RCT of a Care Manager Intervention for Major Depression in Primary Care: 2-Year Costs for Patients With Physical vs Psychological Complaints

L. Miriam Dickinson; Kathryn Rost; Paul A. Nutting; Carl E. Elliott; Robert D. Keeley; Harold Pincus

doi:10.1370/afm.216

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Figure 1.
Patient recruitment and participation flowchart.
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Figure 2.
Impact of intervention on treatment costs for patients who have psychological and physical symptoms.

Psy UC: patients complaining of psychological symptoms, usual care; Psy EC: patients complaining of psychological symptoms, enhanced care; Phys UC: patients complaining of physical symptoms, usual care; Phys EC: patients complaining of physical symptoms, enhanced care.

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Table 1.

Operational Definition of Major Constructs

Note: Physical comorbidity not included because it did not differ significantly between enhanced and usual care subjects, nor did it significantly predict outpatient costs over time in models that controlled for the covariates listed in Table 1.
* Similar to other studies⁶ of primary care mental health interventions, we did not include inpatient costs because we did not observe intervention effects on hospitalization.
Intervention costs	Time costs (salary plus fringe benefits) were derived from care manager logs for patient screening, preparation for and delivery of the patient intervention, postsession record keeping, care manager-physician communication, and administrative overhead
Outpatient treatment costs*	Outpatient visit costs based on patient-reported utilization were estimated using 1999 Medicare payment rates, classified by type and length: primary care physical at $35.51, primary care mental health at $55.78, specialty care psychiatrist<45 min at $64.84, specialty care psychiatrist >45 min at $95.99, specialty care other mental health provider <45 min at $59.06, specialty care other mental health provider >45 min at $90.72. Emergency department visit costs were estimated at $500 per episode. Medication costs were estimated from patient-reported utilization of prescribed psychotropic medications, priced at the lowest average generic wholesale price per medication dosage reported in the 2000 Red Book of prescription drugs. All costs reported in this manuscript (for our study and other studies) were adjusted by the Consumer Price Index to reflect year 2000 US dollars
Patient style	Defined as medical record notation by primary care physician that patient complained exclusively of physical symptoms at index visit vs ≥ 1 of the Diagnostic and Statistical Manual – III-R symptoms listed in the Appendix. Nine patients (5%) whose symptoms were difficult to categorize (weight gain/loss and abdominal distress) and who did not acknowledge any psychological distress were initially categorized as complaining of physical symptoms. Inter-rater reliability for patient style was established in the following manner: (1) 20% of the 200 index visit medical records (n = 40) were selected at random; (2) 2 reviewers independently abstracted all patient complaints from those 40 index visits; (3) 2 reviewers independently categorized those 40 patients as having any psychological vs all physical complaints, achieving an inter-rater agreement on patient complaint style of 95%, κ = 0.89³; and (4) 1 reviewer categorized patient style for the remaining patients
Covariates	Baseline sociodemographic and clinical characteristics included age, minority status, insurance status, dysthymia in the previous year, panic attacks in the previous year, presence of work limitations around the house, number of bed or cutback days, emotional role functioning as measured by the SF-36¹¹ (SF-36 Health Survey, the 36-item short form of the Medical Outcomes Study), and outpatient treatment costs for the 6 months before baseline

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Table 2.

Estimated Mean Costs for Total Outpatient and Selected Components, With 95% Confidence Intervals From Bootstrap Distributions

	Usual Care		Enhanced Care
Component	Psychological Complaints Mean $ (95% CI)	Physical Complaints Mean $ (95% CI)	Psychological Complaints Mean $ (95% CI)	Physical Complaints Mean $ (95% CI)
Note: Specialty mental health care not estimated separately because of small number of patients with specialty care costs. Ninety-five percent nonparametric confidence interval (CI) obtained as 2.5th and 97.5th percentiles of the bootstrap distributions.
Primary care	899 (674–1,164)	723 (572–890)	736 (554–953)	849 (697–1,021)
Medications	1,382 (760–2,584)	281 (178–412)	995 (694–1,354)	676 (462–920)
Emergency department	1,105 (700–1,598)	1,076 (677–1,728)	802 (607–1,036)	934 (719–1,196)
Intervention	0	0	291 (272–311)	292 (277–308)
Total outpatient (including intervention)	4,000 (2,959–5,407)	1,922 (1,402–2,665)	3,020 (2,354–3,864)	3,300 (2,629–4,073)

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Supplemental Appendix

Coding of patient complaint and index visit.

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Supplemental data: Appendix - PDF file, 1 page, 59 KB
The Article in Brief

Providing long-term (2-year) treatment in the primary care doctor�s office for depressed patients results in less depression as well as cost savings for patients who report psychological symptoms (such as depressed mood, anxiety, or low self-esteem). Such treatment has limited benefits and increases costs, however, for patients who report mostly physical symptoms. The findings suggest the need for developing new approaches for treating depressed patients who complain of physical symptoms.