-up6. However, there continues to be a large gap between evidence-based care and the care most patients with depression receive7–10.

In previous research conducted by us in 2005, interviews with medical directors and quality improvement coordinators from Minnesota practices about barriers to improving depression care most frequently cited delivery system issues related to screening, diagnosis, follow-up, and education11. Additional surveys of medical groups showed that in fact, with the exception of standardized symptom assessment tools, fewer practice system tools were in place to support depression care (e.g. registries, flow sheets, checklists, practice guidelines, performance feedback, case managers, or reminder systems) compared to other chronic conditions such as diabetes and coronary artery disease12.

Depression care has been a focus of quality improvement efforts in Minnesota for many years, led by the Institute for Clinical Systems Improvement (ICSI), a statewide clinical quality improvement collaborative. These included depression guideline development and implementation efforts, and health plan and employer depression care pay-for-performance programs. In 2008 a new state-wide initiative was launched called Depression Improvement Across Minnesota, Offering a new Direction (DIAMOND). In this initiative, key practice system changes of the collaborative care model were identified for reimbursement through a bundled payment for adult patients with depression in primary care. In this paper, we describe the prevalence of practice system tools for care of depression and other chronic conditions in individual primary care clinics choosing to participate in this initiative in 2008. If these systems continue to be absent from most primary care practices, as they were in 2005, this would provide both a challenge and opportunity for clinics interested in improving depression care.

METHODS

The results presented here are part of a larger study of the DIAMOND initiative being carried out in 82 primary care clinics in Minnesota. The DIAMOND initiative provides training and assistance for clinics implementing an evidence-based collaborative care model for depression. The model is based on methods proven to be effective in the IMPACT study and similar randomized trials13,14. This model for depression care includes a depression registry, care coordination and close follow-up of patients by a non-physician care manager, regular symptom monitoring using a validated instrument, measurement-based stepped care medication adjustments, relapse prevention, and pre-arranged weekly case reviews with a consulting psychiatrist. A detailed description of the DIAMOND initiative has been published15,16. The research program evaluating DIAMOND was approved by the HealthPartners Institutional Review Board.

An email was sent to the physician identified as the medical leader at each of the 82 clinic sites participating in the DIAMOND Study in 2008 prior to the start of the initiative. The email requested completion of a questionnaire to evaluate practice systems for depression, and contained a link to an electronic version of the survey. A reminder email was sent up to three times if no response was received. Persistent non-respondents (approximately 30%) then received phone calls from the study manager and principal investigator (LS) to verify that they had received the survey, answer any questions, and encourage response.

The survey used to evaluate and monitor the changes in practice systems was a modification of a questionnaire that had been developed by the National Committee on Quality Assurance (NCQA), called Physician Practice Connections (PPC). This questionnaire was developed by an expert panel to measure the presence and function of chronic disease practice systems within the framework of the Chronic Care Model (CCM) for use in evaluating various pay-for-performance demonstrations. The development process built on an extensive literature review, input from experts and key stakeholders, and multiple pre-testing efforts with physician practices17–19. The PPC addresses five of the six domains of the CCM: health systems (sometimes designated health care organization), delivery system redesign, clinical information systems, decision support, and self-management support.20 This instrument was subsequently modified to become the basis for the NCQA recognition program for patient-centered medical homes nationally (as the PPC-PCMH).

In order to modify the original PPC for this study, 53 (out of 98) individual items relevant to depression care or the CCM were selected that were not specific for various other chronic conditions (and in some cases slightly modified only by adding the term depression to the current wording of the question to focus on depression as opposed to all chronic conditions). Nine other new items were added to cover specific practice systems required for the DIAMOND initiative, as well as a previously tested question asking for the organizational priority for improving depression (on a scale from 1–10). This revised version, called the Physician Practice Connections for Research in Depression (PPC-RD) thus consisted of a total of 63 items and took about 10 minutes to complete. The entire PPC-RD survey is included as an appendix (available online).

We classified the items in the PPC-RD survey into three categories: DIAMOND (21 items specific to depression and consistent with the DIAMOND care management approach), non-DIAMOND depression (20 items relevant for depression and the CCM but not specific for DIAMOND), and non-depression CCM (21 items relevant for any chronic condition). A Depression-Specific scale was comprised of the 21 DIAMOND and the 20 non-DIAMOND depression items; this scale did not include items unless they were directly relevant to practice systems for depression care (e.g. items about immunization and a care manager for asthma were not included). A CCM scale was comprised of the 20 non-DIAMOND depression and the 21 non-depression CCM items; this scale did not include practice systems that were highly specific to the DIAMOND intervention (e.g. measuring depression severity monthly, having a care manager for depression). Both scales were scored as the proportion (0-100%) of all items in the scale that were present. Most items asked if practice systems that were present “work well” or “need improvement”, and items reported as needing improvement only received half credit compared to those that worked well. In addition, the Depression-Specific and CCM scales were each subdivided into scores for each of the five domains of the CCM. Items from the original PPC, including those slightly modified to focus on depression, were assigned to the same CCM subscale they were assigned to in the original PPC. New items added to the PPC-RD to measure DIAMOND practice systems were assigned to the CCM subscales based on the judgment of the entire investigator team.

We described the characteristics of the participating clinics, the depression priority scores, the results for each Depression-Specific scale item, the Depression-Specific scale score and subscale scores, and the CCM scale score and subscale scores. Bivariate relationships between the PPC-RD scales and depression care priority were estimated using Pearson correlation coefficients. In addition, general linear models tested whether PPC-RD scale scores differed as a function of four clinic characteristics, using a critical value of p < 0.05 to denote statistical significance of pairwise comparisons. We did not adjust the p-value for multiple comparisons, but note that given the 48 comparisons that were performed, two or three would be expected to occur by chance alone.

RESULTS

We obtained completed PPC-RD surveys from all 82 clinics. In Minnesota, most primary care physicians are organized into single or multi-specialty organizations termed “medical groups” that usually include a number of clinics or practice sites. There were 22 medical groups represented in our sample, and 10 (45%) of these had one or more psychiatrists on staff within the medical group. In aggregate, the medical groups reported that about 50% of patients had commercial insurance, 20% had Medicare, 11% had Medicaid, 13% had some other type of insurance, and 3% were uninsured. Among the 22 medical groups, 8 were represented in this analysis by 1 clinic, 7 by 2–3 clinics, and 7 by 4 or more clinics. Just over half of the clinics were in the Twin Cities metropolitan area (Table 1). The clinics varied widely in their staffing by adult primary care physicians and RNs. An electronic medical record (EMR) which included all laboratory, radiology and pharmacy ordering and data functions was present in 61% of the clinics. Nearly half of the clinics had a care manager for patients with diabetes, but few had care managers for other chronic conditions, including depression. The average priority for improving depression care was 5.8 (SD = 2.3). Approximately a quarter of clinic leaders rated their clinic as having a low priority for improving depression care (rating 1–4), while 41% rated it a high priority (rating 7–10).

Table 1 Characteristics of the 82 Primary Care Clinics and Priority for Improving Depression care
Full size table

Table 2 displays responses to the 41 Depression-Specific scale items from the PPC-RD survey. Very few practice system tools were rated as present and functioning well for depression care. The majority of clinics did not have performance measurements or quality improvement initiatives for depression care, and these were rated as needing improvement when they were present. The delivery system redesign tools that were most often in place and functioning well for depression care were use of standing orders and medication reviews. Only a few clinics had practice systems for patient appointment reminders, pre-visit planning, and evaluation of alcohol/chemical dependency that were rated as well-functioning for depression care. A small minority of clinics had other key elements of care delivery systems that have been shown to improve depression care: involving non-physician staff, regular measurement of symptom severity, monitoring treatment response and adherence, follow-up of missed appointments, or a care manager. Most clinics did not have tracking systems for depression patients or their care.

Table 2 Presence and Functionality of 41 Depression-Specific Scale Items from the PPC-RD Survey in 82 Clinics by Chronic Care Model Domain*
Full size table

A majority of clinics did have a depression care guideline and systems to assure that depression diagnostic codes were used and that treatment was intensified, but most reported that the latter did not function well. Few clinics had a well-functioning practice system for psychiatrists to review care for patients who were failing to improve. Self-management support systems were most often in place for individualized care management plans and treatment goals, and review of clinical measures (e.g. PHQ9 scores). Only rudimentary practice systems were in place to address loss to follow-up, failure to refill anti-depressants, barriers to treatment, relapse prevention or referral to self-management programs.

The composite score for Depression-Specific scale was 24, much lower than the more general CCM scale score of 44 (Table 3). The Depression-Specific subscale scores were also lower for Delivery System Redesign, Clinical Information Systems, and Decision Support. For both Depression-Specific and CCM scales, the highest subscale score was for Decision Support and the lowest for Health Systems. Correlations between the clinic priority for improving depression care and the depression and CCM PPC-RD scales and subscales were low, ranging from 0.02 – 0.19, and non-significant with the exception of the Depression-Specific Decision Support subscale (r = 0.29, p = 0.008).

Table 3 Mean (Standard Deviation) and Significance of Paired Comparisons of PPC-RD Depression-Specific and CCM Scale and Subscale Scores from 82 Clinics
Full size table

We next examined the associations of other clinic characteristics with the PPC-RD scales. Twin Cities metropolitan area clinics had higher scores than non-metropolitan area clinics on the CCM scale (46 vs. 41, p = 0.04) as well as its Clinical Information Systems (67 vs. 56, p = 0.007) and Decision Support subscales (73 vs. 63, p = 0.04). Clinics with 3–5 primary care physicians had the highest scores on the Depression-Specific and CCM scales and most of the subscales. The differences were statistically significant from all other categories of physician staffing for the CCM scale and the CCM Decision Support subscale (Table 4). Clinics with the largest number of RNs had the lowest scores on the Depression-Specific and CCM scales and most of the subscales. The differences were statistically significant from all other categories of RN staffing for the Depression-Specific scale and its Decision Support subscale (Table 4). Clinics with a fully functional EMR had a higher overall CCM scale (46.1 vs. 40.8, p = 0.05) and Clinical Information Systems subscale of both the CCM scale (68.3 vs. 53.3, p <.001) and Depression-Specific scale (18.0 vs. 9.4, p = 0.05) compared to clinics with other medical records systems.

Table 4 PPC-RD Depression-Specific Scale Scores and Decision Support (DS) Subscales, Stratified by Number of Adult Primary Care Physicians (PCPs) and Registered Nurses (RNs) in Clinic
Full size table

DISCUSSION

Our survey results show that few practice system tools were in place for depression in Minnesota clinical practices prior to the start of the DIAMOND Initiative, even among those clinics and medical groups with enough interest in improving depression to volunteer to participate in a major initiative on the topic. Only a small portion of those practice systems that were present were reported to be functioning well. Overall, the Depression-Specific composite scale score was much lower than the CCM composite scale score, suggesting that practice systems for depression care are less well-developed than general chronic disease practice systems.

While the literature on the relation between practice systems and quality of care is still developing, the evidence for this relationship is increasing21–26. The CCM was developed based on that concept and its supporting evidence is largely focused on practice systems20. The many randomized trials proving how to improve depression care were essentially tests of depression practice system interventions2,3. Finally, we have previously shown that scores on the original PPC were correlated with measures of both process and outcome quality for diabetes among 40 medical groups in Minnesota27. Unfortunately, these systems are still infrequently present, even in larger medical groups. In their study of 1,104 medical groups larger than 20 physicians, Casalino et al. demonstrated that even these larger organizations had relatively few practice systems for care management28.

While metropolitan area clinics had somewhat higher scores for some practice systems for chronic disease care, metropolitan clinic location did not confer any advantage in having more practice systems for depression care. The association of small-to-medium size clinics with 3–5 adult primary care physicians with a higher CCM scale score suggests that larger clinics with more providers in Minnesota are not more likely to have advanced practice systems for chronic disease care. However, it is important to keep in mind that individual clinic size does not necessarily correlate with the size of its overall medical group or number of care sites. The inverse association of staffing by RNs with the presence of practice system tools for chronic care and depression care was quite surprising to us. Perhaps clinics relying primarily on medical assistants and licensed practical nurses have a greater need for well-established systems to guide them in the provision of care. Because about 10% of clinics lacked data on this variable, it should be interpreted somewhat cautiously.

In clinics with a fully functional EMR, there was some evidence for modestly higher overall scores on the CCM scale measuring chronic disease practice systems. Not surprisingly, the Clinical Information Systems subscales were associated with the presence of a fully functional EMR. However, given the remarkably high frequency of well-developed EMRs in this sample of clinics, it is noteworthy that presence of an EMR does not insure that other practice systems have been developed to facilitate consistent, high quality depression care.

In previous research in Minnesota medical groups in 2005 that included some but not all of the clinics in the current sample, we found far fewer practice systems for depression care than for other chronic diseases, especially compared to diabetes care for which practice systems are well-developed12. Qualitative analysis of interviews with medical group leaders showed that barriers to improving depression care included the following factors: low reimbursement, competing demands by payors, internal change, difficulty measuring and diagnosing depression, the time and complexity of depression care, lack of provider and patient willingness to address depression, and problems in access and coordination with mental health care11. Responses to similar questions on the current questionnaire regarding flow-sheets for depression care, adoption of depression practice guidelines, and the presence of care managers for depression showed little change on average over the ensuing 3 years. Although the Health Plan Employer Data and Information Set (HEDIS) benchmarks may not be ideal for measuring depression care, they provide a national standard for comparison. Mean HEDIS rates in 2005 and 2008 for anti-depressant medication continuation at 3 months (61% vs. 63%) and 6 months (45% and 46% ) have changed little for patients with commercial insurance, suggesting that the lack of progress that motivated the current depression initiative in Minnesota is mirrored in the rest of the nation29,30.

Our study has a number of limitations. By design, our sample over-represents non-metropolitan area clinics. All of the study clinics were from medical groups that were members of ICSI and volunteered for DIAMOND; thus they may not be representative of Minnesota clinics in other ways as well. However, since this sample of clinics had few of the practice systems needed to improve depression care, it seems likely that typical clinics have even fewer. The scales used here have not yet been shown in a longitudinal study to predict better depression care, but ongoing work in the DIAMOND study will provide data to answer this question via periodic reassessment of the PPC-RD in these 82 clinics and measurement of depression care and symptoms in their patients.

We conclude that there is much room for improvement in practice systems for depression care. Such practice systems are needed for clinics to become accredited as medical homes, and it is likely that their implementation will result in much-needed improvements in care for patients with depression.