Article Figures & Data
Figures
- Figure 1
Study patient flow diagram.
DIAMOND = Depression Improvement Across Minnesota-Offering a New Direction; UCB = usual care before implementation; UCA = usual care in DIAMOND clinic after implementation; DCA = DIAMOND care after implementation; UC = usual care in comparison clinics.
Tables
Characteristic All N = 2,348 DCA n = 340 UCA n = 861 UCB n = 697 UC n = 450 P Value Sequence, % 1 12.2 29.4 20.4 1.6 2 24.0 32.1 37.4 18.9 3 13.0 12.3 17.0 16.6 4 14.5 12.1 15.1 24.3 5 17.0 12.3 10.1 38.6 Not sequenced 19.1 100.0 Clinic unknown 0.2 1.8 Female, % 72.7 75.9 70.9 73.6 72.2 .31 Age, mean (SD), y 44.4 (14.9) 44.4 (14.5) 44.5 (15.7) 44.2 (14.3) 44.3 (14.6) .97 Insurance type, % <.001 Commercial 65.3 67.7 61.3 68.3 66.4 State program 25.1 25.9 27.1 22.5 24.7 Medicare 6.9 4.4 10.2 5.2 5.3 Other/unknown 2.7 1.8 1.4 4.1 3.6 Education, % .37 High school or less 31.0 31.2 31.4 31.5 28.9 Some college 38.2 37.9 35.5 40.2 40.2 College degree 31.0 30.9 33.1 28.3 30.9 Marital status, % <.005 Married 45.8 45.9 42.3 47.9 49.3 Never married 23.4 23.8 28.0 20.5 18.7 Other 31.2 33.3 29–8 31.5 32.0 Hispanic, % 3.8 6.2 3.7 2.2 4.7 <.01 Race, % <.001 White 88.7 83.8 90.4 91.2 85.3 Black 5.1 8.2 4.3 3.0 7.6 Other 6.2 7.1 5.5 5.8 7.1 Antidepressant medication >4 wk, % 47.0 42.9 50.9 48.5 40.4 <.005 Depression care (medication or therapy) >4 wk, % 58.6 57.1 63.3 58.3 51.3 <.001 Baseline PHQ-9 score, mean (SD) 12.4 (4.5) 13.4 (4.7) 12.0 (4.4) 12.4 (4.5) 12.5 (4.5) <.001 7–9 32.2 25.3 35.9 30.6 32.7 <.001 10–14 38.9 36.5 40.5 39.9 36.0 15–19 19.6 25.9 15.8 20.4 21.1 >20 9.3 12.4 7.8 9.2 10.2 Previous depression care, % <.005 None 37.4 44.7 36.7 35.7 36.0 Once 23.5 21.8 25.1 20.2 26.7 2 or more 36.0 31.5 33.8 41.5 34.9 Depression treatment, % Medication 98.6 97.7 98.6 99.0 98.7 .39 Counseling 27.5 39.1 25.7 25.1 26.0 <.001 Group therapy 3.8 4.7 3.5 2.9 4.9 .25 Psychiatrist 5.5 6.2 4.8 5.9 5.8 .69 Other 4.0 5.6 4.0 4.2 2.4 .16 Employment, % <.01 Employed for wages 56.9 60.3 52.4 60.3 58.0 Self-employed 5.4 1.8 6.3 5.3 6.4 Out of work 12.1 14.4 13.7 9.4 11.1 Unable to work 9.3 7.1 9.9 9.3 10.2 Other 16.1 16.3 17.3 15.6 14.3 Poverty, % .34 Below 2 times poverty level 34.9 34.3 37.2 32.8 34.0 Above 2 times poverty level 65.2 65.7 62.8 67.2 66.1 DCA = DIAMOND care after; DIAMOND = Depression Improvement Across Minnesota–Offering a New Direction; PHQ-9 = 9-item Patient Health Questionnaire depression scale; UC = usual care; UCA = usual care after; UCB = usual care before.
Variable No. Percent or Mean No. (SD) Range Clinic Location Metropolitan Twin Cities 38 50.7 Nonmetropolitan 37 49.3 Ownership Health system 51 68.0 Health plan 2 2.7 Physicians 21 28.0 No. of primary care physicians for adults 8.6 (7.8) 1–39 1–2 8 10.7 3–5 21 28.0 6–10 33 44.0 >10 13 17.3 Any in medical group Psychiatrists 37 49.3 Mental health therapists 38 50.7 No. of NPs/PAs for adults 2.1 (1.9) 0–8 0 16 21.3 1–2 32 42.7 >2 27 36.0 Sites in medical group 15.6 (11.8) 1–48 1–2 4 5.3 3–5 16 21.3 6–10 4 5.3 >10 50 66.7 Patients’ insurance Commercial 52.4 (18.9) 4–80 0%–10% 2 2.7 11%–25% 6 8.0 >25% 64 85.3 Medicare 23.8 (10.6) 10–38 0%–10% 12 16.0 11%–25% 35 46.7 >25% 25 33.3 Medicaid 12.0 (11.3) 3–55 0%–10% 48 64.0 11%–25% 20 26.7 >25% 4 5.3 Uninsured 3.9 (3.1) 0–10 0%–10% 72 96.0 NP = nurse practitioner; PA = physician assistant.
- Table 3
Model-Predicted Depression Care Process and Outcome Measures, Adjusted for Secular Trend and Weighted by Survey Response and Treatment Selection Likelihoods
Treatment Model No. Care Process 6 mo Response 6 mo (%) Remission 6 mo (%) PHQ-9 Baseline 6 mo Usual care before 466 Mean 6.5a 46.1 35.8 12.2b 7.8c SE 0.2 2.7 2.6 0.2 0.3 Cohen’s f2,d 0.088 Usual care after 559 Mean 6.4a 46.3 35.0 12.7 7.7c SE 0.2 2.7 2.6 0.2 0.3 Cohen’s f2,d 0.127 DIAMOND care after 245 Mean 10.9 46.7 36.4 13.2 8.0c SE 0.3 4.4 4.2 0.3 0.4 Usual care 308 Mean 6.7a 46.4 33.9 12.3e 7.8c SE 0.3 3.1 3.0 0.2 0.4 Cohen’s f2,d 0.058 P valuef <.001 .99 .94 <.06 .92 DIAMOND = Depression Improvement Across Minnesota–Offering a New Direction; PHQ-9 = 9-item Patient Health Questionnaire depression scale; SE = standard error.
↵a P <.001 relative to DIAMOND care after treatment group.
↵b P <.01.
↵c P <.001 change from baseline to 6 months.
↵d Cohen’s f2 for comparison group relative to DIAMOND care after.
↵e P <.05.
↵f P values for treatment group effect at denoted measurement point.
- Table 4
Model-Predicted Secondary Outcomes, Adjusted for Secular Trend and Weighted by Survey Response and Treatment Selection Likelihoods
Productivity Loss Health Status Satisfaction Treatment Model No.a Baseline 6 mo Baseline 6 mo Baseline 6 mo Usual care before Mean 296 37.0 24.5b 3.04 3.16c 3.41d 3.44d SE 1.4 1.6 0.04 0.05 0.05 0.05 Cohen’s f2 0.002 0.018 Usual care after Mean 311 36.7 26.9b 3.00 3.10e 3.45d 3.37d SE 1.5 1.6 0.04 0.05 0.05 0.06 Cohen’s f2 0.001 0.001 DIAMOND care after Mean 135 39.8 31.0 2.97 3.13 3.74 3.95e SE 2.5 3.8 0.07 0.08 0.06 0.07 Usual care Mean 191 37.7 26.9b 2.92 3.12b 3.21d 3.35d SE 1.8 2.1 0.05 0.06 0.06 0.07 Cohen’s f2 0.008 0.018 P valuef .70 .40 .27 .86 <.001 <.001 DIAMOND = Depression Improvement Across Minnesota–Offering a New Direction; SE = standard error.
↵a For productivity loss analysis; numbers for other outcomes are the same as for primary outcomes.
↵b P <.001 change from baseline to 6 months.
↵c P <.01 change from baseline to 6 months.
↵d P <.001 relative to DIAMOND care after.
↵e P <.05 change from baseline to 6 months.
↵f P values are for treatment group effect at denoted measurement point.
Supplemental Tables
Supplemental Tables
Files in this Data Supplement:
- Supplemental data: Tables - PDF file
The Article in Brief
A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
Leif I. Solberg , and colleagues
Background The "Depression Improvement Across Minnesota--Offering a New Direction (DIAMOND)" initiative tested implementation of the collaborative care model for depression in real-world practices. The study evaluated whether providing 75 primary care practices with payment change, intensive training, and support would improve patient-reported depression outcomes.
What This Study Found While the intervention improved patient satisfaction, it had little impact on other outcomes. Enrolled patients reported receiving more desired care processes, however, patients receiving DIAMOND care had neither better depression outcomes nor better improvement in work productivity or health status. Specifically, the study found that patients who received DIAMOND care reported more collaborative care depression services than three other comparison groups and more satisfaction with their care. Depression remission rates, however, were not significantly different among the four groups.
Implications
- These findings illustrate the difficulties of widespread implementation of evidence-based practices that require major changes in roles and extensive financial and leadership support.
Annals Journal Club
Sep/Oct 2015: Implementation Science is Challenging: When RCT Evidence Doesn't Translate into Practice
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
Solberg LI, Crain L, Maciosek MV. A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care. Ann Fam Med. 2015;13(5):412- 420.
Discussion Tips
Dissemination/implementation of evidence-based interventions into practice has spawned its own field of work. According to the authors of this study, the collaborative care model for depression is supported by at least 79 randomized controlled trials. So why didn't it work as well as expected when scaled up by these experienced, highly successful implementers? This AJC provides a chance to answer that question and to develop broader understanding of the challenges of improving patient outcomes in real world practice settings.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research, systematic reviews, and practice on this topic?
- How strong is the study design for answering the question? What are the pros and cons of a stepped wedge design vs a randomized clinical trial? 2,3
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- How the findings were interpreted?
- What are the main study findings?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- What contextual factors are important for interpreting the findings?
- How might this study change your practice? Policy? Education? Research?
- How does this study make you rethink how you apply clinical trial results to your practice or local setting?
- Who are the constituencies for the findings, and how might they might be engaged in interpreting or using the findings?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.
- Sanson-Fisher RW, Bonevski B, Green LW, D'Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions Am J Prev Med. 2007;33(2):155-161.
- Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ. 2015;350:h391.
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