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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
What's Good for the Patient Is Good for the Business Case
A request for clarification on patient demographics
Related Research
The Unavoidable Constraints of Delivering Improved Depression Care
Commentary on Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis
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John A. Bachman, Brentwood, USA Psychologist
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In numerous previous publications, Rost and colleagues have emphasized the clinical importance of treating depression as the chronic disease it is. That is, their research extends “enhanced” primary care interventions over two years and shows that the positive clinical outcomes attained within six months of treatment initiation are sustainable over 24 months. In their latest contribution published here, Rost et al. add valuable information to the developing “business case” for depression in primary care. Their analyses show that with enhanced care “incremental QALYs significantly increase with time while incremental costs decline.” (The exclusion of productivity costs from the analyses produced a conservative estimate of cost-effectiveness.) Their data suggest that the reduced health care utilization from enhanced care management was sufficient to pay for its cost during the second year of treatment. The potential for such medical cost-offsets accruing to health plans that provide ongoing care management to depressed enrollees increases the likelihood of their investing in the chronic illness-primary care model of depression management. Competing interests: None declared |
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Dean A. Seehusen, Evans, GA Family Physician, Eisenhower Army Medical Center
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This article by Rost et al is a valuable contribution to the literature depression treatment. Viewing and treating depression from a disease management standpoint tacitly feels right. It is encouraging to know that it might also be cost effective. Like any reader of the medical literature should be, I am always wary of any post hoc analysis. I would be interested in knowing if there were any other significant differences between the 211 patients included in this study and the 268 excluded, other than their being depressed despite recent treatment, that might explain the differential response to therapy noted. Competing interests: None declared |
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Kurt C. Stange, USA Family Physician, Editor
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The editorial by Dr. deGruy refers to a related manscript to the paper by Rost et al published in this issue of Annals. The related paper shows a substantial cost-offset for employer purchasers when depressed patients are treated. Interested readers may find this related article as follows: Rost, K.M., Smith, J.L., Elliott C.E., and Dickinson L.M. (2004). The effect of improving primary care depression management on employee absenteeism and productivity: A randomized trial. Medical Care, 42, 1202- 1210. Competing interests: None declared |
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Kathryn Rost, Aurora CO Professor, UCHSC, Jeffrey M. Pyne, L. Miriam Dickinson, and Anthony T. LoSasso
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Many thanks to Dr. Lin for her carefully considered comments. Dr. Lin and I are in total agreement that enhanced depression treatment needs to be incorporated as a part of routine care for patients who benefit by it. However, our research team has uncovered little to no evidence that enhanced depression care improves outcomes for primary care patients who remain depressed despite treatment. Every investigator who has analyzed his/her cohort by new treatment episode reports that patients who remain depressed despite treatment achieve little improvement with these models. Patients who remain depressed despite treatment include an estimated 10- 30% of patients with treatment-resistant depression who may achieve better outcomes in specialty care settings, as they would for any other disease. This targeting is particularly true for all primary care physicians who treat patients covered by multiple insurers because these physicians do not have ready access to psychiatric consultation for medication adjustment provided in staff model HMOs and the Impact study. Instead of trying to disseminate these programs to all depressed patients, we are focusing our efforts to disseminate ongoing programs rather than acute programs because acute intervention demonstrates little effectiveness at 2 years. Rather than trying to illustrate a 'best-case scenario', our research designed our cost-effectiveness analysis to illustrate what we believe to be the 'real-case scenario' that should guide program adoption. If we do not target improved depression care to the population who will benefit and deliver it on an ongoing basis, one day a bright graduate school student will evalute its outcomes and report that it does not 'work'. They will be right. Also respectfully submitted, Kathryn Rost, PhD Competing interests: None declared |
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Elizabeth H.B. Lin MD, MPH, Seattle, USA Primary Care Physician/Scientific Investigator, Group Health Cooperative
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In this issue of Annals of Family Medicine, Dr. Kathryn Rost and colleagues showed that by identifying patients newly treated for depression, there is potential cost savings in the second year after treatment, and while the number of depression free days continue to accrue. This study illustrates a “best-case scenario” because it includes the subset of patients who started a new depression treatment episode and benefited from the enhanced depression care intervention. It excludes those patients who have been already receiving treatment and did not benefit from this level of enhanced depression care. This primary care population was middle aged (mean age= 43 yrs), and had 2.1 physical co morbidities. Dr. Rost’s article contributes to the hot topic of cost-effectiveness of enhanced depression services care management. Strategies to identify patients most likely to show cost-effectiveness of depression care management have ranged from targeting patients most likely to achieve good clinical outcomes as in Dr. Rost and colleagues’ sample, to focusing on patients at highest risk of poor outcomes including high users of health services and /or those with severe medical comorbidities. A key issue facing our health care system and health policy leaders stems from the disparity and stigma that still compromise depression treatment in general medical settings. Many a beneficial treatment for diabetes and heart disease or cancer has been widely adopted before cost- effectiveness studies. By now there is a wealth of scientific evidence demonstrating the benefits of enhanced care for depression in primary care settings. Moreover, the consistent link between depression and adverse “hard” outcomes such as mortality highlight the need to address mood disorders as well as physical conditions for improving patient outcomes. Granted, cost of services need to be considered as we disseminate enhanced depression care into everyday practice. However, our policy leaders need to acknowledge this double standard and lessen the disparity between mental and behavioral health services versus physical health services for primary care patients. Respectfully Submitted, Elizabeth HB Lin MD, MPH Competing interests: None declared |
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