Depression is one of the top chronic illnesses treated by primary care practices, but providers may be ill-equipped to manage it, compared with other conditions such as asthma, heart failure, and diabetes.
In a new study, Dr. Tara F. Bishop and her colleagues write that their findings show that more attention should be given “to developing policies and incentives to increase the use of care management processes for depression in primary care.”
Drawing upon data collected in 2012 and 2013 from the National Study of Physician Organizations survey, the researchers assessed whether 1, 070 practices used at least one of five established care management processes across depression, asthma, heart failure, and diabetes. The practice sizes of the physicians surveyed varied, although academic faculty practices and those that had less than 33% primary care physicians were excluded (Health Aff. 2016;35[3]:394-400), Dr. Bishop, a health policy analyst affiliated with Cornell University, New York, and her colleagues wrote.
When compared against an overall mean score of 4.8 on a 20-point scale for care management, the mean score for depression was 0.8, which was significantly lower than the other three chronic conditions (P less than .001). This means that when depression was treated in primary care practices, less than one established management strategy was used.
Registries were the most common care management process employed for depression treatment, but at 30%, was much lower for depression than in the other conditions, which ranged from 33% to 52%. Patient education and patient reminders were virtually unused in depression (P less than .0001).
In addition to registries, the care processes evaluated were nurse care managers, quality data, patient reminders, and patient education provided by support staff. Diabetes scored the highest at 1.7 (standard error, 0.13). Asthma and heart failure each had a score of 1.1 (SE, 1.13 and .07, respectively). Also included in the primary analysis were characteristics such as the extent to which the practice operated according to value-based measures such as patient satisfaction and other external incentives, and the level of health information technology employed.
For a secondary analysis, Dr. Bishop and her colleagues drew from additional data collected from an earlier round of the survey, as well as 2007-2010 data from the National Study of Small and Medium-Sized Physician Practices. A noted limitation of the study was that while all data were derived from responses given by the one person from each practice surveyed who was deemed to be the most knowledgeable overall, this was not verifiably the case. In all, the investigators compared 83 practices from across the country of 20 or more physicians with 719 practices nationwide that had fewer than 20 physicians.
The profile of a typical primary care setting in which depression is treated that emerged from the data was a practice that had been established for at least 2 decades, with an average of 21 physicians (SE, 11.2), 81% of whom were nonspecialists. The mean pay-for-performance score was 0.85 (SE, 0.05), the mean health IT score was 7.22 (SE, 0.28), and the mean score for public reporting was 0.87 (SE, .03).
Among larger practices, when controlling for practice characteristics, diabetes care management was the only one to have increased significantly across the years examined: from 2.57 in 2006-2007 to 3.22 in 2012-2013. In practices with fewer than 20 physicians, there were no significant changes in the care management processes scores for any of the chronic care delivered. However, in all practice sizes, higher pay-for-performance scores were associated with the use of depression care management processes. Smaller, hospital-owned practices that offered multispecialty care and greater levels of health IT were associated with lower depression care management scores.
Additionally, Dr. Bishop and her colleagues found that scores for depression treatment positively correlated with a practice having been established longer, being in the South vs. the Northeast, and having higher health IT scores. Negative correlations were found for depression care management and a practice being multispecialty rather than primary care only, and the practice being in the Midwest vs. the Northeast.
It is unclear whether the minimal use of chronic care processes for depression is attributable to what the authors called “the historical separation between mental and physical health care” or other factors, Dr. Bishop and her colleagues wrote.
The Robert Wood Johnson Foundation funded the study. Dr. Bishop declared support from a National Institute on Aging career development award.
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