Cost-effectiveness of Practice-Initiated Quality Improvement for Depression: Results of a Randomized Controlled Trial

• Published in: JAMA : the journal of the American Medical Association 2001-09, Vol.286 (11), p.1325-1330
• Main Authors: Schoenbaum, Michael, Unützer, Jürgen, Sherbourne, Cathy, Duan, Naihua, Rubenstein, Lisa V, Miranda, Jeanne, Meredith, Lisa S, Carney, Maureen F, Wells, Kenneth
• Format: Article
• Language: English
• Subjects: Adult and adolescent clinical studies; Biological and medical sciences; Cost of Illness; Cost-Benefit Analysis; Depression; Depressive Disorder - economics; Depressive Disorder - therapy; Employment; Family Practice - economics; Family Practice - standards; Health Care Costs - statistics & numerical data; Health Services Research - methods; Humans; Intervention; Managed Care Programs - economics; Managed Care Programs - standards; Medical sciences; Mental depression; Mental Health Services - economics; Mental Health Services - standards; Mood disorders; Outcome and Process Assessment (Health Care); Primary care; Primary Health Care - economics; Primary Health Care - standards; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Quality Assurance, Health Care - economics; Quality-Adjusted Life Years; Social costs; Studies; United States
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.286.11.1325

CONTEXT Depression is a leading cause of disability worldwide, but treatment rates in primary care are low. OBJECTIVE To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment. DESIGN Group-level randomized controlled trial conducted June 1996 to July 1999. SETTING Forty-six primary care clinics in 6 community-based managed care organizations. PARTICIPANTS One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression. INTERVENTIONS Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment. MAIN OUTCOME MEASURES Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions. RESULTS Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P = .35) and $485 (13%) in QI-therapy (P = .28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P = .19) and 47 (P = .01) fewer days with depression burden and were employed 17.9 (P = .07) and 20.9 (P = .03) more days during the study period. CONCLUSIONS Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.