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Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care
General Hospital Psychiatry 27 (2005) 383 – 391
Psychiatry and Primary Care Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Ju¨rgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.
Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary careB Stuart Levine, M.D., M.H.A.a,T, Jqrgen Unqtzer, M.D., M.P.H.b, Judy Y. Yip, Ph.D.a, Marc Hoffing, M.D., M.P.H.c, Moon Leung, Ph.D.a, Ming-Yu Fan, Ph.D.b, Elizabeth H.B. Lin, M.D., M.P.H.d, Lydia Grypma, M.D.e, Wayne Katon, M.D.b, Linda H. Harpole, M.D., M.P.H.f, Christopher A. Langston, Ph.D.g a SCAN Health Plan, Long Beach, CA 90801, USA Department of Psychiatry, University of Washington, Seattle, WA 98195, USA c Desert Medical Group, Inc., Palm Springs, CA 92262, USA d Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA e Southern California Permanente Medical Group, San Diego, CA 92120, USA f Research and Development, GlaxoSmithKline, Research Triangle Park, NC 27709, USA g The John A. Hartford Foundation, New York, NY 10022, USA Received 16 February 2005; revised 31 May 2005; accepted 2 June 2005 b
Abstract Objective: This study describes physicians’ satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Method: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians’ satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician’s experience with the IMPACT collaborative care model. Results: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients’ clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Conclusions: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses. D 2005 Elsevier Inc. All rights reserved. Keywords: Depression; Satisfaction; Quality of care
1. Introduction
B
J. Unqtzer was supported by John A. Hartford Foundation, New York, NY #98297-G, and California Health Care Foundation, Oakland, CA #983138B. T Corresponding author. Tel.: +1 562 989 4441; fax: +1 562 997 3188. E-mail address: [email protected] (S. Levine). 0163-8343/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2005.06.001
Major depression and dysthymic disorder affect between 5% and 10% of older adults seen in primary care [1–3], but fewer than half of depressed older adults receive effective treatment in primary care [4] and only a small minority of depressed older adults are treated by mental health specialists [5–9]. Initial research efforts to improve primary care for depressed older adults in recent
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years have had limited success [4]. Only 19% of depressed older patients receiving usual care in a study of collaborative care model experienced a substantial improvement in depression after 12 months, despite the fact that more than half had received antidepressant prescriptions in primary care [10]. Increased demands to treat depression in the primary care setting and pressure to provide high quality costeffective services [11] have resulted in elevated interest on the part of primary care practices and physicians in ways to enhance their capacity to treat depression. The Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) trial demonstrated that a collaborative stepped care program for depression in primary care can substantially improve quality of care and clinical outcomes for depressed older adults [10,12]. In this study, we report on the experience of more than 400 primary care providers who participated in this multisite trial. Specifically, we examined primary care physicians’ perception of and satisfaction with current care of older adults with depression and their experience and satisfaction with the IMPACT care model.
2. Methods 2.1. Site and subjects Project IMPACT is a multisite, randomized controlled trial of a collaborative disease management program for latelife depression in primary care vs. care as usual [12]. The study involved 18 participating primary care clinics belonging to eight healthcare organizations. Participating organizations encompassed a wide range of financing and delivery models, including two staff-model health maintenance organizations (HMOs), two group-model HMOs, the Department of Veteran Affairs, two university-affiliated primary care systems and one private practice physician group. The IMPACT study has been described in detail elsewhere [10,12]. The study followed 1,801 depressed older adults from the participating primary care clinics for 2 years. Half were assigned to care as usual and the other half had access for 12 months to a new collaborative care program for late-life depression in their regular primary care clinic. This program assigned patients aged 60 years and older to a depression care manager, a nurse or psychologist, based in their regular primary care clinic. These care managers were trained to work in close collaboration with the patients’ regular physicians for up to 12 months to educate and support patients initiating treatment for depression, track symptoms and side effects, assist with changes in antidepressant treatment as needed and provide behavioral activation and a brief course of counseling for depression called problem-solving treatment in primary care. At each site, a team psychiatrist and a primary care physician with experience in geriatric medicine provided consultation and backup to the care managers and the
patients’ regular PCP. Team psychiatrists also saw 10% of depressed older adults for consultation in primary care. 2.2. Survey instrument development and methods Because no validated instrument existed in the literature that could be used for this study, the primary care physician investigators in the IMPACT study developed a survey by consensus process to assess several aspects of physician’s perception of depression treatment in primary care (see Appendix B for actual survey). The survey focused on physicians’ satisfaction with current resources available to treat patients with late-life depression, their selfrated ability to provide quality depression care and their perceptions of the effectiveness of a chronic disease management model. Physician’s perception of the adequacy and effectiveness of depression care managers, specific intervention components felt to be particularly helpful, perceived impact of the IMPACT program on patients’ clinical outcomes and potential effects of the intervention resources on changing practice behavior were also included (see Appendix B for details). The questions were written to be modeled after standard satisfaction questions, and most response categories were on a five-point Likert scale. All primary care physicians who were practicing in one of the primary care clinics participating in the IMPACT study were asked to fill out a preintervention survey and a postintervention survey approximately 12 months after initiation of the IMPACT trial in their clinics. Because the IMPACT intervention randomized patients with depression and not their physicians, participating physicians could have patients in the intervention, in usual care or in both. The number of intervention patients that each physician had ranged from 0 to 25, with an average of 2 (1.8) per physician. Physicians whose patients received the IMPACT intervention were also asked additional questions specifically related to the IMPACT program on the postintervention survey. 2.3. Response rate Project coordinators at each of the study sites attempted to distribute the surveys to all participating primary care physicians (n = 490). These included 266 practicing primary care physicians at all the study sites and 224 physicians in training (residents) who worked at two of the participating study sites. Of the 490 eligible physicians contacted, 450 returned their preintervention surveys (91.8% response rate) and 306 (62.4% response rate) returned their surveys after the intervention, including 184 (60%) of the primary care physicians and 122 (40%) of the residents. A total of 267 physicians (54.5%) returned both pre- and postintervention surveys. The lower response rate at follow-up was largely due to physician’s turnover, particularly among resident physicians. We conducted analyses comparing responses among physicians who responded to the preintervention survey only to those who responded to both the pre- and
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
385
Table 1 Physicians’ evaluation of current depression care Preintervention survey
All (n = 450)
T/v 2 value
Nonresident (n = 257)
Resident (n = 193)
Satisfaction with current resources for treating depression Mean (S.D.) 2.67 (1.02) % Somewhat or very satisfied 53.6%
2.7 (1.08) 54.3%
2.62 (0.94) 52.06%
0.84 0.12
0.403 0.727
Self-rated ability to provide depression treatment Mean (S.D.) 3.09 (0.94) % Excellent/very good 63.5%
3.05 (1.02) 66.5%
3.15 (0.95) 59.4%
1.07 2.43
0.287 0.118
Helpfulness of chronic disease management model for treating depression Mean (S.D.) 1.7 (0.92) 1.61 (0.84) % Rated at least somewhat helpful 88.0% 91.3%
1.84 (1.01) 83.6%
2.62 6.16
0.001 0.013
Helpfulness of chronic disease management model for treating diabetes or heart failure Mean (S.D.) 1.77 (1.02) 1.63 (0.97) % Rated at least somewhat helpful 86.3% 88.6%
1.95 (1.05) 83.3%
3.35 2.62
0.001 0.105
P valueT
T P values represent v 2 tests between nonresident physicians and resident physicians.
postintervention surveys and found no significant differences in baseline responses (satisfaction with current resources, self-rated ability to provide depression treatment, helpfulness of chronic disease management model in treating depression and for treating diabetes or heart failure) between these two groups.
between physicians from different study sites, between resident and nonresident physicians and between physicians in fee-for-service or capitated practice settings. Qualitative comments were also collected from all physicians and examined for common themes.
2.4. Analysis We reported our results by comparing our survey responses before and after the intervention, treating our responses initially as a continuous variable because of the five-point Likert scale. Detailed raw data responses are reported under each response for each survey question (see bAppendix BQ). In general, the lower the score, the more positive the response is. To facilitate our report of the results, we also converted the Likert-scale responses to dichotomous measures (e.g., bsomewhat/very helpfulQ, bexcellent/very goodQ). t Tests or ANOVA tests were used for continuous variables, and v 2 tests or Fisher’s Exact Tests were used for dichotomous variables. In addition, t test, ANOVA and v 2 tests were used to examine differences
3. Results In the preintervention survey, about half (53.6%) of the physicians surveyed reported being satisfied with the current resources available for treating patients with late-life depression in their primary care settings (Table 1). We did not identify significant differences in the proportion of providers who were satisfied with available resources among nonresident or resident physicians (54.3% vs. 52.6%, v 2 = 0.12, df =1, P = .727; mean difference between two groups = 0.08) or among physicians working in fee-forservice vs. capitated practice settings (Table 2). We did, however, observe significant organizational differences in physician’s satisfaction with available resources. The
Table 2 Physicians’ evaluation of current depression care by participating health care organization Variable
Category
Satisfaction with current resources for treating depression Mean score (S.D.)
Organization
Plan type
1 2 3 4 5 6 7 8 Capitated Fee-for-service
2.00 2.6 3.2 2.64 2.79 3.00 2.84 2.27 2.66 2.68
(0.93) (0.98) (1.01) (0.96) (1.11) (1.19) (1.03) (0.84) (1.04) (1.00)
F value ( P)
3.46 (.0013)
0.22 (.83)
2
Self-rated ability to provide depression treatment
% (n) Somewhat or very satisfied
v ( P)
Mean score (S.D.)
87.5 56.6 30.0 52.9 48.1 46.7 44.75 71.1 54.4 51.5
16.95 (.018)
2.13 3.00 3.05 3.32 3.37 2.89 2.97 3.00 3.04 3.21
(7) (77) (6) (54) (25) (21) (17) (32) (172) (67)
0.31 (.58)
(0.83) (1.00) (0.69) (0.91) (0.97) (0.9) (0.68) (0.90) (0.94) (0.92)
F value ( p)
3.56 (.001)
1.79 (.08)
% (n) Rated as good or excellent
v 2 ( P)
100 66.2 75.0 50.0 50.0 71.7 78.9 68.9 66.3 56.8
24.24 (.001)
(8) (90) (15) (52) (26) (33) (30) (31) (210) (75)
3.57 (.06)
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proportion of providers who were satisfied ranged from 30% to 87.5% (v 2 = 16.9, df = 7, P = .02) among the participating health care organizations (Table 2). About 64% of the participating physicians rated their ability to provide quality depression treatment as bexcellentQ or bvery goodQ (63.5%, mean =3.09) (Table 1). We observed no significant difference in the self-rated ability between nonresident (66.5%, mean = 3.05) and resident physicians (59.4%, mean = 3.15) (v 2 = 2.43, df =1, P = .12] or between physicians practicing in fee-for-service or capitated settings. We did find significant organizational differences among physicians’ perceptions of their ability to care for patients with depression among the participating health care organizations, with the proportion of physicians who rated their ability to care for depression as bvery good or excellentQ ranging from 50% to 100% (v 2 =24.24, df = 7, P = .001). ANOVA tests for physician’s self-rated ability as a continuous variable produced similar results (Table 2). Physicians in general had a positive impression of the value of disease management programs for treating chronic conditions. More than 85% of physicians said they would find a chronic disease management program at least somewhat helpful for treating patient with diabetes, heart failure or depression (Table 1). Nonresident physicians were
somewhat more likely than resident physicians to consider a chronic disease management model helpful for treating depression (91.3% vs. 83.6%, v 2 =6.16, df =1, P = .013). There was little variability in physicians’ perception of the value of chronic disease management across participating organizations. On the postintervention survey, physicians whose patients were enrolled in the IMPACT program generally had a very positive experience with the intervention. More than 90% described the IMPACT depression program to be helpful in treating patients with depression (Table 3). A total of 93% were very or somewhat satisfied with the resources available for treating depression among patients assigned to the IMPACT model, compared with only 61% of physicians who were satisfied with available resources for their patients who were assigned to usual care. Both nonresident and resident physicians had an equally positive impression of the IMPACT program. When asked if this kind of program would be useful for the treatment for other chronic conditions such as heart diseases and diabetes, 87% of physicians responded bat least somewhat helpful.Q Ninety-four percent of PCPs found the IMPACT care managers to be somewhat or very helpful in treating depression, and 89% reported that the care managers
Table 3 Physicians’ experience with IMPACT depression care model Postintervention survey
All (n = 181)a
Nonresident (n = 154)
Resident (n = 27)
Satisfaction with resources for treating IMPACT patients with depression Mean (S.D.) 1.44 (0.64) % Very/somewhat satisfied 93.3%
1.39 (0.62) 94.0%
1.67 (0.68) 88.9%
.039 .396
Helpfulness of IMPACT depression program in treating depression Mean (S.D.) 1.49 (0.66) % Very/somewhat helpful 91.7%
1.47 (0.66) 92.2%
1.59 (0.69) 88.9%
.368 .227
Helpfulness of this type of program in treating diabetes or heart disease Mean (S.D.) 1.57 (0.73) % Very/somewhat helpful 87.6%
1.58 (0.74) 87.4%
1.52 (0.7) 88.9%
.677 1.000
Helpfulness of IMPACT clinical specialist in treating depression Mean (S.D.) 1.41 (0.67) % Very/somewhat helpful 93.6%
1.37 (0.63) 94.4%
1.63 (0.79) 88.9%
.064 .383
Provision of care by IMPACT clinical specialist Mean (S.D.) % Rated just the right amount of care
1.95 (0.33) 88.9%
1.96 (0.33) 88.9%
1.89 (0.32) 88.9%
.317 1.000
Perception of the role of IMPACT program on patient’s clinical outcomes Mean (S.D.) 1.84 (0.77) % Felt the program improved patient’s clinical outcomes 82.0%
1.8 (0.77) 82.8%
2.04 (0.76) 77.8%
.142 .586
On-site consultants influenced whether you would be more likely to refer depression patients Mean (S.D.) 1.73 (0.85) 1.74 (0.88) % Rated definitely/possibly 85.4% 84.0%
1.7 (0.61) 92.6%
.856 .375
On-site consultants influenced whether you would be more likely to diagnose/treat depressed patients Mean (S.D.) 2.31 (1.24) 2.37 (1.27) % Rated definitely/possibly 66.5% 62.9%
2.04 (1.02) 85.2%
.205 .027
a
These are physicians who returned their postintervention surveys and had patients enrolled in the IMPACT intervention. T P values represent the Fisher’s Exact Tests between nonresident physicians and resident physicians.
P valueT
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
provided bjust the right amount of careQ (Table 3). A total of 82% also felt the program improved their patients’ clinical outcomes. When physicians were asked to identify the two most helpful features of the IMPACT program, bproactive follow-up and progress monitoringQ ranked first, followed by bpatient education.Q These positive impressions of the IMPACT model were echoed by qualitative comments from the surveyed physicians. When asked what aspect of the IMPACT study they liked the least, the surveyed physicians commented that because of the randomized trial design, only half of their patients had access to the IMPACT model, and the rest of their patients were not getting the support and benefits from the intervention. The following were typical comments: bI do not get any feedback on patients enrolled in usual care,Q and bI tend to lose track of patients involved in usual care.Q When asked what aspect of IMPACT they liked the most, physicians commented on improved follow-up with patients and better communication facilitated by the nurse care managers. Typical comments included: bAssurance of good follow-up for patient and documentation for me.Q bAlways follow-up and have someone looking over my shoulder.Q bThe follow-up provided to those patients assigned to the intervention was much more intensive than what we could have offered with our available resources. The follow-up was what I liked best.Q bGood consistent care I could trust and ongoing communication so I always knew what was being done.Q bImproved access for our patients. I don’t have much time to talk to patients with [sic] lots of other medical issues . . . great for more time to spend.Q bProvided much better care than our psychiatry department which has of late been highly inadequate in caring for our depressed patients.Q Eighty-five percent of physicians expressed that on-site mental health consultants in primary care setting would influence their referral patterns of depressed patients, compared with two thirds who expressed that this program feature would influence their diagnostic or treatment behavior. Among resident physicians, 85% (compared to 62.9% nonresident physicians, P = .03) reported that having a psychiatric consultant on-site would influence their likelihood of making depression diagnoses or treating depressed patients. 4. Discussion Studies on physician’s attitudes and satisfaction have primarily focused on physicians’ access to specialty mental health care [13] and how physicians view various financial arrangements with special emphasis on managed care [14 –20]. Several studies have examined physician’s satisfaction with services intended to expand their practice capacity [21–24]. Other studies have examined physician’s perception of and attitudes toward particular care models or programs, such as hospitalists [25], nurse practitioners [26], geriatric training in caring for community-dwelling elders [27] and disease management programs in general [28].
387
This study reported physician’s satisfaction with a collaborative primary care model with depression treatment for older patients. Our results show that irrespective of the financial and organizational arrangements they are in, primary care physicians face substantial challenges in caring for older patients with complex diseases and conditions such as depression. Recent literature indicates that only about two out of five primary care patients with major depression are appropriately diagnosed and treated [29], and data from the usual care arm of the IMPACT trial [10] indicates that only about one in five depressed older adults in primary care experiences a substantial improvement in depressive symptoms, despite increasing rates of depression treatment in primary care. Our physician survey demonstrates that primary care physicians identify substantial unmet needs in their ability to care for late-life depression in primary care, with only 54% indicating that they were satisfied with current resources to treat depression, prior to the intervention. Our survey also suggests that there is a substantial variation in physician’s satisfaction with resources available to care for depression and with physicians’ self-rated ability to care for depression across the eight participating health care organizations. Unfortunately, organizational characteristics are not available to the authors to examine site differences. Nonetheless, this finding suggests that there may be room for substantial improvement in depression care in some organizations. We did not find significant differences in satisfaction with resources and perceived ability to care for depression among physicians who worked in capitated vs. fee-for-service settings. Before the study, most of the surveyed physicians indicated that a chronic care disease management program would be helpful for treatment of depression. At the postintervention survey, more than 90% of participating physicians reported the IMPACT program to be helpful in treating late-life depression, and 82% felt that the IMPACT program improved the clinical outcomes of their patients. Although patient level outcome comparisons were not available to physicians at the time of the postintervention physician survey, this positive perception of the intervention effect on patient outcomes is consistent with the study findings that indicate that the IMPACT model has demonstrated better results than usual care for treating depression: 49% vs. 20% of depressed older adults experienced improvements in depressive symptoms [10]. We found no significant site differences in providers’ perceived usefulness of the IMPACT model, an observation that is also consistent with patient outcome data indicating that IMPACT participants at all eight participating health care organizations had better depression outcomes than those in usual care [5]. At the 12-month postintervention survey, physicians reported a slight increase in their satisfaction with resources available to treat depression for usual care older patients
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S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
(61%) compared to baseline but a significantly higher satisfaction with the resources available to treat depressed patients assigned to the IMPACT intervention (93%). This suggests that most of the observed improvement is not a generalized secular trend in improved depression care but a result of the IMPACT intervention resources deployed in the participating clinics. We also observed a significant increase in physicians’ self-rated ability to provide quality care for depression between the pre- and postintervention surveys, suggesting that participation in the IMPACT trial resulted in some learning and improved physicians’ ability to treat depression. Findings that participation in a collaborative care program enhanced physician’s satisfaction and selfefficacy in treating depression have important implications for future strategies to improve depression outcomes among primary care patients. Existing research demonstrate that physician’s education alone was insufficient to improve patient outcomes [30] when primary care services were not reorganized to deliver chronic disease care management. The IMPACT intervention provides an effective model to achieve enhanced outcomes for depression. Participating physicians identified close patient followup and patient education as the most helpful components of the IMPACT model. Given physicians’ limited time and resources, IMPACT care managers who had the time and a structured protocol to provide education and systematic follow-up were seen to be crucial features of the program that could both strengthen the physician–patient relationship and facilitate an adequate and effective treatment course for patients. Physicians in our survey indicated that an on-site psychiatric consultant would have more of an effect on their referral behavior than on their diagnostic or treatment behavior. The differences in the perceived benefits of on-site psychiatric consultation between resident physicians and nonresident physicians suggest that exposure to psychiatric consultants and evidence-based collaborative care models such as IMPACT during residency training may have a bigger effect on practice patterns for physicians in training than those who are already in practice, making an argument for exposing physicians to such evidence-based models of care during their training. Exposing physicians to collaborative disease management models during residency may also increase their belief in the value of this model and their advocacy for it in future practice. There are several limitations to this study. First, we have a substantial number of nonresponses in our physician follow-up survey. This is mostly related to PCP turnover, particularly among resident physicians who rotated off or graduated during the IMPACT study. However, we found no significant systematic baseline differences between the physicians who did and did not respond to the follow-up surveys. We also did not find substantial differences when we analyzed only those responses from the 267 physicians who completed both surveys, suggesting that our missing postintervention survey data may not have introduced a
substantial bias. Second, we do not have detailed information about physicians’ demographics (e.g., age or gender) or clinical background (e.g., primary care specialty and years in practice) that would be helpful to explore relationships between physician’s characteristics and satisfaction with depression care or the IMPACT model. Thirdly, organizations that are interested in improving depression care may have been particularly likely to participate in the IMPACT trial, and it is not clear that our findings can generalize to all primary care practices. However, the primary care providers in the participating organizations were not selected based on their interest in improving depression care, and we feel that they represent a diverse group of providers working in a wide range of health care settings. Fourthly, because we evaluated physician’s perceptions and attitudes about depression treatment for older adults, our results may not generalize to younger adults. Finally, we do not have data to link outcomes of individual patients to individual providers and can only compare aggregate physician’s perceptions of patient outcomes with aggregate patient outcomes. In summary, primary care physicians in the IMPACT trial were very satisfied with this innovative collaborative care model for treating depressed older adults in their primary care practices and felt that similar care management models would also be helpful for treating other chronic medical illnesses. Physicians who are more satisfied and confident in their ability to manage depression may be more likely to treat depression and project satisfaction and confidence to their patients. This may be particularly important when caring for patients with depression. Collaborative care models such as IMPACT have the potential to increase patient outcomes and provider satisfaction not only for depressed patients but also for a range of other chronic medical conditions. Acknowledgments We would like to acknowledge the contributions and support of the patients, the primary care providers, and the staff at the study coordinating center and at all participating study sites, which include Duke University, Durham, NC; The South Texas Veterans Health Care System, The Central Texas Veterans Health Care System; and The San Antonio Preventive and Diagnostic Medicine Clinic; Indiana University School of Medicine, Indianapolis, IN; Health and Hospital Corporation of Marion County; Group Health Cooperative of Puget Sound in cooperation with the University of Washington, Seattle, WA; Kaiser Permanente of Northern California, Oakland and Hayward, CA; Kaiser Permanente of Southern California, San Diego, CA; Desert Medical Group, Palm Springs, CA. This study is the result of work supported in part by the patients, the resources and the use of facilities at the South Texas Veterans Health Care System and the Central Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily represent the views of the Depart-
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
ment of Veterans Affairs. We would also like to acknowledge the contributions of the IMPACT study advisory board and the programming support by Tonya Marmon.
1 Very Helpful [219]
Appendix A. IMPACT investigators
b) For depression?
The IMPACT Investigators include (in alphabetical order) Patricia Arean, Ph.D. (Co-PI); Thomas R. Belin, Ph.D.; Noreen Bumby, D.O.; Christopher Callahan, M.D. (PI); Paul Ciechanowski, M.D., M.P.H.; Ian Cook, M.D.; Jeffrey Cordes, M.D.; Steven R. Counsell, M.D.; Richard Della Penna, M.D. (Co-PI); Jeanne Dickens, M.D.; MingYu Fan, Ph.D.; Michael Getzell, M.D.; Howard Goldman, M.D., Ph.D.; Lydia Grypma, M.D. (Co-PI); Linda Harpole, M.D., M.P.H. (PI); Mark Hegel, Ph.D.; Hugh Hendrie, M.B., Ch.B., D.Sc. (Co-PI); Polly Hitchcock Noel, Ph.D. (Co-PI); Marc Hoffing, M.D. (PI), M.P.H.; Enid M. Hunkeler, M.A. (PI); Wayne Katon, M.D. (PI); Kurt Kroenke, M.D.; Stuart Levine, M.D., M.H.A. (CoPI); Elizabeth H.B. Lin, M.D., M.P.H. (Co-PI); Tonya Marmon, M.S.; Eugene Oddone, M.D., M.H.Sc. (Co-PI); Sabine Oishi, M.S.P.H.; Diane Powers, M.A.; R. Jerome Rauch, M.D.; Michael Sands, M.D.; Michael Schoenbaum, Ph.D.; Rik Smith, M.D.; David C. Steffens, M.D., M.H.S.; Christopher A. Steinmetz, M.D.; Lingqi Tang, Ph.D.; Iva Timmerman, M.D.; Jqrgen Unqtzer, M.D., M.P.H. (PI); John W. Williams Jr., M.D., M.H.S. (PI); Jason Worchel, M.D.; Mark Zweifach, M.D. Appendix B. Prestudy IMPACT provider survey Please take a few minutes to answer the following questions. Circle the number that corresponds best to your response. 1. How satisfied are you with the resources currently available to treat elderly patients with depression in your practice? 1 Very Satisfied [35]
2 Somewhat Satisfied [204]
3 Neither [104]
4 Somewhat Dissatisfied [80]
5 Very Dissatisfied [23]
1 Very Helpful [222]
389
2 3 Somewhat Neither Helpful [165] [25]
2 3 Somewhat Neither Helpful [168] [27]
4 Somewhat Unhelpful [17]
5 DK Very Unhelpful [19]
4 Somewhat Unhelpful [14]
5 DK Very Unhelpful [12]
4. If you could change one thing to improve care for depressed elderly patients,what would you change? ______ Appendix C. Poststudy IMPACT provider survey The IMPACT study is a depression management program that assists the primary care provider deliver quality depression treatment for elderly depressed patients. During the course of the IMPACT study you had ______ patients receiving the IMPACT intervention. Please take a few minutes to answer the following questions. Circle the number that best corresponds to your response. 1. How would you rate your ability to provide quality depression treatment for elderly patients in your practice? 1 Excellent [38]
2 Very Good [99]
3 Good [121]
4 Fair [41]
5 Poor [6]
2. How satisfied are you with the resources currently available in your practice to treat elderly patients with depression who are not enrolled in the IMPACT study? 1 Very Satisfied [48]
2 Somewhat Satisfied [136]
3 Neither [57]
4 Somewhat Dissatisfied [54]
5 Very Dissatisfied [7]
2. How would you rate your ability to provide quality depression treatment for elderly patients in your practice?
Please answer the following questions if you have had at least one patient in the IMPACT intervention program:
1 Excellent [23]
3. How satisfied are you with the resources currently available in your practice to treat elderly patients with depression who are enrolled in the IMPACT intervention program?
2 Very Good [93]
3 Good [169]
4 Fair [148]
5 Poor [16]
3. How helpful would you find a chronic disease management model where another team member located in your primary care clinic (e.g., a nurse, nurse practitioner, mental health consultant) would help you co-manage patients with chronic diseases. a) For medical conditions such as diabetes or heart failure?
1 Very Satisfied [113]
2 Somewhat Satisfied [53]
3 Neither [11]
4 Somewhat Dissatisfied [1]
5 Very Dissatisfied
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4. Overall, how helpful did you find the IMPACT depression program in providing care for your elderly patients with depression?
Do on-site mental health consultants influence whether you would be more likely to: a) Refer patients with depression?
1 Very Helpful [109]
1 2 3 4 5 Definitely Possibly Unsure Possibly No Definitely No [80] [66] [17] [7] [1]
2 Somewhat Helpful [57]
3 Neither [14]
4 Somewhat Unhelpful [1]
5 Very Unhelpful
5. How helpful would you find this type of program for your patients with diabetes or heart disease? 1 Very Helpful [100]
2 Somewhat Helpful [56]
3 Neither [20]
4 Somewhat Unhelpful [2]
5 Very Unhelpful
6. How helpful was the IMPACT depression clinical specialist in providing care to your elderly patients with depression? 1 Very Helpful [114]
2 Somewhat Helpful [46]
3 Neither [8]
4 Somewhat Unhelpful [3]
5 Very Unhelpful
7. The amount of care provided by the IMPACT depression clinical specialist was 1 Not [14]
2 Enough [152]
3 Just Right [5]
Too much
8. Please check the top TWO areas where you felt the IMPACT depression program was most helpful in providing care for your elderly depressed patients. (check two) 5 5 5 5 5 5 5
Patient Education Depression Diagnosis Treatment (medication and/or counseling) Proactive follow-up and monitoring of progress Feedback on your patients’ progress provided by IMPACT Not helpful in any area Other:
9. Do you feel that the IMPACT depression program improved the clinical outcomes of your patients with depression who were enrolled in the program? 1 2 3 Definitely Possibly Unsure Improved [63] [78] [26]
4 5 Possibly No Definitely No Improvement Improvement [5]
10. The IMPACT intervention provides additional mental health services, on-site in primary care.
b) Diagnose and treat patients with depression? 1 2 3 4 5 Definitely Possibly Unsure Possibly No Definitely No [49] [64] [27] [14] [16] 11. What did you like least about the IMPACT program? _____________________________________________ 12. What did you like best about the IMPACT program? _____________________________________________ Thank you for your time! References [1] Oxman TE, Barrett JE, Barrett J, et al. Symptomatology of late-life minor depression among primary-care patients. Psychosomatics 1990;31:174 – 80. [2] Lyness JM, Caine ED, King DA, et al. Psychiatric disorders in older primary care patients. J Gen Intern Med 1999;14:249 – 54. [3] Schulberg HC, Katon WJ, Simon GE, et al. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry 1999;60(Suppl. 7):19 – 26. [4] Callahan CM. Quality improvement research on late life depression in primary care. Med Care 2001;39(8):772 – 84. [5] Klap R, Unroe TK, Unqtzer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry 2003;11:517 – 24. [6] Unqtzer J, Katon W, Sullivan M, et al. Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness. Milbank Q 1999;77:225 – 56. [7] Waxman HM, Carner EA. Physicians’ recognition, diagnosis, and treatment of mental disorders in elderly medical patients. Gerontologist 1984;24:593 – 7. [8] Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services: three ECA sites. Arch Gen Psychiatry 1984; 41:971 – 8. [9] Goldstrom ID, Burns BJ, Kessler LG, et al. Mental health services use by elderly adults in a primary care setting. J Gerontol 1987;42:147 – 53. [10] Unqtzer J, Katon W, Callahan CM, et al. Collaborative care management of later life depression in the primary care setting: a randomized controlled trial. JAMA 2002;22:2836 – 45. [11] Schreter RK. Ten trends in managed care and their impact on the biopsychosocial model. Hosp Community Psychiatry 1993;44:325 – 7. [12] Unqtzer J, Katon WJ, Williams JW, et al. Improving primary care for depression in late life: the design of a multi-center randomized trial. Med Care 2001;39:785 – 99. [13] Van Voorhees BW, Wang NY, Ford DE. Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians. Gen Hosp Psychiatry 2003;25(3):149 – 57. [14] Murray A, Montgomery JE, Chang H, et al. Doctor discontent: a comparison of physician satisfaction in different delivery system settings. J Gen Intern Med 2001;7:451 – 9.
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391 [15] Gazewood JD, Long DR, Madsen R. Physician satisfaction with Medicaid managed care: the Missouri experience. J Fam Pract 2000;1:20 – 6. [16] Nadler ES, Sims S, Tyrance PH, et al. Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment. Am J Med 1999;1:38 – 44. [17] Keating NL, Landon BE, Ayanian JZ, et al. Practice, clinical management, and financial arrangements of practicing generalists: are they associated with satisfaction? J Gen Intern Med 2004;5(Part 1):410 – 8. [18] Cykert S, Hansen C, Layson R, et al. Primary care physicians and capitated reimbursement: experience, attitudes, and predictors. J Gen Intern Med 1997;3:192 – 4. [19] Grumbach K, Osmond D, Vranizan K, et al. Primary care physiciansT experience of financial incentives in managed-care systems. N Engl J Med 1998;21:1516 – 21. [20] Grembowski D, Ulrich CM, Paschane D, et al. Managed care and primary physician satisfaction. J Am Board Fam Prac 2003;5:383 – 93. [21] Forrest CB, Glade GB, Alison E, et al. Coordination of specialty referrals and physician satisfaction with referral care. Arch Pediatr Adolesc Med 2000;5:499 – 506. [22] Rau J, Cross JL, Hofherr LK, et al. Physician satisfaction with human immunodeficiency virus type 1 and hepatitis B virus testing in San Diego county. Med Care 1996;1:1 – 10. [23] Meyerhoff A, Jacobs RJ, Greenberg DP, et al. Clinician satisfaction with vaccination visits and the role of multiple injections, results from
[24]
[25]
[26]
[27]
[28]
[29]
[30]
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the COVISE study (combination vaccines impact on satisfaction and epidemiology). Clin Pediatr 2004;1:87 – 93. Katz SJ, Moyer CA, Douglas T, et al. Effect of a triage-based e-mail system on clinic resource use and patient and physician satisfaction in primary care: a randomized controlled trial. J Gen Intern Med 2003;9: 736 – 44. Auerbach AD, Davis RB, Phillips RS. Physician views on caring for hospitalized patients and the hospitalist model of inpatient care. J Gen Intern Med 2001;2:116 – 9. Aquilino ML, Damiano PC, Willard JC, et al. Primary care physician perceptions of the nurse practitioner in the 1990s. Arch Fam Med 1999;3:224 – 7. Schwartzberg JG, Guttman R. Effect of training on physician attitudes and practices in home and community care of the elderly. Arch Fam Med 1997;5:439 – 44. Fernandez A, Grumbach K, Vranizan K, et al. Primary care physicians’ experience with disease management programs. J Gen Intern Med 2001;3:163 – 7. Katon W, Russo J, Von Korff M, et al. Long-term effects of a collaborative care intervention in persistently depressed primary care patients. J Gen Intern Med 2002;17:741 – 8. Lin EH, Simon GE, Katzelnick DJ, et al. Does physician education on depression management improve treatment in primary care? J Gen Intern Med 2001;16:614 – 9.
Psychiatry and Primary Care Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Ju¨rgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.
Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary careB Stuart Levine, M.D., M.H.A.a,T, Jqrgen Unqtzer, M.D., M.P.H.b, Judy Y. Yip, Ph.D.a, Marc Hoffing, M.D., M.P.H.c, Moon Leung, Ph.D.a, Ming-Yu Fan, Ph.D.b, Elizabeth H.B. Lin, M.D., M.P.H.d, Lydia Grypma, M.D.e, Wayne Katon, M.D.b, Linda H. Harpole, M.D., M.P.H.f, Christopher A. Langston, Ph.D.g a SCAN Health Plan, Long Beach, CA 90801, USA Department of Psychiatry, University of Washington, Seattle, WA 98195, USA c Desert Medical Group, Inc., Palm Springs, CA 92262, USA d Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA e Southern California Permanente Medical Group, San Diego, CA 92120, USA f Research and Development, GlaxoSmithKline, Research Triangle Park, NC 27709, USA g The John A. Hartford Foundation, New York, NY 10022, USA Received 16 February 2005; revised 31 May 2005; accepted 2 June 2005 b
Abstract Objective: This study describes physicians’ satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Method: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians’ satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician’s experience with the IMPACT collaborative care model. Results: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients’ clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Conclusions: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses. D 2005 Elsevier Inc. All rights reserved. Keywords: Depression; Satisfaction; Quality of care
1. Introduction
B
J. Unqtzer was supported by John A. Hartford Foundation, New York, NY #98297-G, and California Health Care Foundation, Oakland, CA #983138B. T Corresponding author. Tel.: +1 562 989 4441; fax: +1 562 997 3188. E-mail address: [email protected] (S. Levine). 0163-8343/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2005.06.001
Major depression and dysthymic disorder affect between 5% and 10% of older adults seen in primary care [1–3], but fewer than half of depressed older adults receive effective treatment in primary care [4] and only a small minority of depressed older adults are treated by mental health specialists [5–9]. Initial research efforts to improve primary care for depressed older adults in recent
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years have had limited success [4]. Only 19% of depressed older patients receiving usual care in a study of collaborative care model experienced a substantial improvement in depression after 12 months, despite the fact that more than half had received antidepressant prescriptions in primary care [10]. Increased demands to treat depression in the primary care setting and pressure to provide high quality costeffective services [11] have resulted in elevated interest on the part of primary care practices and physicians in ways to enhance their capacity to treat depression. The Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) trial demonstrated that a collaborative stepped care program for depression in primary care can substantially improve quality of care and clinical outcomes for depressed older adults [10,12]. In this study, we report on the experience of more than 400 primary care providers who participated in this multisite trial. Specifically, we examined primary care physicians’ perception of and satisfaction with current care of older adults with depression and their experience and satisfaction with the IMPACT care model.
2. Methods 2.1. Site and subjects Project IMPACT is a multisite, randomized controlled trial of a collaborative disease management program for latelife depression in primary care vs. care as usual [12]. The study involved 18 participating primary care clinics belonging to eight healthcare organizations. Participating organizations encompassed a wide range of financing and delivery models, including two staff-model health maintenance organizations (HMOs), two group-model HMOs, the Department of Veteran Affairs, two university-affiliated primary care systems and one private practice physician group. The IMPACT study has been described in detail elsewhere [10,12]. The study followed 1,801 depressed older adults from the participating primary care clinics for 2 years. Half were assigned to care as usual and the other half had access for 12 months to a new collaborative care program for late-life depression in their regular primary care clinic. This program assigned patients aged 60 years and older to a depression care manager, a nurse or psychologist, based in their regular primary care clinic. These care managers were trained to work in close collaboration with the patients’ regular physicians for up to 12 months to educate and support patients initiating treatment for depression, track symptoms and side effects, assist with changes in antidepressant treatment as needed and provide behavioral activation and a brief course of counseling for depression called problem-solving treatment in primary care. At each site, a team psychiatrist and a primary care physician with experience in geriatric medicine provided consultation and backup to the care managers and the
patients’ regular PCP. Team psychiatrists also saw 10% of depressed older adults for consultation in primary care. 2.2. Survey instrument development and methods Because no validated instrument existed in the literature that could be used for this study, the primary care physician investigators in the IMPACT study developed a survey by consensus process to assess several aspects of physician’s perception of depression treatment in primary care (see Appendix B for actual survey). The survey focused on physicians’ satisfaction with current resources available to treat patients with late-life depression, their selfrated ability to provide quality depression care and their perceptions of the effectiveness of a chronic disease management model. Physician’s perception of the adequacy and effectiveness of depression care managers, specific intervention components felt to be particularly helpful, perceived impact of the IMPACT program on patients’ clinical outcomes and potential effects of the intervention resources on changing practice behavior were also included (see Appendix B for details). The questions were written to be modeled after standard satisfaction questions, and most response categories were on a five-point Likert scale. All primary care physicians who were practicing in one of the primary care clinics participating in the IMPACT study were asked to fill out a preintervention survey and a postintervention survey approximately 12 months after initiation of the IMPACT trial in their clinics. Because the IMPACT intervention randomized patients with depression and not their physicians, participating physicians could have patients in the intervention, in usual care or in both. The number of intervention patients that each physician had ranged from 0 to 25, with an average of 2 (1.8) per physician. Physicians whose patients received the IMPACT intervention were also asked additional questions specifically related to the IMPACT program on the postintervention survey. 2.3. Response rate Project coordinators at each of the study sites attempted to distribute the surveys to all participating primary care physicians (n = 490). These included 266 practicing primary care physicians at all the study sites and 224 physicians in training (residents) who worked at two of the participating study sites. Of the 490 eligible physicians contacted, 450 returned their preintervention surveys (91.8% response rate) and 306 (62.4% response rate) returned their surveys after the intervention, including 184 (60%) of the primary care physicians and 122 (40%) of the residents. A total of 267 physicians (54.5%) returned both pre- and postintervention surveys. The lower response rate at follow-up was largely due to physician’s turnover, particularly among resident physicians. We conducted analyses comparing responses among physicians who responded to the preintervention survey only to those who responded to both the pre- and
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
385
Table 1 Physicians’ evaluation of current depression care Preintervention survey
All (n = 450)
T/v 2 value
Nonresident (n = 257)
Resident (n = 193)
Satisfaction with current resources for treating depression Mean (S.D.) 2.67 (1.02) % Somewhat or very satisfied 53.6%
2.7 (1.08) 54.3%
2.62 (0.94) 52.06%
0.84 0.12
0.403 0.727
Self-rated ability to provide depression treatment Mean (S.D.) 3.09 (0.94) % Excellent/very good 63.5%
3.05 (1.02) 66.5%
3.15 (0.95) 59.4%
1.07 2.43
0.287 0.118
Helpfulness of chronic disease management model for treating depression Mean (S.D.) 1.7 (0.92) 1.61 (0.84) % Rated at least somewhat helpful 88.0% 91.3%
1.84 (1.01) 83.6%
2.62 6.16
0.001 0.013
Helpfulness of chronic disease management model for treating diabetes or heart failure Mean (S.D.) 1.77 (1.02) 1.63 (0.97) % Rated at least somewhat helpful 86.3% 88.6%
1.95 (1.05) 83.3%
3.35 2.62
0.001 0.105
P valueT
T P values represent v 2 tests between nonresident physicians and resident physicians.
postintervention surveys and found no significant differences in baseline responses (satisfaction with current resources, self-rated ability to provide depression treatment, helpfulness of chronic disease management model in treating depression and for treating diabetes or heart failure) between these two groups.
between physicians from different study sites, between resident and nonresident physicians and between physicians in fee-for-service or capitated practice settings. Qualitative comments were also collected from all physicians and examined for common themes.
2.4. Analysis We reported our results by comparing our survey responses before and after the intervention, treating our responses initially as a continuous variable because of the five-point Likert scale. Detailed raw data responses are reported under each response for each survey question (see bAppendix BQ). In general, the lower the score, the more positive the response is. To facilitate our report of the results, we also converted the Likert-scale responses to dichotomous measures (e.g., bsomewhat/very helpfulQ, bexcellent/very goodQ). t Tests or ANOVA tests were used for continuous variables, and v 2 tests or Fisher’s Exact Tests were used for dichotomous variables. In addition, t test, ANOVA and v 2 tests were used to examine differences
3. Results In the preintervention survey, about half (53.6%) of the physicians surveyed reported being satisfied with the current resources available for treating patients with late-life depression in their primary care settings (Table 1). We did not identify significant differences in the proportion of providers who were satisfied with available resources among nonresident or resident physicians (54.3% vs. 52.6%, v 2 = 0.12, df =1, P = .727; mean difference between two groups = 0.08) or among physicians working in fee-forservice vs. capitated practice settings (Table 2). We did, however, observe significant organizational differences in physician’s satisfaction with available resources. The
Table 2 Physicians’ evaluation of current depression care by participating health care organization Variable
Category
Satisfaction with current resources for treating depression Mean score (S.D.)
Organization
Plan type
1 2 3 4 5 6 7 8 Capitated Fee-for-service
2.00 2.6 3.2 2.64 2.79 3.00 2.84 2.27 2.66 2.68
(0.93) (0.98) (1.01) (0.96) (1.11) (1.19) (1.03) (0.84) (1.04) (1.00)
F value ( P)
3.46 (.0013)
0.22 (.83)
2
Self-rated ability to provide depression treatment
% (n) Somewhat or very satisfied
v ( P)
Mean score (S.D.)
87.5 56.6 30.0 52.9 48.1 46.7 44.75 71.1 54.4 51.5
16.95 (.018)
2.13 3.00 3.05 3.32 3.37 2.89 2.97 3.00 3.04 3.21
(7) (77) (6) (54) (25) (21) (17) (32) (172) (67)
0.31 (.58)
(0.83) (1.00) (0.69) (0.91) (0.97) (0.9) (0.68) (0.90) (0.94) (0.92)
F value ( p)
3.56 (.001)
1.79 (.08)
% (n) Rated as good or excellent
v 2 ( P)
100 66.2 75.0 50.0 50.0 71.7 78.9 68.9 66.3 56.8
24.24 (.001)
(8) (90) (15) (52) (26) (33) (30) (31) (210) (75)
3.57 (.06)
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proportion of providers who were satisfied ranged from 30% to 87.5% (v 2 = 16.9, df = 7, P = .02) among the participating health care organizations (Table 2). About 64% of the participating physicians rated their ability to provide quality depression treatment as bexcellentQ or bvery goodQ (63.5%, mean =3.09) (Table 1). We observed no significant difference in the self-rated ability between nonresident (66.5%, mean = 3.05) and resident physicians (59.4%, mean = 3.15) (v 2 = 2.43, df =1, P = .12] or between physicians practicing in fee-for-service or capitated settings. We did find significant organizational differences among physicians’ perceptions of their ability to care for patients with depression among the participating health care organizations, with the proportion of physicians who rated their ability to care for depression as bvery good or excellentQ ranging from 50% to 100% (v 2 =24.24, df = 7, P = .001). ANOVA tests for physician’s self-rated ability as a continuous variable produced similar results (Table 2). Physicians in general had a positive impression of the value of disease management programs for treating chronic conditions. More than 85% of physicians said they would find a chronic disease management program at least somewhat helpful for treating patient with diabetes, heart failure or depression (Table 1). Nonresident physicians were
somewhat more likely than resident physicians to consider a chronic disease management model helpful for treating depression (91.3% vs. 83.6%, v 2 =6.16, df =1, P = .013). There was little variability in physicians’ perception of the value of chronic disease management across participating organizations. On the postintervention survey, physicians whose patients were enrolled in the IMPACT program generally had a very positive experience with the intervention. More than 90% described the IMPACT depression program to be helpful in treating patients with depression (Table 3). A total of 93% were very or somewhat satisfied with the resources available for treating depression among patients assigned to the IMPACT model, compared with only 61% of physicians who were satisfied with available resources for their patients who were assigned to usual care. Both nonresident and resident physicians had an equally positive impression of the IMPACT program. When asked if this kind of program would be useful for the treatment for other chronic conditions such as heart diseases and diabetes, 87% of physicians responded bat least somewhat helpful.Q Ninety-four percent of PCPs found the IMPACT care managers to be somewhat or very helpful in treating depression, and 89% reported that the care managers
Table 3 Physicians’ experience with IMPACT depression care model Postintervention survey
All (n = 181)a
Nonresident (n = 154)
Resident (n = 27)
Satisfaction with resources for treating IMPACT patients with depression Mean (S.D.) 1.44 (0.64) % Very/somewhat satisfied 93.3%
1.39 (0.62) 94.0%
1.67 (0.68) 88.9%
.039 .396
Helpfulness of IMPACT depression program in treating depression Mean (S.D.) 1.49 (0.66) % Very/somewhat helpful 91.7%
1.47 (0.66) 92.2%
1.59 (0.69) 88.9%
.368 .227
Helpfulness of this type of program in treating diabetes or heart disease Mean (S.D.) 1.57 (0.73) % Very/somewhat helpful 87.6%
1.58 (0.74) 87.4%
1.52 (0.7) 88.9%
.677 1.000
Helpfulness of IMPACT clinical specialist in treating depression Mean (S.D.) 1.41 (0.67) % Very/somewhat helpful 93.6%
1.37 (0.63) 94.4%
1.63 (0.79) 88.9%
.064 .383
Provision of care by IMPACT clinical specialist Mean (S.D.) % Rated just the right amount of care
1.95 (0.33) 88.9%
1.96 (0.33) 88.9%
1.89 (0.32) 88.9%
.317 1.000
Perception of the role of IMPACT program on patient’s clinical outcomes Mean (S.D.) 1.84 (0.77) % Felt the program improved patient’s clinical outcomes 82.0%
1.8 (0.77) 82.8%
2.04 (0.76) 77.8%
.142 .586
On-site consultants influenced whether you would be more likely to refer depression patients Mean (S.D.) 1.73 (0.85) 1.74 (0.88) % Rated definitely/possibly 85.4% 84.0%
1.7 (0.61) 92.6%
.856 .375
On-site consultants influenced whether you would be more likely to diagnose/treat depressed patients Mean (S.D.) 2.31 (1.24) 2.37 (1.27) % Rated definitely/possibly 66.5% 62.9%
2.04 (1.02) 85.2%
.205 .027
a
These are physicians who returned their postintervention surveys and had patients enrolled in the IMPACT intervention. T P values represent the Fisher’s Exact Tests between nonresident physicians and resident physicians.
P valueT
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
provided bjust the right amount of careQ (Table 3). A total of 82% also felt the program improved their patients’ clinical outcomes. When physicians were asked to identify the two most helpful features of the IMPACT program, bproactive follow-up and progress monitoringQ ranked first, followed by bpatient education.Q These positive impressions of the IMPACT model were echoed by qualitative comments from the surveyed physicians. When asked what aspect of the IMPACT study they liked the least, the surveyed physicians commented that because of the randomized trial design, only half of their patients had access to the IMPACT model, and the rest of their patients were not getting the support and benefits from the intervention. The following were typical comments: bI do not get any feedback on patients enrolled in usual care,Q and bI tend to lose track of patients involved in usual care.Q When asked what aspect of IMPACT they liked the most, physicians commented on improved follow-up with patients and better communication facilitated by the nurse care managers. Typical comments included: bAssurance of good follow-up for patient and documentation for me.Q bAlways follow-up and have someone looking over my shoulder.Q bThe follow-up provided to those patients assigned to the intervention was much more intensive than what we could have offered with our available resources. The follow-up was what I liked best.Q bGood consistent care I could trust and ongoing communication so I always knew what was being done.Q bImproved access for our patients. I don’t have much time to talk to patients with [sic] lots of other medical issues . . . great for more time to spend.Q bProvided much better care than our psychiatry department which has of late been highly inadequate in caring for our depressed patients.Q Eighty-five percent of physicians expressed that on-site mental health consultants in primary care setting would influence their referral patterns of depressed patients, compared with two thirds who expressed that this program feature would influence their diagnostic or treatment behavior. Among resident physicians, 85% (compared to 62.9% nonresident physicians, P = .03) reported that having a psychiatric consultant on-site would influence their likelihood of making depression diagnoses or treating depressed patients. 4. Discussion Studies on physician’s attitudes and satisfaction have primarily focused on physicians’ access to specialty mental health care [13] and how physicians view various financial arrangements with special emphasis on managed care [14 –20]. Several studies have examined physician’s satisfaction with services intended to expand their practice capacity [21–24]. Other studies have examined physician’s perception of and attitudes toward particular care models or programs, such as hospitalists [25], nurse practitioners [26], geriatric training in caring for community-dwelling elders [27] and disease management programs in general [28].
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This study reported physician’s satisfaction with a collaborative primary care model with depression treatment for older patients. Our results show that irrespective of the financial and organizational arrangements they are in, primary care physicians face substantial challenges in caring for older patients with complex diseases and conditions such as depression. Recent literature indicates that only about two out of five primary care patients with major depression are appropriately diagnosed and treated [29], and data from the usual care arm of the IMPACT trial [10] indicates that only about one in five depressed older adults in primary care experiences a substantial improvement in depressive symptoms, despite increasing rates of depression treatment in primary care. Our physician survey demonstrates that primary care physicians identify substantial unmet needs in their ability to care for late-life depression in primary care, with only 54% indicating that they were satisfied with current resources to treat depression, prior to the intervention. Our survey also suggests that there is a substantial variation in physician’s satisfaction with resources available to care for depression and with physicians’ self-rated ability to care for depression across the eight participating health care organizations. Unfortunately, organizational characteristics are not available to the authors to examine site differences. Nonetheless, this finding suggests that there may be room for substantial improvement in depression care in some organizations. We did not find significant differences in satisfaction with resources and perceived ability to care for depression among physicians who worked in capitated vs. fee-for-service settings. Before the study, most of the surveyed physicians indicated that a chronic care disease management program would be helpful for treatment of depression. At the postintervention survey, more than 90% of participating physicians reported the IMPACT program to be helpful in treating late-life depression, and 82% felt that the IMPACT program improved the clinical outcomes of their patients. Although patient level outcome comparisons were not available to physicians at the time of the postintervention physician survey, this positive perception of the intervention effect on patient outcomes is consistent with the study findings that indicate that the IMPACT model has demonstrated better results than usual care for treating depression: 49% vs. 20% of depressed older adults experienced improvements in depressive symptoms [10]. We found no significant site differences in providers’ perceived usefulness of the IMPACT model, an observation that is also consistent with patient outcome data indicating that IMPACT participants at all eight participating health care organizations had better depression outcomes than those in usual care [5]. At the 12-month postintervention survey, physicians reported a slight increase in their satisfaction with resources available to treat depression for usual care older patients
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(61%) compared to baseline but a significantly higher satisfaction with the resources available to treat depressed patients assigned to the IMPACT intervention (93%). This suggests that most of the observed improvement is not a generalized secular trend in improved depression care but a result of the IMPACT intervention resources deployed in the participating clinics. We also observed a significant increase in physicians’ self-rated ability to provide quality care for depression between the pre- and postintervention surveys, suggesting that participation in the IMPACT trial resulted in some learning and improved physicians’ ability to treat depression. Findings that participation in a collaborative care program enhanced physician’s satisfaction and selfefficacy in treating depression have important implications for future strategies to improve depression outcomes among primary care patients. Existing research demonstrate that physician’s education alone was insufficient to improve patient outcomes [30] when primary care services were not reorganized to deliver chronic disease care management. The IMPACT intervention provides an effective model to achieve enhanced outcomes for depression. Participating physicians identified close patient followup and patient education as the most helpful components of the IMPACT model. Given physicians’ limited time and resources, IMPACT care managers who had the time and a structured protocol to provide education and systematic follow-up were seen to be crucial features of the program that could both strengthen the physician–patient relationship and facilitate an adequate and effective treatment course for patients. Physicians in our survey indicated that an on-site psychiatric consultant would have more of an effect on their referral behavior than on their diagnostic or treatment behavior. The differences in the perceived benefits of on-site psychiatric consultation between resident physicians and nonresident physicians suggest that exposure to psychiatric consultants and evidence-based collaborative care models such as IMPACT during residency training may have a bigger effect on practice patterns for physicians in training than those who are already in practice, making an argument for exposing physicians to such evidence-based models of care during their training. Exposing physicians to collaborative disease management models during residency may also increase their belief in the value of this model and their advocacy for it in future practice. There are several limitations to this study. First, we have a substantial number of nonresponses in our physician follow-up survey. This is mostly related to PCP turnover, particularly among resident physicians who rotated off or graduated during the IMPACT study. However, we found no significant systematic baseline differences between the physicians who did and did not respond to the follow-up surveys. We also did not find substantial differences when we analyzed only those responses from the 267 physicians who completed both surveys, suggesting that our missing postintervention survey data may not have introduced a
substantial bias. Second, we do not have detailed information about physicians’ demographics (e.g., age or gender) or clinical background (e.g., primary care specialty and years in practice) that would be helpful to explore relationships between physician’s characteristics and satisfaction with depression care or the IMPACT model. Thirdly, organizations that are interested in improving depression care may have been particularly likely to participate in the IMPACT trial, and it is not clear that our findings can generalize to all primary care practices. However, the primary care providers in the participating organizations were not selected based on their interest in improving depression care, and we feel that they represent a diverse group of providers working in a wide range of health care settings. Fourthly, because we evaluated physician’s perceptions and attitudes about depression treatment for older adults, our results may not generalize to younger adults. Finally, we do not have data to link outcomes of individual patients to individual providers and can only compare aggregate physician’s perceptions of patient outcomes with aggregate patient outcomes. In summary, primary care physicians in the IMPACT trial were very satisfied with this innovative collaborative care model for treating depressed older adults in their primary care practices and felt that similar care management models would also be helpful for treating other chronic medical illnesses. Physicians who are more satisfied and confident in their ability to manage depression may be more likely to treat depression and project satisfaction and confidence to their patients. This may be particularly important when caring for patients with depression. Collaborative care models such as IMPACT have the potential to increase patient outcomes and provider satisfaction not only for depressed patients but also for a range of other chronic medical conditions. Acknowledgments We would like to acknowledge the contributions and support of the patients, the primary care providers, and the staff at the study coordinating center and at all participating study sites, which include Duke University, Durham, NC; The South Texas Veterans Health Care System, The Central Texas Veterans Health Care System; and The San Antonio Preventive and Diagnostic Medicine Clinic; Indiana University School of Medicine, Indianapolis, IN; Health and Hospital Corporation of Marion County; Group Health Cooperative of Puget Sound in cooperation with the University of Washington, Seattle, WA; Kaiser Permanente of Northern California, Oakland and Hayward, CA; Kaiser Permanente of Southern California, San Diego, CA; Desert Medical Group, Palm Springs, CA. This study is the result of work supported in part by the patients, the resources and the use of facilities at the South Texas Veterans Health Care System and the Central Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily represent the views of the Depart-
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
ment of Veterans Affairs. We would also like to acknowledge the contributions of the IMPACT study advisory board and the programming support by Tonya Marmon.
1 Very Helpful [219]
Appendix A. IMPACT investigators
b) For depression?
The IMPACT Investigators include (in alphabetical order) Patricia Arean, Ph.D. (Co-PI); Thomas R. Belin, Ph.D.; Noreen Bumby, D.O.; Christopher Callahan, M.D. (PI); Paul Ciechanowski, M.D., M.P.H.; Ian Cook, M.D.; Jeffrey Cordes, M.D.; Steven R. Counsell, M.D.; Richard Della Penna, M.D. (Co-PI); Jeanne Dickens, M.D.; MingYu Fan, Ph.D.; Michael Getzell, M.D.; Howard Goldman, M.D., Ph.D.; Lydia Grypma, M.D. (Co-PI); Linda Harpole, M.D., M.P.H. (PI); Mark Hegel, Ph.D.; Hugh Hendrie, M.B., Ch.B., D.Sc. (Co-PI); Polly Hitchcock Noel, Ph.D. (Co-PI); Marc Hoffing, M.D. (PI), M.P.H.; Enid M. Hunkeler, M.A. (PI); Wayne Katon, M.D. (PI); Kurt Kroenke, M.D.; Stuart Levine, M.D., M.H.A. (CoPI); Elizabeth H.B. Lin, M.D., M.P.H. (Co-PI); Tonya Marmon, M.S.; Eugene Oddone, M.D., M.H.Sc. (Co-PI); Sabine Oishi, M.S.P.H.; Diane Powers, M.A.; R. Jerome Rauch, M.D.; Michael Sands, M.D.; Michael Schoenbaum, Ph.D.; Rik Smith, M.D.; David C. Steffens, M.D., M.H.S.; Christopher A. Steinmetz, M.D.; Lingqi Tang, Ph.D.; Iva Timmerman, M.D.; Jqrgen Unqtzer, M.D., M.P.H. (PI); John W. Williams Jr., M.D., M.H.S. (PI); Jason Worchel, M.D.; Mark Zweifach, M.D. Appendix B. Prestudy IMPACT provider survey Please take a few minutes to answer the following questions. Circle the number that corresponds best to your response. 1. How satisfied are you with the resources currently available to treat elderly patients with depression in your practice? 1 Very Satisfied [35]
2 Somewhat Satisfied [204]
3 Neither [104]
4 Somewhat Dissatisfied [80]
5 Very Dissatisfied [23]
1 Very Helpful [222]
389
2 3 Somewhat Neither Helpful [165] [25]
2 3 Somewhat Neither Helpful [168] [27]
4 Somewhat Unhelpful [17]
5 DK Very Unhelpful [19]
4 Somewhat Unhelpful [14]
5 DK Very Unhelpful [12]
4. If you could change one thing to improve care for depressed elderly patients,what would you change? ______ Appendix C. Poststudy IMPACT provider survey The IMPACT study is a depression management program that assists the primary care provider deliver quality depression treatment for elderly depressed patients. During the course of the IMPACT study you had ______ patients receiving the IMPACT intervention. Please take a few minutes to answer the following questions. Circle the number that best corresponds to your response. 1. How would you rate your ability to provide quality depression treatment for elderly patients in your practice? 1 Excellent [38]
2 Very Good [99]
3 Good [121]
4 Fair [41]
5 Poor [6]
2. How satisfied are you with the resources currently available in your practice to treat elderly patients with depression who are not enrolled in the IMPACT study? 1 Very Satisfied [48]
2 Somewhat Satisfied [136]
3 Neither [57]
4 Somewhat Dissatisfied [54]
5 Very Dissatisfied [7]
2. How would you rate your ability to provide quality depression treatment for elderly patients in your practice?
Please answer the following questions if you have had at least one patient in the IMPACT intervention program:
1 Excellent [23]
3. How satisfied are you with the resources currently available in your practice to treat elderly patients with depression who are enrolled in the IMPACT intervention program?
2 Very Good [93]
3 Good [169]
4 Fair [148]
5 Poor [16]
3. How helpful would you find a chronic disease management model where another team member located in your primary care clinic (e.g., a nurse, nurse practitioner, mental health consultant) would help you co-manage patients with chronic diseases. a) For medical conditions such as diabetes or heart failure?
1 Very Satisfied [113]
2 Somewhat Satisfied [53]
3 Neither [11]
4 Somewhat Dissatisfied [1]
5 Very Dissatisfied
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S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391
4. Overall, how helpful did you find the IMPACT depression program in providing care for your elderly patients with depression?
Do on-site mental health consultants influence whether you would be more likely to: a) Refer patients with depression?
1 Very Helpful [109]
1 2 3 4 5 Definitely Possibly Unsure Possibly No Definitely No [80] [66] [17] [7] [1]
2 Somewhat Helpful [57]
3 Neither [14]
4 Somewhat Unhelpful [1]
5 Very Unhelpful
5. How helpful would you find this type of program for your patients with diabetes or heart disease? 1 Very Helpful [100]
2 Somewhat Helpful [56]
3 Neither [20]
4 Somewhat Unhelpful [2]
5 Very Unhelpful
6. How helpful was the IMPACT depression clinical specialist in providing care to your elderly patients with depression? 1 Very Helpful [114]
2 Somewhat Helpful [46]
3 Neither [8]
4 Somewhat Unhelpful [3]
5 Very Unhelpful
7. The amount of care provided by the IMPACT depression clinical specialist was 1 Not [14]
2 Enough [152]
3 Just Right [5]
Too much
8. Please check the top TWO areas where you felt the IMPACT depression program was most helpful in providing care for your elderly depressed patients. (check two) 5 5 5 5 5 5 5
Patient Education Depression Diagnosis Treatment (medication and/or counseling) Proactive follow-up and monitoring of progress Feedback on your patients’ progress provided by IMPACT Not helpful in any area Other:
9. Do you feel that the IMPACT depression program improved the clinical outcomes of your patients with depression who were enrolled in the program? 1 2 3 Definitely Possibly Unsure Improved [63] [78] [26]
4 5 Possibly No Definitely No Improvement Improvement [5]
10. The IMPACT intervention provides additional mental health services, on-site in primary care.
b) Diagnose and treat patients with depression? 1 2 3 4 5 Definitely Possibly Unsure Possibly No Definitely No [49] [64] [27] [14] [16] 11. What did you like least about the IMPACT program? _____________________________________________ 12. What did you like best about the IMPACT program? _____________________________________________ Thank you for your time! References [1] Oxman TE, Barrett JE, Barrett J, et al. Symptomatology of late-life minor depression among primary-care patients. Psychosomatics 1990;31:174 – 80. [2] Lyness JM, Caine ED, King DA, et al. Psychiatric disorders in older primary care patients. J Gen Intern Med 1999;14:249 – 54. [3] Schulberg HC, Katon WJ, Simon GE, et al. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry 1999;60(Suppl. 7):19 – 26. [4] Callahan CM. Quality improvement research on late life depression in primary care. Med Care 2001;39(8):772 – 84. [5] Klap R, Unroe TK, Unqtzer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry 2003;11:517 – 24. [6] Unqtzer J, Katon W, Sullivan M, et al. Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness. Milbank Q 1999;77:225 – 56. [7] Waxman HM, Carner EA. Physicians’ recognition, diagnosis, and treatment of mental disorders in elderly medical patients. Gerontologist 1984;24:593 – 7. [8] Shapiro S, Skinner EA, Kessler LG, et al. Utilization of health and mental health services: three ECA sites. Arch Gen Psychiatry 1984; 41:971 – 8. [9] Goldstrom ID, Burns BJ, Kessler LG, et al. Mental health services use by elderly adults in a primary care setting. J Gerontol 1987;42:147 – 53. [10] Unqtzer J, Katon W, Callahan CM, et al. Collaborative care management of later life depression in the primary care setting: a randomized controlled trial. JAMA 2002;22:2836 – 45. [11] Schreter RK. Ten trends in managed care and their impact on the biopsychosocial model. Hosp Community Psychiatry 1993;44:325 – 7. [12] Unqtzer J, Katon WJ, Williams JW, et al. Improving primary care for depression in late life: the design of a multi-center randomized trial. Med Care 2001;39:785 – 99. [13] Van Voorhees BW, Wang NY, Ford DE. Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians. Gen Hosp Psychiatry 2003;25(3):149 – 57. [14] Murray A, Montgomery JE, Chang H, et al. Doctor discontent: a comparison of physician satisfaction in different delivery system settings. J Gen Intern Med 2001;7:451 – 9.
S. Levine et al. / General Hospital Psychiatry 27 (2005) 383 – 391 [15] Gazewood JD, Long DR, Madsen R. Physician satisfaction with Medicaid managed care: the Missouri experience. J Fam Pract 2000;1:20 – 6. [16] Nadler ES, Sims S, Tyrance PH, et al. Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment. Am J Med 1999;1:38 – 44. [17] Keating NL, Landon BE, Ayanian JZ, et al. Practice, clinical management, and financial arrangements of practicing generalists: are they associated with satisfaction? J Gen Intern Med 2004;5(Part 1):410 – 8. [18] Cykert S, Hansen C, Layson R, et al. Primary care physicians and capitated reimbursement: experience, attitudes, and predictors. J Gen Intern Med 1997;3:192 – 4. [19] Grumbach K, Osmond D, Vranizan K, et al. Primary care physiciansT experience of financial incentives in managed-care systems. N Engl J Med 1998;21:1516 – 21. [20] Grembowski D, Ulrich CM, Paschane D, et al. Managed care and primary physician satisfaction. J Am Board Fam Prac 2003;5:383 – 93. [21] Forrest CB, Glade GB, Alison E, et al. Coordination of specialty referrals and physician satisfaction with referral care. Arch Pediatr Adolesc Med 2000;5:499 – 506. [22] Rau J, Cross JL, Hofherr LK, et al. Physician satisfaction with human immunodeficiency virus type 1 and hepatitis B virus testing in San Diego county. Med Care 1996;1:1 – 10. [23] Meyerhoff A, Jacobs RJ, Greenberg DP, et al. Clinician satisfaction with vaccination visits and the role of multiple injections, results from
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