The Effect of Adherence to Practice Guidelines on Depression Outcomes

  1. Kimberly A. Hepner, PhD;
  2. Melissa Rowe, PhD;
  3. Kathryn Rost, PhD;
  4. Scot C. Hickey, MA;
  5. Cathy D. Sherbourne, PhD;
  6. Daniel E. Ford, MD;
  7. Lisa S. Meredith, PhD; and
  8. Lisa V. Rubenstein, MD, MSPH
  1. From RAND Health Program, Santa Monica, California; Florida State University, Tallahassee, Florida; Johns Hopkins School of Medicine, Baltimore, Maryland; and Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California.

    Abstract

    Background: Few studies have assessed clinician adherence to depression practice guidelines and the relationship between clinician adherence and depression outcomes.

    Objective: To estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes.

    Design: Observational analysis of data collected from 1996 to 1998 in 3 randomized clinical trials.

    Setting: 45 primary care practices in 13 U.S. states.

    Patients: 1131 primary care patients with depression.

    Measurements: Expert panel methods were used to develop a patient survey–based index that measured adherence to clinical practice guidelines on depression. Rates of adherence to the 20 indicators that form the index were evaluated. Multivariable regression that controlled for case mix was used to assess how index scores predicted continuous and dichotomous depression measures at 12, 18, and 24 months.

    Results: Quality of care was high (clinician adherence ≥79%) for 6 indicators, including primary care clinician detection of depression. Quality of care was low (adherence, 20% to 38%) for 8 indicators, including management of suicide risk (3 indicators), alcohol abuse (2 indicators), and elderly patients; assessment of symptoms and history of depression; and treatment adjustment for patients who did not respond to initial treatment. Greater adherence to practice guidelines significantly predicted fewer depressive symptoms on continuous measures (P < 0.001 for 12 months, P < 0.01 for 18 months, and P < 0.001 for 24 months) and dichotomous measures (P < 0.05 for 18 and 24 months).

    Limitations: Data are based on patient self-report. Possible changes in practice since 1998 may limit the generalizability of the findings.

    Conclusions: Adherence to guidelines was high for one third of the recommendations that were measured but was very low for nearly half of the measures, pointing to specific needs for quality improvement. Guideline-concordant depression care appears to be linked to improved outcomes in primary care patients with depression.

    Article and Author Information

    • Acknowledgments: The authors thank the MacArthur Foundation Initiative on Depression and Primary Care for assisting with the development of the quality review criteria; Bernadette Benjamin and Jose Arbelaez for expert programming; Jeff Smith, Maureen Carney, Chantal Avila, and Carole Oken for data collection and data management; Kathryn Magruder and Paul Nutting for their work on the overall collaborations; and Bob Bell for statistical consultation. They also thank the organizations participating in the studies: Kaiser Permanente Medical Care Programs in the Northern California Region, Oakland, California; Veterans Affairs Greater Los Angeles, Los Angeles, California; Ambulatory Sentinel Practice Network, Denver, Colorado; and NYL Care Health Plans of the Mid-Atlantic, Greenbelt, Maryland. Finally, they thank the clinicians and patients who contributed their time and effort for these studies.

    • Grant Support: By the National Institute of Mental Health (grants R01MH64658, P50MH54623, R01 MH54444, and MH 63651), the Agency for Healthcare Research and Quality (grant R01-HS08349), the John D. and Catherine T. MacArthur Foundation (grant 96-42 901 A-HE), and the Veterans Affairs Health Services Research and Development Service Center of Excellence for the Study of Healthcare Provider Behavior (grant LIP 65-030).

    • Potential Financial Conflicts of Interest: Consultancies: K. Rost, D.E. Ford (Pfizer Inc.). Honoraria: K. Rost. Grants pending: K. Rost.

    • Requests for Single Reprints: Kimberly A. Hepner, PhD, RAND Health Program, 1776 Main Street, Santa Monica, CA 90407; e-mail, hepner{at}rand.org.

    • Current Author Addresses: Drs. Hepner, Rowe, Sherbourne, and Meredith and Mr. Hickey: RAND Health Program, 1776 Main Street, Santa Monica, CA 90407.

    • Dr. Rost: Department of Medical Humanities and Social Sciences, Florida State University, 1115 West Call Street, Tallahassee, FL 32306.

    • Dr. Ford: Department of General Internal Medicine, Johns Hopkins School of Medicine, 733 North Broadway, Suite 115, Baltimore, MD 21205.

    • Dr. Rubenstein: Veterans Affairs Greater Los Angeles (152), 16111 Plummer Street, Sepulveda, CA 91343.

    • Author Contributions: Conception and design: K.A. Hepner, M. Rowe, K. Rost, C.D. Sherbourne, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

    • Analysis and interpretation of the data: K.A. Hepner, M. Rowe, K. Rost, S.C. Hickey, C.D. Sherbourne, D.E. Ford, L.V. Rubenstein.

    • Drafting of the article: K.A. Hepner, C.D. Sherbourne, L.V. Rubenstein.

    • Critical revision of the article for important intellectual content: K.A. Hepner, M. Rowe, K. Rost, C.D. Sherbourne, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

    • Final approval of the article: K.A. Hepner, M. Rowe, K. Rost, S.C. Hickey, C.D. Sherbourne, D.E. Ford, L.V. Rubenstein.

    • Provision of study materials or patients: L.S. Meredith, L.V. Rubenstein.

    • Obtaining of funding: K. Rost, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

    • Administrative, technical, or logistic support: M. Rowe, S.C. Hickey, L.V. Rubenstein.

    • Collection and assembly of data: M. Rowe, K. Rost, S.C. Hickey, D.E. Ford, L.S. Meredith, L.V. Rubenstein.

    Responses to this article

    • In Response
      • Lisa V. Rubenstein and
      • Kimberly A. Hepner, PhD
      Ann Intern Med published online October 26, 2009
    • Diagnosis of depression in clinical practice
      • giuseppe colloca
      Ann Intern Med published online October 26, 2009
    • The importance of efficient depression management in primary care
      • Christos G Theleritis and
      • Thomas J Paparrigopoulos and George N Papadimitriou
      Ann Intern Med published online October 26, 2009
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    1. Ann Intern Med September 4, 2007 vol. 147 no. 5 320-329
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