Primary care physicians play a front-line role in treating depression, diagnosing and managing half of the 8 million ambulatory visits for the condition each year. Yet primary care practices routinely underuse effective chronic disease management tools when treating depression, compared to when treating medical conditions such as diabetes and asthma, reports a new study led by Weill Cornell Medicine researchers.
Patients with chronic diseases benefit from proactive population-based care. Disease registries help practices track when patients need specific interventions; nurse-care managers help patients navigate the healthcare system; and patient educators empower patients to more actively manage their condition. Such care-management strategies have been shown to help people with depression; one especially promising approach, called the Collaborative Care Model, integrates mental health providers into a primary care setting. However, little was known about how often or how well primary care practices provided care management for behavioral health conditions. The findings, published March 7 in the March issue of Health Affairs, are important, the investigators say, because patients with depression are increasingly turning to primary care physicians for behavioral healthcare since many therapists and psychiatrists do not accept private and federal health insurance as payment.
"This study opens our eyes to the fact that in primary care, there is an underuse of proven methods to manage depression as a chronic illness. Even though a lot of depression is cared for in primary care, we may not be managing it as well as we could," said lead author Dr. Tara Bishop, the Nanette Laitman Clinical Scholar in Healthcare Policy and Research/Clinical Evaluation and an associate professor of healthcare policy and research in the Division of Outcomes and Effectiveness Research at Weill Cornell Medicine.
Dr. Bishop and her colleagues analyzed data from the National Study of Physician Organizations, the largest survey of physician practices in the United States that focuses on the use of care-management practices in depression, asthma, diabetes and congestive heart failure. They found that primary care practices on average used 0.8 care management processes for depression, compared to 1.7 for diabetes. (Scores for the other two conditions were in-between.)
Practices also were less likely to use registries, nurse care managers, and patient educators when treating patients for depression compared to the three medical conditions. This disparity was greater among small- and medium-sized practices than among large practices (those with 20 or more physicians). In large practices, the use of care management strategies has improved over time for diabetes, according to a comparison of data from 2012 and 2013 with information collected in earlier surveys. But in small and medium practices, while it has improved for diabetes, it hasn't for depression, asthma or congestive heart failure.
"The use of these processes was pretty low across the board," Dr Bishop noted. But results were especially dismal in depression care.
She speculates that primary care physicians may not feel that they are or should be responsible for behavioral health, or may not feel equipped to provide this dimension of care. Policy changes such as payment incentives or reporting requirements in healthcare quality metrics can help focus attention on the issue, she said.
"There are a lot of strategies that can be put in place to manage depression as a chronic illness," Dr. Bishop said. "But we need to find ways to incentivize their use going forward."