Annotated Abstracts of Journal Articles
2014, 3rd Quarter
Annotations by Shehzad K. Niazi, MD, FRCPC, FAPM and
Michael Sharpe, MD, FAPM
Katon W, Russo J, Reed SD, et al
Am J Psychiatry 2014 Aug 26 [Epub ahead of print]
ANNOTATION (Niazi & Sharpe)
This is data from Depression Among Women Now (DAWN) Study, which is a randomized controlled trial showing the efficacy of integrated care for depression in OB/GYN patients. This paper looks at whether the intervention is effective for patients who have either no insurance or had public insurance. Comparative group was patients with commercial insurance.
The Finding: Effect-size for women with no insurance/public coverage was 0.81 (95% CI=0.41, 0.95) while it was 0.39 (95% CI=–0.08, 0.84) for women with commercial insurance. In other words collaborative care model was MORE effective for women with no insurance or for those who had public insurance.
Strength and Weaknesses: Non-English-speaking women were excluded.
Relevance: Collaborative care models are beneficial for women with limited or poor social support and resources. This study highlights another important point: in an underserved population such as the one included in this study, there may be delay in response to treatment.
Objective: The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance.
Method: The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire-9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale).
Results: The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=-0.08, 0.84) for women with commercial insurance.
Conclusions: Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.
ANNOTATION (Niazi & Sharpe)
The Finding: Collaborative care for depression improved depression care and functional outcomes when compared with usual care.
Strength and Weaknesses: It was a randomized controlled trial conducted at two University-affiliated OB/GYN clinics. Non-English speakers were excluded from the study. Even after excluding patients with current and ongoing domestic violence, more than 50% of the study population had significant PTSD symptoms. This likely explained the delay in robust response to depression treatment. Participants receiving collaborative care for depression in this study showed robust response at 12 and 18 months when compared to the group receiving usual care; there was no difference between the two groups at month 6.
Relevance: Yet another piece of evidence that collaborative care models to treat depression can be effectively used in a wide variety of settings.
Objective: To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care.
Methods: A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.
Results: Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36).
Conclusion: Collaborative depression care adapted to women’s health settings improved depressive and functional outcomes and quality of depression care.
ANNOTATION (Niazi & Sharpe)
This APA report is one of the more significant publications to come out this year.
The Finding: This study looked at commercially insured as well as Medicare/Medicaid data of 3,487,000,000 individuals. After comparing the costs of caring for individuals with (2,993,000,000) and without (494,000,000) psychiatric and substance abuse issues, the authors found that 14% of patients are diagnosed with psychiatric and substance abuse issues. These patients account for 30% of total healthcare expenditures. This was due to fragmented care.
The authors concluded that integrated models of care can save $26-$48 billion dollars. Most of the cost savings are likely to come from reduction in facility-based expenditures such as inpatient and emergency room care. Based on available evidence, additional cost savings can come from effective and proactive patient participation in their care plan to manage chronic medical illnesses more effectively.
Strength and Weaknesses: Sample size is quite large. The study used administrative claims data and likely missed individuals who were not diagnosed with psychiatric disorders. This can occur at times when patients receive care without a corresponding diagnosis coded. An example would be when a patient is prescribed an antidepressant medication for depression from the primary care physician who has listed several of his comorbidities but not depression in billing data. Prescription-based criteria for grouping patients can be problematic for medications such as SSRIs as they are used to treat a variety of conditions.
The study required that any drug that can be used to treat four or more conditions should have a diagnosis associated with the prescription within 30 days of its use to identify the condition for which it was being used. The authors were able to use prescription-based analysis that likely improved the identification but they could only do this for patients with commercial insurance; they did not have the prescription data for the Medicaid population.
Relevance: This is an important report, as this provides the financial evidence supporting programs that manage the whole patient using integrated services informed by collaborative care models. This can help with dissemination of such practice models to the organizations that have not yet fully embraced such care models.
Continually escalating healthcare costs have prompted payers to seek ways to improve member health while reducing the growth of healthcare claims expenditures. One such initiative is the integration of medical and behavioral healthcare (IMBH). Some of the advances in IMBH have been driven by primary care providers, while others have been driven by behavioral healthcare practitioners. The field of psychiatry is poised to become a major participant as IMBH evolves. Psychiatry has a direct role in the value proposition of integrated/collaborative care and stands to benefit from the savings generated by effective integration programs.
The analysis provided in this report is intended to be used to help educate psychiatrists about the elevated levels of healthcare costs related to beneficiaries who have chronic medical and behavioral comorbidities. Based on the experience of recent successful IMBH programs, this report also estimates the portion of the elevated healthcare costs that can be controlled through such programs. We also discuss the possibility of shared savings that can bring some of those savings back to behavioral health and psychiatry.
Medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as those beneficiaries who don‘t have the comorbid MH/SUD conditions. The additional healthcare costs incurred by people with behavioral comorbidities are estimated to be $293 billion in 2012 across commercially-insured, Medicaid, and Medicare beneficiaries in the United States. Most of the increased cost for those with comorbid MH/SUD conditions is attributed to medical services (more than behavioral), creating a large opportunity for savings on the medical side through integration of behavioral and medical services. Based on our literature review on the results of effective IMBH programs, we calculate that 9-16% of this total additional spending may be saved through effective integration of care, although additional work and direct experience will be needed in this area. Figure 1 shows the resulting projected potential cost savings achieved by integration for each of the three large insurance markets. This is the value proposition for IMBH.