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Biomedical subjects

Paul A Nutting

Publications and source records attributed to Paul A Nutting.

At least 19 recordsLinked to original sources
PubMed2006

Implementing a depression improvement intervention in five health care organizations: experience from the RESPECT-Depression trial.

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

Depression↗
PubMed2006

A fidelity measure for integrated management of depression in primary care.

BACKGROUND: Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure. OBJECTIVES: We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model. METHODS: Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months. RESULTS: 3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity. CONCLUSIONS: Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

Adult↗
PubMed2006

Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes.

OBJECTIVE: There is a need for practical, efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss. The objective of this study was to evaluate such a computer-assisted intervention. METHODS: Type 2 diabetes primary care patients (n=335) from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or computer-aided enhanced usual care (UC). Intervention consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counsellor interaction and follow-up calls. Outcomes were changes in dietary behaviours (fat and fruit/vegetable intake), haemoglobin Alc (HbA1c), lipids, weight, quality of life, and depression. RESULTS: TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favouring intervention, but these differences did not reach significance. The intervention proved feasible and was implemented successfully by a variety of staff. CONCLUSIONS: This relatively low-intensity intervention appealed to a large, generally representative sample of patients, was well implemented, and produced improvement in targeted behaviours. Implications of this practical clinical trial for dissemination are discussed.

Computers↗
PubMed2006

Robustness of a computer-assisted diabetes self-management intervention across patient characteristics, healthcare settings, and intervention staff.

BACKGROUND: A major problem in the dissemination of most interventions found to be efficacious is that they are of limited or unknown generalizability. OBJECTIVE: To document the "robustness," or external validity, of a computer-assisted diabetes self-management program across different patient characteristics, healthcare settings (mixed payer vs health maintenance organization), intervention staff, and outcomes. STUDY DESIGN: A randomized controlled trial evaluating a computer-assisted behavior change program for adult patients with type 2 diabetes mellitus (n = 217) vs a computerized health risk assessment. METHODS: Outcomes were identified using the RE-AIM framework and included program adoption among physicians, reach across patient groups, implementation, and behavioral (fat intake and physical activity) and biological (glycosylated hemoglobin and lipid levels) effectiveness measures. RESULTS: The program achieved 41% patient participation, variable adoption across healthcare settings (76% of health maintenance organization physicians vs 18% of non-health maintenance organization physicians participated), good implementation, and improvement in behavioral outcomes. There were few significant interactions between treatment condition and patient characteristics, type of healthcare setting, or interventionist experience on effectiveness measures. CONCLUSIONS: Patients and physicians were willing to participate in a computer-assisted dietary and physical activity goal-setting intervention, although participation varied by healthcare setting. Interventionists from different backgrounds successfully delivered the intervention, and the results appear robust across various patient and delivery characteristics.

Aged↗
PubMed2005

How complexity science can inform a reflective process for improvement in primary care practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

Organizational Case Studies↗
PubMed2005

Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care.

OBJECTIVE: There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care settings. This report presents 12-month follow-up results from a computer-assisted, patient-centered intervention to improve the level of recommended services patients received from a variety of primary care settings. RESEARCH DESIGN AND METHODS: A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on two primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program (PRP). Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale, lipid and HbA1c levels, and the Patient Health Questionnaire-9 depression scale. RESULTS: The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition. There was overall improvement on secondary outcomes of lipids, HbA1c, quality of life, and depression scores; between-condition differences were not significant. CONCLUSIONS: Staff in small, mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care. Alternative explanations for why these process improvements did not lead to improved outcomes, and suggested directions for future research are discussed.

Colorado↗
PubMed2004

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial.

OBJECTIVE: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. DESIGN: Cluster randomised controlled trial. SETTING: Five healthcare organisations in the United States and 60 affiliated practices. PATIENTS: 405 patients, aged > or = 18 years, starting or changing treatment for depression. INTERVENTION: Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. MAIN OUTCOME MEASURES: Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (> or = 50% decrease in scores) and remission (score of < 0.5). RESULTS: At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). CONCLUSION: Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Adult↗
PubMed2004

A practical randomized trial to improve diabetes care.

OBJECTIVE: There is a well-documented gap between diabetes care guidelines and the services received by patients in almost all health care settings. This project reports initial results from a computer-assisted, patient-centered intervention to improve the level of recommended services received by patients from a wide variety of primary care providers. DESIGN AND SETTINGS: Eight hundred eighty-six patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on 2 primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed. Secondary outcomes were evaluated using the Problem Areas in Diabetes scale and the Patient Health Questionnaire (PHQ)-9 depression scale, and the RE-AIM framework was used to evaluate potential for dissemination. RESULTS: The program was well-implemented and significantly improved both number of recommended laboratory assays (3.4 vs 3.1; P <.001) and patient-centered aspects of diabetes care patients received (3.6 vs 3.2; P <.001) compared to those in randomized control practices. Activities that were increased most were foot exams (follow-up rates of 80% vs 52%; P <.003) and nutrition counseling (76% vs 52%; P <.001). CONCLUSIONS: Patients are very willing to participate in a brief computer-assisted intervention that is effective in enhancing quality of diabetes care. Staff in primary care offices can consistently deliver an intervention of this nature, but most physicians were unwilling to participate in this translation research study.

Attitude of Health Personnel↗
PubMed2004

Does a depression intervention result in improved outcomes for patients presenting with physical symptoms?

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1). depression management and outcomes under usual care conditions, and 2). the impact of an intervention to improve management and outcomes. DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P =.06), receipt of any antidepressant (63.0% vs 20.1%; P =.001), and an adequate antidepressant trial (34.9% vs 5.9%; P =.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P =.01) and an adequate antidepressant trial (46.0% vs 23.8%; P =.004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Adult↗
PubMed2002

Barriers to initiating depression treatment in primary care practice.

OBJECTIVE AND DESIGN: This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression. PARTICIPANTS AND SETTING: Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis. METHODS: The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles. RESULTS: The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers. Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters. CONCLUSIONS: Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.

Acute Disease↗
PubMed2002

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression.

BACKGROUND AND OBJECTIVES: To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline. RESEARCH DESIGN: Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions. SUBJECTS: In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months. MEASURES: Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview. RESULTS: Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care. CONCLUSIONS: The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

Adult↗
PubMed2002

Family physicians' referral decisions: results from the ASPN referral study.

OBJECTIVE: To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN: Prospective cohort study. POPULATION: All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED: Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS: Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS: Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Decision Making↗
PubMed2002

Impact of primary care depression intervention on employment and workplace conflict outcomes: is value added?

BACKGROUND: Depression causes significant functional impairment in sufferers and often leads to adverse employment outcomes for working individuals. Recovery from depression has been associated with better employment outcomes at one year. AIMS OF THE STUDY: The study s goals were to assess a primary care depression intervention s impact on subsequent employment and workplace conflict outcomes in employed patients with depression. METHODS: In 1996-1997, the study enrolled 262 employed patients with depression from twelve primary care practices located across ten U.S. states; 219 (84%) of the patients were followed at one year. Intent-to-treat analyses assessing intervention effects on subsequent employment and workplace conflict were conducted using logistic regression models controlling for individual clinical and sociodemographic characteristics, job classification and local employment conditions. To meet criteria for subsequent employment, persons working full-time at baseline had to report they were working full-time at follow-up and persons working part-time at baseline had to report working part-/full-time at follow-up. Workplace conflict was measured by asking patients employed at follow-up whether, in the past year, they had arguments or other difficulties with people at work . RESULTS: Findings showed that 92.1% of intervention patients met criteria for subsequent employment at one year, versus 82.0% of usual care patients (c2=4.42, p=.04). Intervention patients were less likely than usual care patients to report workplace conflict in the year following baseline (8.1% vs. 18.9%, respectively; c2=4.11; p=.04). The intervention s effect on subsequent employment was not mediated by its effect on workplace conflict. DISCUSSION: The intervention significantly improved employment outcomes and reduced workplace conflict in depressed, employed persons at one year. Economic implications for employers related to reduced turnover costs, for workers related to retained earnings, and for governments related to reduced unemployment expenditures and increased tax receipts may be considerable. LIMITATIONS: Although similar primary care depression interventions have been shown to produce comparable effects on subsequent employment at one year, replications in larger samples of depressed, employed patients in different economic climates may be necessary to increase the generalizability and precision of estimates. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Primary care interventions that enhance depression treatment and improve clinical outcomes can contribute meaningful added value to society by improving employment and workplace outcomes. IMPLICATIONS FOR HEALTH POLICIES: Federal/state governments may realize economic benefits from reduced unemployment expenditures and increased tax receipts should primary care depression interventions that improve employment outcomes be broadly disseminated. Policy initiatives to increase the dissemination of such interventions may be an innovative approach for improving labor force participation by depressed individuals. IMPLICATIONS FOR FURTHER RESEARCH: Formal cost-benefit analyses are needed to explore whether economic benefits to societal stakeholders from these and other labor outcomes equal or exceed the incremental costs of disseminating similar primary care interventions nationally. Researchers in other nations may wish to consider investigating the impact primary care depression interventions might have on employment and workplace outcomes in their countries.

Adult↗
PubMedDate not supplied

Are attributes of organizational performance in large health care organizations relevant in primary care practices?

Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.

Efficiency, Organizational↗
PubMedDate not supplied

The frequency and behavioral outcomes of goal choices in the self-management of diabetes.

PURPOSE: The purpose of this study was to determine the frequency and effectiveness of behavioral goal choices in the self-management of diabetes and to test goal-setting theory hypotheses that self-selection and behavioral specificity of goals are key to enhancing persistence. METHODS: Participants with type 2 diabetes in a randomized controlled trial (n = 422) completed baseline behavioral assessments using a clinic-based, interactive, self-management CD-ROM that allowed them to select a behavioral goal and receive mail and telephone support for the initial 6 months of the trial followed by additional behavioral assessments. Frequency of behavioral goal selection and 6-month behavioral data were collected. RESULTS: Approximately 49%, 27%, and 24% of the participants, respectively, set goals to increase physical activity (PA), reduce fat intake, or increase fruits and vegetables (F&V) consumed. At baseline, participants who selected PA, reduced fat consumption, or F&V were significantly, and respectively, less active, consumed more dietary fat, and ate fewer F&V regardless of demographic characteristics. Participants who selected a reduced-fat goal showed a significantly larger decrease than did those that selected PA or F&V goals. Participants who selected an F&V goal showed significant changes in F&V consumption. Participants who selected a PA goal demonstrated significant changes in days of moderate and vigorous physical activity. CONCLUSIONS: When participants are provided with information on health behavior status and an option of behavioral goals for managing type 2 diabetes, they will select personally appropriate goals, resulting in significant behavioral changes over a 6-month period.

Analysis of Variance↗
PubMedDate not supplied

Primary care physician specialty referral decision making: patient, physician, and health care system determinants.

PURPOSE: To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making. METHODS: Physicians (n=142) and their practices (n=83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n=34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. RESULTS: Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gate-keeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. CONCLUSIONS: PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

Adult↗
PubMedDate not supplied

RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints.

PURPOSE: Depression care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints. METHODS: We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled care management for 24 months. The study sample included 200 adults beginning a new depression treatment episode where patient presentation style could be identified. Outpatient costs were defined as intervention plus outpatient treatment costs for the 2 years. Cost-offset analysis used general linear mixed models, 2-part models, and bootstrapping to test hypotheses regarding a differential intervention effect by patients' style, and to obtain 95% confidence intervals for costs. RESULTS: Intervention effects on outpatient costs over time differed by patient style (P <.05), resulting in a $980 cost decrease for depressed patients who complain of psychological symptoms and a 1,378 dollars cost increase for depressed patients who complain of physical symptoms only. CONCLUSIONS: Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group.

Adult↗