Depression management within GP-centered health care — A case-control study based on claims data

Accepted Manuscript Depression management within GP-centered health care — A case-control study based on claims data

Antje Freytag, Markus Krause, Thomas Lehmann, Sven Schulz, Florian Wolf, Janine Biermann, Jürgen Wasem, Jochen Gensichen PII: DOI: Reference:

S0163-8343(16)30250-X doi: 10.1016/j.genhosppsych.2016.12.008 GHP 7166

To appear in:

General Hospital Psychiatry

Received date: Revised date: Accepted date:

2 September 2016 19 December 2016 20 December 2016

Please cite this article as: Antje Freytag, Markus Krause, Thomas Lehmann, Sven Schulz, Florian Wolf, Janine Biermann, Jürgen Wasem, Jochen Gensichen , Depression management within GP-centered health care — A case-control study based on claims data. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ghp(2016), doi: 10.1016/j.genhosppsych.2016.12.008

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ACCEPTED MANUSCRIPT Title: Depression management within GP-centered health care – a case-control study based on claims data Title Page

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Title

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Running Title

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Depression management within GP-centered health care Authors 1

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Antje Freytag Dr. rer. pol.* , Markus Krause * , Thomas Lehmann Dr. rer. pol. , Sven Schulz Dr. med. , Florian Wolf Dr. med. 1 3 3 1,4 , Janine Biermann Dr. rer. medic. , Jürgen Wasem Prof. rer. pol. , Jochen Gensichen Prof. Dr. med. *Authors contributed equally.

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Affiliations

Institute of General Practice and Family Medicine, Jena University Hospital, Germany

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Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Germany

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Institute for Healthcare Management and Research, University of Duisburg-Essen, Campus Essen, Germany

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Institute of General Practice and Family Medicine, University Hospital of LMU Munich, Germany

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Corresponding Author

Institute of General Practice and Family Medicine, University Hospital of LMU Munich, Pettenkoferstr. 8a/10, 80336 Munich, Germany

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Phone: ++ 49 (0) 89 4400-53779Fax: ++ 49 (0) 89 4400-53520 Mail: [email protected]

None

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Sources of Support

Trial registration None

Prior Publication Congress Contribution: “ GP-Centered Health Care for patients with depression: a claims-data analysis” (“Hausarztzentrierte th Versorgung von Patienten mit Depression: Eine GKV-Routinedatenanalyse”) to be presented at DEGAM 30 Sept 2016, Francfort, Germany Number of pages 21

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ACCEPTED MANUSCRIPT Number of figures 0 Number of tables 4 Number of appendices 1

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Number of references

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50

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Word Count text

3727 Words (no more than 4,000 words of text (not including title page, abstract, references, tables, figures, figure legends, or appendices)

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Word count abstract 186 words (no more than 200 words.)

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Date

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19.12.2016

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Abstract OBJECTIVE

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For most patients with depression, GPs are the first and long-term medical providers. GP-

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centered health care (GPc-HC) programs target patients with chronic diseases. What are the effects of GPc-HC on primary care depression management?

METHOD

An observational retrospective case-control study was conducted using health insurance claims data of patients with depressive disorder from July 2011 to December 2012.

RESULTS

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ACCEPTED MANUSCRIPT From 40,298 patients insured with the largest health plan in Central Germany participating in the GPc-HC program (intervention group, IG), we observed 4,645 patients with depression over 18 months: 72.2% women; 66.6 years (mean); multiple conditions (morbidity-weight 2.50 (mean), 86%>1.0). We compared them with 4,013 patients who did not participate (control group). In participants we found lower number of incomplete/non-specified

one

GP-practice

(49.1%vs.58.0%;PP-8.9;p<0.01); more

GP-initiated

referrals

to

GP-contacts specialists

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(18.19vs.15.59;MD+2.60;p<0.01);

more

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than

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depression diagnoses (4.46vs.4.82;MD-0.36;p<0.01); lower rate of patients consulting more

(82.9%vs.79.3%;PP+3.6;p<0.05), more antidepressant pharmacotherapy prescribed by a GP

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(37.9%vs.35.4%;PP+2.5;p<0.05), more frequent guideline-concordant therapy duration

care” (38.2%vs.30.2%;PP+8.0;p<0.01).

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CONCLUSION

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(19.2%vs.13.1%;PP+6.1;p<0.01) and more patients receiving “GP-psychosomatic basic

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Depressive patients participating in a GPc-HC program may be more often diagnosed by a GP, receive symptom-monitoring and appropriate depression treatment.

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Keywords: Depression; General Practitioners; GP-centered health care; Health Care

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Quality; Administrative Claims, Healthcare.

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ACCEPTED MANUSCRIPT Main Text 1. Introduction Depressive disorders show the highest burden of disease [1] and that despite their effect

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might have still been underestimated [2]. The life-time prevalence for depressive disorders is

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between 11.6% and 19% [1, 3-5]. About every tenth patient consulting a general practitioner (GP) in Germany suffers from depression [6, 7]. GPs are often the first health care provider a

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patient consults [4, 8] and are integrally involved in diagnostics and initiation of treatment for

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patients with depressive disorders. About 10-25% of patients with major depressive disorder develop a chronic course with persistent symptoms of at least 2 years [9-13].In Germany,

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enhanced primary care (‘GP-centered health care’; short: GPc-HC) is being promoted in order to strengthen the role of GPs and to improve the quality of primary care. GPc-HC

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programs started in 2004 and have to be provided by social health insurance funds (SHI). More than 75 of such programs currently exist in Germany, and more than 16,000 GPs and

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3.7 million patients participate in them [14]. One program was established in 2011 in the

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federal state of Thuringia by a major SHI, the AOK PLUS that covers 41% of the population in central Germany. This program tries to establish a tighter GP-patient-relationship and

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takes particular account of the growing number of the chronically sick [15]. The program represents a structured, evidence based, patient-oriented and collaborative care program

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which aims to improve the GP-driven care process mainly by financial incentives to participating GPs (For details see the ‘intervention’ section). Previously established GPc-HC programs address a population of older and chronically sick patients with multiple conditions and may have resulted in more intense and coordinated health care [16-18]. These effects seem to be attributed to more intensive monitoring of symptoms, improved medication and increased patient’ adherence [18]. Evidence shows that GP-centered programs have improved health care for chronic diseases in Belgium [19] and that depression can be successfully managed by primary care based symptom monitoring 4

ACCEPTED MANUSCRIPT [20]. The GPc-HC programs promote the intensity of such a primary care based monitoring [18]. The objective of our study was to examine the effects of the GPc-HC program on diagnostics of depression, monitoring and care coordination in participating patients with depressive

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disorders compared to non-participating patients.

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2. Methods 2.1 Data and study population

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In a retrospective case-control study patients with depressive disorder were observed over 18 months (from July 2011 to December 2012). Individual health insurance claims for

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beneficiaries from the AOK PLUS served as data for the analyses. They included

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administrative data (age, gender), information about outpatient physician care (diagnosis, consultations and procedures, provider specialty) and drug prescription (prescribed drugs,

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number of defined daily doses). Inpatient information was only available for hospital

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utilization (hospital cases, diagnosis), not for inpatient pharmacotherapy. From the 40,298 patients who participated in the GPc-HC program throughout the

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observation period of 18 months [18], we selected a subset of 4,645 patients with depressive disorders (participants/intervention group, IG) diagnosed by a GP in terms of administrative

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diagnosis according to the ICD-10-codes F32.*, F33.* and F34.1. The group of patients receiving usual care in non-participating general practices, was matched to the 40,298 patients in the former intervention group by applying propensity score matching (PSM) in order to correct for possible differences between the groups [18]. From the total sample of 40,298 patients in the former control group, we identified 4,013 patients who did not participate in the GPc-HC program and met our criteria for depressive disorder in 2011 (nonparticipants/control group, CG). To validate the administrative diagnosis, only patients with at least one depression diagnosis documented by a GP in the enrollment period (January 2011 5

ACCEPTED MANUSCRIPT to June 2011) as well as at least one in the follow-up period (July 2011 to December 2012) were included. As patients often received different diagnosis codes with different degrees of depression severity in 2011, we applied a ranking to assign a single degree of depression severity to each patient, which is commonly used in claims data analyses of depression [21, 22]: 1)

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severe depression (F32.2, F32.3, F33.2, F33.3); 2) moderate depression (F32.1, F33.1); 3) mild depression (F32.0; F33.0); 4) incomplete or non-specified depression (F32.8, F32.9,

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F33.8, F33.9, F33.4) and 5) Dysthymia (F34.1). Considering the low number of assigned Dysthymia (IG n=55, 1.2%; CG n=53, 1.3%), we did not present the measured quality

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indicators for this depression subtype. Taking account of a frequent comorbidity with

obsessive-compulsive

disorder

(F42*)

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depression, we identified phobic anxiety disorders (F40.*), other anxiety disorders (F41.*), and

post-traumatic

stress

disorder

(F43.1),

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irrespective of the specialty of the diagnosing physician.

medical

specialists

for

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Provider specialty was categorized into two mutually exclusive groups: (1) GPs and (2) psychiatry,

psychiatry

and

psychotherapy,

neurology,

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psychotherapeutic medicine or psychological psychotherapist or hospital treatment with main

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diagnosis depression as psychiatric hospital care. GP practice type was categorized into single-handed or group practice, according to the

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number of billing physicians and into urban or rural area.

2.2 Intervention GPc-HC has it’s theoretical and clinical basis in the collaborative care approach that strengthens the GPs gatekeeping function as first-line service for patients in connection with stepped-care approaches to secondary care (active referrals and supervision during specialist treatment). The deployment of a special health care assistant enables patient care teams to intensify monitoring (follow-ups on a regular basis) and to apply daily-routineimplemented processes of quality improvement using practice data on patient care 6

ACCEPTED MANUSCRIPT systematically [23-25]. The core elements of the Thuringian GPc-HC program for patients were: they had to commit themselves to choose their GP as a first-line service (except for gynecologists and ophthalmologists). Core elements for GPs were: 1) participation in clinical peer-group trainings (“quality circles”; three per year, 2h each session); 2) use of an evidence based IT-pharmacotherapy-tool supporting the prescription of lead substances and

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generics; 3) bonuses for the prescription of lead substances and generics; 4) incentives to

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make use of specifically and further qualified health-care assistants in clinical patient-care; 5)

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incentives to enroll and monitor patients with multiple/chronic conditions. The financial incentives were paid in addition to the regular payment system.

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2.3 Outcome measures

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Outcomes measurement was based on established outpatient quality outcomes [26] and the German National Guideline for major depressive disorder [27-29]. We identified three fields

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for primary care to patients with depressive disorders in Germany: detection, monitoring and

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delivery of treatment. Quality of care was measured by the following outcome parameters. Detection: The rate of incomplete or non-specified depression diagnoses (F32.8, F32.9,

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F33.8, F33.9), generated as a confirmed diagnosis by a GP over the 18 months’ observation

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period and according to the guideline which requests a specific ICD-10 diagnosis for initializing a therapy.

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Monitoring: The rate of patients with an encoded depression in case of treatment consulting more than one family practice, since this reflects the GP’s gatekeeping and care coordination role. The number of GP contacts measured as days with accounting for medical services and an encoded depression in case of treatment, as higher numbers reflect more intensive monitoring of affected patients. The number of patients with at least one home visit by a GP, as well as the average number of GP home visits per patient, identified by the respective remuneration items for home visits (1410; 1411, 1413; 1415), because depression is often associated with other common and functional disabling chronic diseases [30-33]. 7

ACCEPTED MANUSCRIPT Delivery of treatment: The number of patients with an encoded depression in case of treatment and the utilization of an inpatient or outpatient psychiatric specialist service on the referral of a GP, as high numbers might reflect good gatekeeping and care coordination. The number of patients receiving antidepressant pharmacotherapy prescribed by a GP, measured as patients with prescribed and collected antidepressant and an encoded

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depression in case of treatment. The number of patients with a recent and sufficient

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outpatient antidepressant pharmacotherapy by GP. A recent pharmacotherapy was

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assumed, if a first antidepressant prescription was detected within 180 days before the first prescription in the observational period. A sufficient therapy was assumed if the prescriptions

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covered 180 defined daily doses (DDD) representing the average period of time for a continuation therapy (4-9 months) recommended by guidelines [27, 28, 34, 35]. The number

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of patients receiving “psychosomatic basic care” by a GP (identified by the respective remuneration items for “psychosomatic basic care”: 35100; 35110) as a basic and low-

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threshold treatment option for depression in primary care [28].

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2.4 Analyses

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We compared cases and controls and analyzed the presented outcomes differentiated by the severity of depression and comorbid anxiety disorder. Statistical analysis was performed by

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independent samples t-test for continuous parameters (mean differences, MD) and independent chi-squared test for binary outcomes (change in percentage points, PP). For

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each test the significance level was set to 5%. Differences between both groups were reported with a 95% confidence interval. In contrast to the general study population group [18], we identified differences of the propensity matching scores in our selected subset of patients with depressive disorder between participants and non-participants. Therefore, descriptive analyses were complemented by multivariable outcomes adjustment considering the available and statistically significant factors: age, gender, morbidity (measured using the morbidity weight applied in the morbidity-based risk adjustment scheme in Germany),

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ACCEPTED MANUSCRIPT number of outpatient consultations from baseline period, practice type (single-handed or group practice) and location (urban or rural area). For computing, we used MS-Access 2010 and IBM SPSS Statistics V23.0 [IBM Corp., Armonk, NY]. Ethics approval was granted by the Local Ethics Committee of Jena University Hospital, approval No. 4058-04/14. Design, performance and report of the claims data

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analysis were based on the recommendations of the GPS (Good Practice Secondary Data

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Analysis) [36] and the STROBE recommendations [37].

3 Results

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3.1 Population

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In a population of 584,987 adults insured with the SHI AOK Plus in Thuringia from 2010 to 2012, 40,298 (6.9%) were participants (early enrollers) in the GPc-HC program. We identified

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4,645 patients with depressive disorders (administrative prevalence of 11.5%). In the group

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of non-participants, the rate of depression was lower: we selected 4,013 patients with depressive disorders (administrative prevalence of 10.0%) (table 1). Patients with depressive

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disorder differ between the two groups in age (IG 66.6 vs. CG 68.4; MD -1.8; p<0.01), gender (women, IG 75.2% vs. CG 77.6%; PP -2.4; p=0.01), morbidity weight (IG 2.50 vs. CG 2.65;

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MD -0.15; p<0.01) and outpatient consultations from baseline period from June 2009 to

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December 2010 (IG 24.06 vs. CG 25.57; MD -1.51; p<0.01). In participants more patients were assigned to a complete ICD-10 based depression diagnosis: severe (IG 10.8% vs. CG 6.1%; PP +4.7; p<0.05), moderate (IG 12.4% vs. CG 11.6%; PP +0.8; p>0.05), mild depression (IG 5.6% vs. CG 4.3%; PP +1.2; p<0.05) and dysthymia (IG 1.2% vs. CG 1.3%; PP -0.1; p>0.05), less to incomplete or non-specified depression (IG 70.1% vs. CG 76.7%; PP -6.6; p<0.05). The prevalence of comorbid anxiety disorder did not differ statistically between the groups (IG 27.2% vs. CG 25.6%; PP +1.6; p>0.05).

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ACCEPTED MANUSCRIPT In both groups, most patients were treated in single-handed practices (IG 62.3% vs. CG 75.4%, PP -13.1, p<0.01), but participants were substantially more often treated in group practices (IG 37.7% vs. CG 24.6%; PP +13.1, p<0.01). More participants were treated in practices located in rural areas (IG 30.7% vs. CG 25.8%, PP +4.9, p<0.01).

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3.2 Detection

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The number of complete ICD-10 based depression diagnoses by GPs (table 2) did not differ

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between the two groups (IG 6.14 vs. CG 6.06; MD 0.08; p>0.05). The number of incomplete or non-specified depression diagnoses was lower in participants in general (IG 4.46 vs. CG

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4.82; MD -0.36; p<0.01) and was lower in participants with a comorbid anxiety disorder (IG

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4.33 vs. CG 4.89; MD -0.56; p<0.01). 3.3 Monitoring

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We observed lower rates of patients consulting more than one family practice (table 3) in the

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participating group (IG 49.1% vs. CG 58.0%; PP -8.9; p<0.01). Differentiated by depression severity, we found particularly lower rates for participating patients with severe (PP -25.4;

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p<0.01), incomplete or non-specified depression (PP -8.7; p<0.01), as well as for patients

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with comorbid anxiety disorder (PP -8.9; p<0.01). The number of GP contacts over 18 months was higher in the participants (IG 18.19 vs. CG

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15.51; MD 2.60; p<0.01). Differentiated by depression severity, we found a greater number for all types of specific depression, particularly in patients with severe (MD +4.52; p<0.01) and mild (MD +5.61; p<0.01) depression as well as for patients with a comorbid anxiety disorder (MD +3.36; p<0.01). The number of GP contacts after a recent outpatient antidepressant pharmacotherapy by GP was also higher in the participants (IG 3.84 vs. CG 2.88; MD +0.96; p<0.01). Differentiated by depression severity, we found a greater number of GP contacts in patients with moderate (MD +1.63; p<0.01) or incomplete or non-specified depression (MD +0.85; p<0.01), as well as for patients with comorbid anxiety disorder (MD +0.81; p<0.05). 10

ACCEPTED MANUSCRIPT Considering the number of patients with at least one home visit by a GP in case of an outpatient treatment, we observed no statistically significant difference between both groups (IG 27.5% vs. CG 28.0%; PP -0.5; p>0.05). Investigating only patients with at least one home visit by a GP we found a greater number of home visits per patient in the participants (IG 10.47 vs. CG 9.07; MD +1.40; p<0.01). Differentiated by depression severity, there were

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higher numbers for patients with severe (MD +4.97; p<0.01) and mild depression (MD +6.03;

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p<0.01).

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3.4 Delivery of treatment

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The number of patients with specialist services (table 4) was lower in the participants (IG 23.5% vs. CG 26.7%; PP -3.2; p<0.01). The difference in the total group went on the account

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of patients with incomplete or non-specified depression (PP -4.0; p<0.01). Regarding only patients with at least one specialist service, there were more GP initiated referrals to this

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treatment in the participants (IG 82.9% vs. CG 79.3%; PP +3.6; p<0.05). Differentiated by

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depression severity we found a statistically significant difference for severe depression (PP +11.3; p<0.05) as well as for comorbid anxiety disorder (PP +6.5; p<0.05).

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The rate of patients receiving an outpatient antidepressant pharmacotherapy by a GP was

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higher in the participants (IG 37.9% vs. CG 35.4%; PP +2.5; p<0.05). Differentiated by depression severity we found a statistically significant difference for patients with moderate

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depression (PP +11.9; p<0.01) and patients with a comorbid anxiety disorder (PP +4.3; p<0.05). The number of patients with a recent and sufficient outpatient antidepressant pharmacotherapy by GP was higher in the participants (IG 19.2% vs. CG 13.1%; PP +6.1; p<0.01). Differentiated by depression severity we found a statistically significant difference for incomplete or non-specified depression (PP +5.8; p<0.05) as well as for comorbid anxiety disorder (PP +7.5; p<0.05). The number of patients receiving psychological treatment based on “psychosomatic basic care” by a GP was higher in the participants (IG 38.2% vs. CG 30.2%; PP +8.0; p<0.01). This 11

ACCEPTED MANUSCRIPT particularly holds for all types of specific depression as well as for patients with a comorbid anxiety disorder (PP +10.1; p<0.01). The adjusted results (by age, gender, morbidity, number of outpatient consultations from baseline period, practice type and area) substantially confirm the unadjusted results and are

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provided in the digital supplement.

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4. Discussion 4.1 Population

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In a population participating in a GPc-HC program, we selected patients with depression in 2011. Compared to the general study population, participating patients with depression were

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older (MD+ 2.44 years), rather female (PP +16.75) and more often had multiple conditions (morbidity weight: MD +0.67). This corresponds with the fact that the prevalence of

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depression increases by age [5, 38], that women more often receive the diagnosis [3, 4] and

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that patients with depression more often suffer from other somatic or mental illnesses [4, 22, 30, 39]. In our study 73.1% of the patients got an incomplete or non-specified ICD-10 based

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diagnosis. This rate is similar to other studies with a range from 50% to 73% [22, 40]. We identified less severe and moderate depression and a similar rate of mild depression

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compared to other studies [41-43]. The rate of patients with a comorbid anxiety disorder in

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2011 was 26.4% and is also comparable to other findings [22]. As a general limitation of claims data analyses it is not possible to include patients with depression into the study where physicians deliberately do not document an explicit depression diagnosis code in order to avoid stigmatization.

4.2 Detection The observed lower rate of incomplete or non-specified ICD-10 based diagnoses in participants we value as a program effect. As both, specific as well as incomplete or nonspecified depression diagnosis, were able to trigger the program’s morbidity-oriented lump 12

ACCEPTED MANUSCRIPT sum payment, we do not interpret the observed effect as up-coding. As a specific depression diagnosis is necessary for deriving guideline-based depression treatment [29] a higher rate of specific diagnosis increases the probability of guideline-based treatment in the participants [44].

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4.3 Monitoring

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The higher rate of patients consulting not more than one family practice and the higher rate

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of GP contacts in the participants reflect a closer relationship between GP and patient. This does especially hold for patients with a high burden of disease due to severe depression or a

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comorbid anxiety disorder. Furthermore, participating patients with a recent antidepressant pharmacotherapy by a GP had more GP contacts after initiating the therapy, which

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corresponds to the German guideline recommendations [27]. These results have to be valued as important against the background that patients with depressive disorder normally

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present long-lasting symptoms [12] and large time-lapses between symptoms and the

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subsequent treatment [45]. Moreover, participating patients received more home visits and may benefit from a more intensified GP-patient relationship, since patients with a depressive

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disorder often suffer from other common mental or somatic diseases [4, 22, 39] and functional disability [31, 32]. However, the real program effect might have been even greater

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when taking into account the additional home visits by primary care practice-based health care assistants - a treatment option which was financially promoted by the GP-centered

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health care program.

4.4 Delivery of treatment The observation, that fewer participating patients received overall specialist services seems of minor relevance for the program’s outcomes assessment since GPs have only limited influence on the actual specialist services provision. When focusing on services, the GP is able to coordinate and deliver an antidepressant treatment – namely GP-referrals to specialist services, GP-delivered psychological treatment based on “psychosomatic basic 13

ACCEPTED MANUSCRIPT care” and GP-prescribed antidepressant therapy. We found indications for increases: First, there were more participants with a more serious depressive disorder or comorbid anxiety disorder who received guideline-recommended specialist treatment [27] on referral by a GP. Though referrals are strongly dependent from regional specialist capacities, the program seems to generate a positive effect. For Thuringia, this is particularly important being

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characterized by a rather low psychiatric supply density [46, 47]. Second, the rate of patients

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receiving “psychosomatic basic care” by a GP was higher. Ideally, this outcome reflects a

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higher extent of psychotherapeutic counseling services by GPs. But due to the fact that more GPs treating participants were qualified to bill “psychosomatic basic care” (IG 65% vs. CG

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45%), we cannot exclude, that we might observe a selection effect here rather than a program effect. Third, the rate of patients receiving GP-prescribed antidepressants was

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higher in participants. And, if such a therapy was started, it was more likely to be long enough according to guideline recommendations. The resulting rates were generally in line

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with other findings of about 16.8% of GPs prescribing antidepressants long enough [21].

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Taking into account that the rates are relatively low altogether, the difference between participants and non-participants can be valued as a rather striking result in favor of the

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4.5 Limitations

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program.

The administrative prevalence for depressive disorder differed slightly between the groups

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(IG 11.5% vs. CG 10.0%). We see three main potentially influencing factors pointing to the major limitations of this study: First, there might be a higher alertness towards the detection and treatment of depression in GPs who are qualified to apply “psychosomatic basic care”. As mentioned before, this qualification (of psychosomatic basic care) was more frequent in GPs of the participating group. Thus, the intervention effect might mix with some selfselection effect. This might be interpreted as a higher proneness of GPs to active care management respectively motivation in the intervention group. But nevertheless it is favorable that GPs who provide extensive and high quality care for their patients – if due to 14

ACCEPTED MANUSCRIPT the program or not – deserve to be paid better than GPs who don’t. Second, we are aware of the SHIs’ general incentive for right-coding (from incomplete or non-specified ICD-10 based diagnosis to specific diagnosis) and up-coding (from lighter to severe depression diagnosis) in the context of the German Risk Adjustment Scheme, which might cause them to strongly motivate GPs towards a more specific diagnosis documentation. And we see a principle

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incentive for participating GPs to document any depression diagnosis in order to trigger the

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payment of a morbidity-oriented lump-sum, though there is no program-induced financial

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incentive to right- or up-code depression diagnosis. These underlying incentives might have motivated the observed effects of ‘detection’, which from a clinical point of view are not

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negative as long as specificity determines therapy recommendations and as long as this is not accompanied by over-treatment. Third, the study was based on claims data, which had

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been collected for non-scientific purposes, clinical as well as patient-reported data was not

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accessible and therefore not part of this analysis [48].

To our knowledge, this is the first study assessing the effect of a German GPc-HC program

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on primary care depression management. Comparability with the effects of other mental health programs is limited and outcomes were heterogeneous. The Cochrane review on

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collaborative care for depression and anxiety provides evidence that the benefit of

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collaborative care might express itself particularly in the management of chronic diseases [49]. The study design was not aimed at identifying single active agents of the complex

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intervention. Thus, we can only speculate that the drivers/incentives for a more intense monitoring of enrolled patients may have played an important role in this context. With a closer therapy relationship, an intensified monitoring and an enhanced delivery of treatment, the GPc-HC program might provide improved depression management in primary care and an appropriate framework for the implementation of collaborative care elements [49, 50].

5. Conclusion

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ACCEPTED MANUSCRIPT The GPc-HC program may result in a larger volume, more intense and better coordinated primary care depression management in elder chronically ill patients with multiple conditions. Further research on the effects by linking claims data to clinical outcomes data would be useful.

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Acknowledgements/disclosure of funding received for this work

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The German Statutory Health Insurance Funds “AOK PLUS - Die Gesundheitskasse für

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Sachsen und Thüringen” kindly authorized the authors to analyze the data.

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Conflict of Interest

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No financial support was provided. SSc and JG are both general practitioners (GPs).

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Supplementary Material

1.

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ACCEPTED MANUSCRIPT

Table 1 Interventio n

Control

N (%) or Mean (SD)

N (%) or Mean (SD) 4013 68,37 (13.86)

8658 67.39 (14.24)

3113 (77.6% ) 2.65 (2.46)

6607 (76.3% ) 2.57 (2.48)

3594 (89.6% ) n=401 3

7588 (87.6% ) n=865 1

-3.6

25.57 (12.88)

24.76 (12.41)

1445 (36.0% )

3086 (35.6% )

1.5 1 -0.7

n=391 4 2952 (75.4% ) 962 (24.6% ) n=386 8 997 (25.8% ) 2871 (74.2% )

n=842 0 5757 (68.4% ) 2663 (31.6% ) n=835 5

Morbidy weight from baseline period

2.50 (2.49)

>1

3994 (86.0%) n=4638

PT

1641 (35.3%)

CE

n=4506

Single

2805 (62.3%)

Group

1701 (37.7%)

AC

Participation in DMP from baseline period GP practice type

ED

24.06 (11.95)

M

Outpatient Consultations from baseline period

GP practice area

n=4487

Rural

1377 (30.7%)

Urban

3110 (69.3%)

1.8 2 -2.4

2.42; -1.22

0.1 5

0.26; -0.05

moderate

502 (10.8%) 575

244 (6.1%) 465 23

P

2.04; -0.98

t=-5.94

p<0.01

x²=6.59

p=0.01

t=-2.83

p<0.01

x²=25.39

p<0.01

t=-5.62

p<0.01

x²=0.434

p=0.51 0

x²=168.0 4

p<0.01

x²=24.65

p<0.01

x²=76.89

p<0.01

13. 1 13. 1

4.9

-4.9

degree of depression severity severe

t or x²

T

3494 (75.2%)

CI [95% ]

IP

Female gender

Sig

CR

4645 66.55 (14.60)

MD or PP

US

N Age

Total

AN

Characteristic s

746 (8.6%) 1040

4.7

p<0.05

0.8

p>0.05

ACCEPTED MANUSCRIPT (12.4%) mild

258 (5.6%)

unspecific/othe r

3255 (70.1%)

Dysthymia

55 (1.2%) 1264 (27.2%)

(12.0% ) 431 (5.0%) 6333 (73.1% ) 108 (1.2%) 2290 (26.4% )

1.3

p<0.05

-6.6

p<0.05

-0.1

p>0.05

1.6

x²=3.00

AC

CE

PT

ED

M

AN

US

CR

IP

T

outpatient anxiety disorder

(11.6% ) 173 (4.3%) 3078 (76.7% ) 53 (1.3%) 1026 (25.6% )

24

p=0.08 7

ACCEPTED MANUSCRIPT Table 2

6.56 (2.78)

6.34 (2.52) 4.82 (2.66)

4.46 (2.73)

n=1264

n=1026

4.33 (2.90)

4.89 (2.86)

CI [95%]

t or x²

P

0.08

1.3%

0.01;0.18

t=1.79

p=0.074

0.22

3.4%

0.00;0.44

t=1.96

p=0.050

-0.36

-8.1%

-0.47;0.24

t=6.17

p<0.01

-0.80;0.33

t=4.66

p<0.01

T

n=1026

Difference in % of IG

IP

n=1264

Difference (IG-CG) MD or PP

-0.56

AC

CE

PT

ED

M

AN

Unspecific/other diagnoses of depression by a GP … with outpatient anxiety disorder

6.14 (2.27)

Control (n=4013) N (%) or Mean (SD) 6.06 (2.16)

CR

Diagnoses of depression by a GP … with outpatient anxiety disorder

Intervention (n=4645) N (%) or Mean (SD)

US

Detection (Table 2)

25

-12.9%

ACCEPTED MANUSCRIPT Table 3

-18.1%

162 (66.4% ) 258 (55.5% ) 104 (60.1% ) 1782 (57.9% ) 598/10 26 (58.3% ) 15.59 (9.76) 15.86 (10.25)

-25.4

-62.0%

18.39 (11.66) 20.36 (12.84) 17.73 (10.65) 18.82 (11.80)

15.00 (8.53) 14.75 (9.70) 15.74 (9.94) 15.46 (10.23)

n=620

n=634

3.84 (3.81) 3.81 (4.23) 3.60 (3.55)

mild

170 (65.9%)

unspecific/ot her

1601 (49.2%) 624/1264 (49.4%)

PT

severe

CE unspecific/ot her

AC severe

moderate

P

x²=68. 30

p<0.0 1

x²=42. 24

p<0.0 1

x²=3.8 2

p=0.0 51

T

t or x²

-12.3%

5.8

8.8%

x²=1.4 9

p=0.2 22

-8.7

-17.7%

x²=48. 22

p<0.0 1

-8.9

-18.0%

x²=18. 10

p<0.0 1

2.60

14.3%

4.52

22.2%

2.16;3.0 5 2.77;6.2 7

t=11.5 3 t=5.08

p<0.0 1 p<0.0 1

3.39

18.4%

t=5.41

5.61

27.6%

1.99

11.2%

3.36

17.9%

2.16;4.6 2 3.48;7.7 5 1.49;2.5 0 2.46;4.2 7

p<0.0 1 p<0.0 1 p<0.0 1 p<0.0 1

2.88 (4.26) 2.57 (3.71)

0.96

25.0%

t=4.24

1.24

32.5%

1.97 (2.94)

1.63

45.3%

0.52;1.4 1 0.20;2.6 9 0.61;2.6 4

ED

18.19 (11.25) 20.38 (13.47)

-6.1

IP

284 (49.4%)

CI [95%]

CR

moderate

Differen ce in % of IG

US

206 (41.0%)

mild

… according to depression severity

-8.9

severe

moderate

… with outpatient anxiety disorder GP contacts after a recent outpatient antidepressa nt pharmacother apy by GP

Differen ce (IGCG) MD or PP

2238 (49.1%)

… with outpatient anxiety disorder GP contacts … according to depression severity

Control (n=401 3) N (%) or Mean (SD) 2329 (58.0% )

AN

Patients consulting more than one family practice … according to depression severity

Interventi on (n=4645) N (%) or Mean (SD)

M

Monitoring (Table3)

26

t=5.16 t=7.71 t=7.30

t=1.70

t=3.17

p<0.0 1 p=0.0 91 p<0.0 1

ACCEPTED MANUSCRIPT

p<0.0 1 p=0.0 27

11.3%

unspecific/ot her

3.86 (3.85) 3.37 (3.63)

3.01 (4.43) 2.56 (3.78)

0.85

22.0%

0.81

24.0%

1279 (27.5%)

1125 (28.0% ) 81 (33.2% ) 103 (22.2% ) 45 (26.0% ) 879 (28.6% ) 210/10 26 (20.5% ) n=112 5

-0.5

-1.8%

x²=0.2 7

p=0.6 05

-4.9

-17.3%

x²=1.8 9

p=0.1 69

3.2

12.6%

x²=1.4 8

p=0.2 23

x²=0.2 7

p=0.6 02

mild

73 (28.3%)

unspecific/ot her

909 (27.9%) 294/1264 (23.3%)

n=1279

PT

severe

8.1%

-2.5%

x²=0.3 1

p=0.5 77

2.8

12.0%

x²=2.5 7

p=0.1 09

9.07 (9.39) 8.42 (7.86)

1.40

13.4%

t=3.42

4.97

37.1%

0.60;2.2 1 2.04;7.9 1

p<0.0 1 p<0.0 1

1.02;4.0 9 1.54;10. 52 0.29;1.4 4 1.16;1.9 4

t=1.19

p=0.2 37

t=2.66

p<0.0 1 p=0.1 93

10.60 (11.89)

9.06 (8.58)

1.54

13.0%

mild

14.27 (17.33) 9.74 (8.90)

8.24 (6.74) 9.17 (9.78)

6.03

42.3%

0.57

5.9%

8.31 (9.17)

7.91 (8.05)

0.40

4.8%

CE

moderate

AC

t=2.22

-0.7

ED

10.47 (10.70) 13.39 (14.36)

2.3

IP

146 (25.4%)

CR

moderate

US

142 (28.3%)

AN

severe

T

0.48

unspecific/ot her

… with outpatient anxiety disorder

t=3.03

3.75 (5.26)

… with outpatient anxiety disorder Number of home visits per Patient

… according to depression severity

p=0.6 49

4.23 (3.32)

M

… with outpatient anxiety disorder Patients recieving home visit … according to depression severity

1.60;2.5 5 0.30;1.4 0 0.09;1.5 2

t=0.46

mild

27

t=3.34

t=1.30

t=0.50

p=0.6 19

ACCEPTED MANUSCRIPT Table 4

-3.2

Differen ce in % of IG -13.6%

severe

163 (32.5%)

94 (38.5%)

-6.0

-18.5%

moderate

190 (33.0%) 55 (21.3%) 667 (20.5%) 480 (38.0%)

168 (36.1%) 43 (24.9%) 755 (24.5%) 405 (39.5%)

-3.1

-9.4%

n=1092

n=1073

… with outpatient anxiety disorder Patients with specialist service by a GP initiated referral

moderate

CE

mild

unspecific/ot her

AC

… with outpatient anxiety disorder Patients with outpatient antidepressan t pharmacother apy by GP

… according to depression severity

severe

moderate mild

-19.5%

-1.5

-3.9%

3.6

4.3%

11.3

13.3%

159/190 (83.7%) 44/55 (80.0%) 549/667 (82.3%) 403/480 (84.0%)

136/168 (81.0%) 36/43 (83.7%) 599/755 (79.3%) 314/405 (77.5%)

2.7

3.2%

-3.7

-4.6%

3.0

3.6%

6.5

7.7%

n=4513

n=3905

1712 (37.9%) 182/461 (39.5%)

1383 (35.4%) 95/225 (42.2%)

2.5

6.6%

-2.7

-6.8%

275/549 (50.1%) 92/253

171/446 (38.3%) 68/169

11.9

32.7%

-3.8

-10.4%

ED

severe

-16.9%

851 (79.3%) 69/94 (73.4%)

PT

… according to depression severity

905 (82.9%) 138/163 (84.7%)

-4.0

CR

unspecific/ot her

-3.6

US

mild

CI [95 %]

t or x²

P

x²=11. 97

p<0.0 1

T

Differen ce (IGCG) MD or PP

IP

Control (n=4013 ) N (%) or Mean (SD) 1073 (26.7%)

x²=2.6 7

p=0.1 03

x²=1.0 8 x²=0.7 4 x²=14. 81 x²=0.5 4

p=0.2 98 p=0.3 90 p<0.0 1 p=0.4 64

x²=4.4 9 x²=4.8 2

p=0.0 34 p=0.0 28

x²=0.4 6 x²=0.2 2 x²=2.0 1 x²=5.9 0

p=0.4 98 p=0.6 37 p=0.1 56 p=0.0 15

x²=5.7 1 x²=0.4 7

p=0.0 17 p=0.4 92

x²=13. 74 x²=0.6

p<0.0 1 p=0.4

AN

Patients with a psychiatric specialist service … according to depression severity

Interventi on (n=4645) N (%) or Mean (SD) 1092 (23.5%)

M

Delivery of treatment (Table 4)

28

ACCEPTED MANUSCRIPT unspecific/ot her

119 (19.2%) 14/75 (18.7%)

83 (13.1%) 8/51 (15.7%)

19/87 (21.8%) 7/40 (17.5%) 78/413 (18.9%) 44/222 (19.8%)

11/74 (14.9%) 2/28 (7.1%) 62/474 (13.1%) 24/195 (12.3%)

4.3

9.6%

6.1

31.8%

unspecific/ot her … with outpatient anxiety disorder Patients with outpatient "psychosomati c basic care" by GP

5 x²=1.4 1

22 p=0.2 35

x²=3.9 9

p=0.0 46

IP

CR 16.0%

6.9

31.7%

10.4

59.4%

5.8

30.7%

7.5

37.9%

x²=8.6 4 x²=0.1 9

p<0.0 1 p=0.6 65

x²=1.2 8 x²=1.5 4 x²=5.6 0 x²=4.2 9

p=0.2 57 p=0.2 15 p=0.0 18 p=0.0 38

x²=59. 18 x²=36. 10

p<0.0 1 p<0.0 1

x²=30. 24 x²=0.9 6 x²=12. 90

p<0.0 1 p=0.3 28 p<0.0 1

x²=22. 55

p<0.0 1

n=3905

CE

severe

PT

ED

n=4513

3.0

US

mild

moderate

AC

mild

unspecific/ot her

… with outpatient anxiety disorder

n=634

4.2%

AN

severe

moderate

… according to depression severity

n=620

1.5

M

… according to depression severity

531/1191 (44.6%)

(40.2%) 1037/30 14 (34.3%) 396/982 (40.3%)

T

… with outpatient anxiety disorder Patients with a recent and sufficient outpatient antidepressan t pharmacother apy by GP

(36.4%) 1146/319 7 (35.8%)

1722 (38.2%) 230/461 (49.9%)

1178 (30.2%) 58/225 (25.8%)

8.0

20.9%

24.1

48.3%

263/549 (47.9%) 117/253 (46.2%) 1094/319 7 (34.2%)

137/446 (30.7%) 70/169 (41.4%) 903/301 4 (30.0%) 376/982 (38.3%)

17.2

35.9%

4.8

10.4%

4.2

12.3%

10.1

20.9%

577/1191 (48.4%)

29