Minnesota Depression Initiative: Higher Patient Satisfaction, No Impact on Depression

A study in the Annals of Family Medicine illustrated the difficulty in effectively implementing evidence-based care, even when the initiative is supported by an experienced quality improvement collaborative, or when when payment incentives are adjusted with the end goal of increasing collaborative care.

The majority of clinical evidence has shown the collaborative care model for depression results in improved patient outcomes, and there is some evidence that the model is cost-effective and even cost saving. But lack of reimbursement for the model’s components was seen as a barrier to implementation.

That changed with Minnesota’s statewide initiative, Depression Improvement Across Minnesota—Offering a New Direction (DIAMOND), which garnered national headlines when it was announced in 2008.

It received additional funding as part of an innovation award, and achieved an incredibly high participation rate within the 75 primary care clinics participating in the program. DIAMOND combined a new payment from all health plans in the state with externally facilitated implementation of evidence-based collaborative care management for adults with depression.

The DIAMOND collaborative care model included seven components: (1) consistent use of the 9-item Patient Health Questionnaire (PHQ-9) depression scale for monitoring depression severity; (2) systematic patient follow-up tracking and monitoring; (3) treatment intensification for patients not improving; (4) relapse prevention planning for patients achieving remission; (5) on-site care manager for educating, monitoring, and coordinating care; (6) scheduled weekly caseload review with a consulting psychiatrist; and (7) monthly descriptive data submissions.

Seventy-five clinics completed training, implemented the DIAMOND care model, and provided DIAMOND care for at least several years. More than 10,000 patients were enrolled in the initiative from March 2008 through May 2013.

There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC).

Patients who received DIAMOND care after implementation reported more collaborative care depression services than the three comparison groups (10.9 vs 6.4—6.7, on a scale of 0 of 14, where higher numbers indicate more services; P < .001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). But depression remission rates were not significantly different among the four groups (36.4% DCA vs. 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94).

“Despite good evidence of implementation of practice systems important to collaborative care, and despite enrolled patients reporting receiving more desired care processes, patients receiving DIAMOND care had neither better depression outcomes nor better improvement in work productivity or health status,” the stud authors said. “These results were surprising and disappointing to the participants in the DIAMOND initiative, especially because measurements by the initiative from clinic data submissions had shown 6-month response and remission rates of 40% and 30% among all patients enrolled, and 66% and 48% among those 61% that could be measured again at 6 months, rates that are almost as good as those seen in intervention groups in the scientific trials.”

The study authors maintain that one likely factor in the lack of improvement was the high quality of usual depression care in Minnesota, making it harder to further improve. The DIAMOND clinics all had gained experience in quality improvement methods prior to the implementation of the program.

“This study shows the difficulties of widespread implementation of evidence-based practices that require major changes in roles and extensive financial and leadership support,” the authors concluded.