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Research ArticleOriginal ResearchA

A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care

Leif I. Solberg, A. Lauren Crain, Michael V. Maciosek, Jürgen Unützer, Kris A. Ohnsorg, Arne Beck, Lisa Rubenstein, Robin R. Whitebird, Rebecca C. Rossom, Pamela B. Pietruszewski, Benjamin F. Crabtree, Kenneth Joslyn, Andrew Van de Ven and Russell E. Glasgow
The Annals of Family Medicine September 2015, 13 (5) 412-420; DOI: https://doi.org/10.1370/afm.1842
Leif I. Solberg
1HealthPartners Research Foundation, Minneapolis, Minnesota
MD
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  • For correspondence: leif.i.solberg@healthpartners.com
A. Lauren Crain
1HealthPartners Research Foundation, Minneapolis, Minnesota
PhD
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Michael V. Maciosek
1HealthPartners Research Foundation, Minneapolis, Minnesota
PhD
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Jürgen Unützer
2University of Washington Medical Center, Seattle, Washington
MD, MPH
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Kris A. Ohnsorg
1HealthPartners Research Foundation, Minneapolis, Minnesota
RN, MPH
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Arne Beck
3Kaiser Permanente Colorado, Denver, Colorado
PhD
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Lisa Rubenstein
4RAND Corporation, Santa Monica, California
MD
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Robin R. Whitebird
1HealthPartners Research Foundation, Minneapolis, Minnesota
PhD, MSW
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Rebecca C. Rossom
1HealthPartners Research Foundation, Minneapolis, Minnesota
MD, MSCR
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Pamela B. Pietruszewski
5Institute for Clinical Systems Improvement, Minneapolis, Minnesota
MA
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Benjamin F. Crabtree
6Robert Wood Johnson Medical School, New Brunswick, New Jersey
PhD
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Kenneth Joslyn
7Private practice, Minneapolis, Minnesota
MD
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Andrew Van de Ven
8University of Minnesota, Minneapolis, Minnesota
PhD
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Russell E. Glasgow
9University of Colorado, Denver, Colorado
PhD
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  • Figure 1
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    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

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    Table 1

    Baseline Survey Patient Characteristics by Treatment Group

    CharacteristicAll N = 2,348DCA n = 340UCA n = 861UCB n = 697UC n = 450P Value
    Sequence, %
     112.229.420.41.6
     224.032.137.418.9
     313.012.317.016.6
     414.512.115.124.3
     517.012.310.138.6
     Not sequenced19.1100.0
     Clinic unknown0.21.8
    Female, %72.775.970.973.672.2.31
    Age, mean (SD), y44.4 (14.9)44.4 (14.5)44.5 (15.7)44.2 (14.3)44.3 (14.6).97
    Insurance type, %<.001
     Commercial65.367.761.368.366.4
     State program25.125.927.122.524.7
     Medicare6.94.410.25.25.3
     Other/unknown2.71.81.44.13.6
    Education, %.37
     High school or less31.031.231.431.528.9
     Some college38.237.935.540.240.2
     College degree31.030.933.128.330.9
    Marital status, %<.005
     Married45.845.942.347.949.3
     Never married23.423.828.020.518.7
     Other31.233.329–831.532.0
    Hispanic, %3.86.23.72.24.7<.01
    Race, %<.001
     White88.783.890.491.285.3
     Black5.18.24.33.07.6
     Other6.27.15.55.87.1
    Antidepressant medication >4 wk, %47.042.950.948.540.4<.005
    Depression care (medication or therapy) >4 wk, %58.657.163.358.351.3<.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
     7–932.225.335.930.632.7<.001
     10–1438.936.540.539.936.0
     15–1919.625.915.820.421.1
     >209.312.47.89.210.2
    Previous depression care, %<.005
     None37.444.736.735.736.0
     Once23.521.825.120.226.7
     2 or more36.031.533.841.534.9
    Depression treatment, %
     Medication98.697.798.699.098.7.39
     Counseling27.539.125.725.126.0<.001
     Group therapy3.84.73.52.94.9.25
     Psychiatrist5.56.24.85.95.8.69
     Other4.05.64.04.22.4.16
    Employment, %<.01
     Employed for wages56.960.352.460.358.0
     Self-employed5.41.86.35.36.4
     Out of work12.114.413.79.411.1
     Unable to work9.37.19.99.310.2
     Other16.116.317.315.614.3
    Poverty, %.34
     Below 2 times poverty level34.934.337.232.834.0
     Above 2 times poverty level65.265.762.867.266.1
    • 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.

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    Table 2

    Clinic Characteristics (n = 75)

    VariableNo.Percent or Mean No. (SD)Range
    Clinic
    Location
     Metropolitan Twin Cities3850.7
     Nonmetropolitan3749.3
    Ownership
     Health system5168.0
     Health plan22.7
     Physicians2128.0
    No. of primary care physicians for adults8.6 (7.8)1–39
     1–2810.7
     3–52128.0
     6–103344.0
     >101317.3
    Any in medical group
     Psychiatrists3749.3
     Mental health therapists3850.7
    No. of NPs/PAs for adults2.1 (1.9)0–8
     01621.3
     1–23242.7
     >22736.0
    Sites in medical group15.6 (11.8)1–48
     1–245.3
     3–51621.3
     6–1045.3
     >105066.7
    Patients’ insurance
    Commercial52.4 (18.9)4–80
     0%–10%22.7
     11%–25%68.0
     >25%6485.3
    Medicare23.8 (10.6)10–38
     0%–10%1216.0
     11%–25%3546.7
     >25%2533.3
    Medicaid12.0 (11.3)3–55
     0%–10%4864.0
     11%–25%2026.7
     >25%45.3
    Uninsured3.9 (3.1)0–10
     0%–10%7296.0
    • NP = nurse practitioner; PA = physician assistant.

    • View popup
    Table 3

    Model-Predicted Depression Care Process and Outcome Measures, Adjusted for Secular Trend and Weighted by Survey Response and Treatment Selection Likelihoods

    Treatment ModelNo.Care Process 6 moResponse 6 mo (%)Remission 6 mo (%)PHQ-9
    Baseline6 mo
    Usual care before466
     Mean6.5a46.135.812.2b7.8c
     SE0.22.72.60.20.3
     Cohen’s f2,d0.088
    Usual care after559
     Mean6.4a46.335.012.77.7c
     SE0.22.72.60.20.3
     Cohen’s f2,d0.127
    DIAMOND care after245
     Mean10.946.736.413.28.0c
     SE0.34.44.20.30.4
    Usual care308
     Mean6.7a46.433.912.3e7.8c
     SE0.33.13.00.20.4
     Cohen’s f2,d0.058
    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.

    • View popup
    Table 4

    Model-Predicted Secondary Outcomes, Adjusted for Secular Trend and Weighted by Survey Response and Treatment Selection Likelihoods

    Productivity LossHealth StatusSatisfaction
    Treatment ModelNo.aBaseline6 moBaseline6 moBaseline6 mo
    Usual care before
     Mean29637.024.5b3.043.16c3.41d3.44d
     SE1.41.60.040.050.050.05
     Cohen’s f20.0020.018
    Usual care after
     Mean31136.726.9b3.003.10e3.45d3.37d
     SE1.51.60.040.050.050.06
     Cohen’s f20.0010.001
    DIAMOND care after
     Mean13539.831.02.973.133.743.95e
     SE2.53.80.070.080.060.07
    Usual care
     Mean19137.726.9b2.923.12b3.21d3.35d
     SE1.82.10.050.060.060.07
     Cohen’s f20.0080.018
    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.

Additional Files

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    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:
      1. How patients were selected, excluded, or lost to follow-up?
      2. How the main variables were measured?
      3. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
      4. Chance?
      5. 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

    1. 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.
    2. 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.
    3. 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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A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
Leif I. Solberg, A. Lauren Crain, Michael V. Maciosek, Jürgen Unützer, Kris A. Ohnsorg, Arne Beck, Lisa Rubenstein, Robin R. Whitebird, Rebecca C. Rossom, Pamela B. Pietruszewski, Benjamin F. Crabtree, Kenneth Joslyn, Andrew Van de Ven, Russell E. Glasgow
The Annals of Family Medicine Sep 2015, 13 (5) 412-420; DOI: 10.1370/afm.1842

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A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
Leif I. Solberg, A. Lauren Crain, Michael V. Maciosek, Jürgen Unützer, Kris A. Ohnsorg, Arne Beck, Lisa Rubenstein, Robin R. Whitebird, Rebecca C. Rossom, Pamela B. Pietruszewski, Benjamin F. Crabtree, Kenneth Joslyn, Andrew Van de Ven, Russell E. Glasgow
The Annals of Family Medicine Sep 2015, 13 (5) 412-420; DOI: 10.1370/afm.1842
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