Dataset Information

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.

ABSTRACT:

Background

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

Objective

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

Design

Secondary analysis from the Quality Improvement in Depression Study dataset.

Participants

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

Measurements

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

Results

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

Conclusions

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

SUBMITTER: Dickinson LM

PROVIDER: S-EPMC2585690 | biostudies-literature | 2008 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.

Dickinson L Miriam LM Dickinson W Perry WP Rost Kathryn K DeGruy Frank F Emsermann Caroline C Froshaug Desireé D Nutting Paul A PA Meredith Lisa L

Journal of general internal medicine 20080805 11

<h4>Background</h4>Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.<h4>Objective</h4>To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.<h4>Design</h4>Secondary analysis from the Quality Improvement in Depression ...[more]

PMID: 18679758

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Project description:BackgroundThe patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care.ObjectiveWe examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care.Design, subjects and main measuresThis longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility.Key resultsAmong age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter.ConclusionsIncreases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

Project description:ContextAntidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression.ObjectiveTo estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression.Data sourcesPubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews.Study selectionRandomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included.Data extractionIndividual patient-level data were obtained from study authors.ResultsMedication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.ConclusionsThe magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

Dataset Information

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.

Background

Objective

Design

Participants

Measurements

Results

Conclusions

Publications

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.

Similar Datasets

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