Customize your JAMA Network experience by selecting one or more topics from the list below.
Get the latest research based on your areas of interest.
Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of Disseminating Quality Improvement Programs for Depression in Managed Primary Care: A Randomized Controlled Trial. JAMA. 2000;283(2):212–220. doi:10.1001/jama.283.2.212
Author Affiliations: RAND, Health Program, Santa Monica, Calif (Drs Wells, Sherbourne, Schoenbaum, Duan, Meredith, Rubenstein, and Ms Carney); UCLA-Neuropsychiatric Institute and Department of Psychiatry and Biobehavioral Sciences (Drs Wells and Unützer) and Department of Medicine (Dr Rubenstein), School of Medicine, University of California, Los Angeles; Department of Psychiatry, Georgetown University Medical Center, Washington, DC (Dr Miranda); and Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, Calif (Dr Rubenstein).
Context Care of patients with depression in managed primary care settings often
fails to meet guideline standards, but the long-term impact of quality improvement
(QI) programs for depression care in such settings is unknown.
Objective To determine if QI programs in managed care practices for depressed
primary care patients improve quality of care, health outcomes, and employment.
Design Randomized controlled trial initiated from June 1996 to March 1997.
Setting Forty-six primary care clinics in 6 US managed care organizations.
Participants Of 27,332 consecutively screened patients, 1356 with current depressive
symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.
Interventions Matched clinics were randomized to usual care (mailing of practice guidelines)
or to 1 of 2 QI programs that involved institutional commitment to QI, training
local experts and nurse specialists to provide clinician and patient education,
identification of a pool of potentially depressed patients, and either nurses
for medication follow-up or access to trained psychotherapists.
Main Outcome Measures Process of care (use of antidepressant medication, mental health specialty
counseling visits, medical visits for mental health problems, any medical
visits), health outcomes (probable depression and health-related quality of
life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.
Results Patients in QI (n = 913) and control (n = 443) clinics did not differ
significantly at baseline in service use, HRQOL, or employment after nonresponse
weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling
or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of
having any medical visit at any point (each P≥.21).
At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit
for mental health problems (P = .001), and QI patients
were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still
met criteria for probable depressive disorder (P
= .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working
at 12 months relative to controls (P = .05).
Conclusions When these managed primary care practices implemented QI programs that
improve opportunities for depression treatment without mandating it, quality
of care, mental health outcomes, and retention of employment of depressed
patients improved over a year, while medical visits did not increase overall.
Create a personal account or sign in to: