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Impacts of evidence-based quality improvement on depression in primary care a randomized experiment

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Abstract

CONTEXT: Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process.

OBJECTIVE: Evaluate impacts of EBQI on practice-wide depression care and outcomes.

DESIGN: Practice-level randomized experiment comparing EBQI with usual care.

SETTING: Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients.

INTERVENTION: Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools.

EVALUATION PARTICIPANTS: Five hundred and sixty-seven representative patients with major depression.

MAIN OUTCOME MEASURES: Appropriate treatment, depression, functional status, and satisfaction.

RESULTS: Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months,P=.07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome,P=.18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months,P=.02); physical functioning did not.

CONCLUSION: Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.

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Authors and Affiliations

  1. VA Greater Los Angeles, 16111 Plummer (152), 91343, North Hills, CA

    Lisa V. Rubenstein MD, MSPH & Martin L. Lee PhD

  2. RAND Health Program, Santa Monica, CA, USA

    Lisa V. Rubenstein MD, MSPH, Lisa S. Meredith PhD, Louise E. Parker PhD, Scot C. Hickey MA & Carole Oken MA

  3. David Geffin School of Medicine and Department of Medicine at UCLA, Los Angeles, CA, USA

    Lisa V. Rubenstein MD, MSPH

  4. Kaiser Permanente Division of Research, Oakland, CA, USA

    Nancy P. Gordon PhD

  5. UCLA School of Public Health, Los Angeles, CA, USA

    Martin L. Lee PhD

Authors
  1. Lisa V. Rubenstein MD, MSPH
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  2. Lisa S. Meredith PhD
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  3. Louise E. Parker PhD
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  4. Nancy P. Gordon PhD
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  5. Scot C. Hickey MA
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Corresponding author

Correspondence to Lisa V. Rubenstein MD, MSPH.

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No conflicts of interest.

L.V.R. was the principal investigator and is guarantor. She designed the study along with L.S.M. and L.E.P. C.O. led data collection. Data analysis was carried out by L.V.R., M.L.L., and S.C.H. with support from all authors. All authors collaborated on interpretation of the data and writing the manuscript. The study could not have taken place without the support of Kaiser Permanente in Northern California and of the VA Greater Los Angeles Healthcare System, Los Angeles, California.

Funding sources: The National Institute for Mental Health, the MacArthur Foundation, and the VA Health Services Research and Development Center of Excellence for the Study of Healthcare Provider Behavior funded the Mental Health Awareness Project upon which this paper is based. The study funders had no involvement in this publication.

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Rubenstein, L.V., Meredith, L.S., Parker, L.E. et al. Impacts of evidence-based quality improvement on depression in primary care a randomized experiment. J GEN INTERN MED 21, 1027–1035 (2006). https://doi.org/10.1111/j.1525-1497.2006.00549.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2006.00549.x

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