A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine
The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.
The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."
The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.
To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.
At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.
A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.
The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said ( N. Engl. J. Med. 2010;363:2611-20 ).
Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.
In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.
"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.
This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.