The full content of Annals is available to subscribers

Subscribe/Learn More  >
Economics |

1 of 2 quality-improvement interventions for depression in managed care was more effective but more costly than usual care

Margretta Diemer, MD, MPH; and Christos Hatzigeorgiou, DO
[+] Article, Author, and Disclosure Information

*See Glossary.

†Information provided by author.

‡Wells KB, Sherbourne C, Schoenbaum M, et al. JAMA. 2000;283:212-20. 10634337

Sources of funding: Agency for Healthcare Research and Quality; National Institute of Mental Health; John D. and Catherine T. MacArthur Foundation.

For correspondence: Dr. M. Schoenbaum, RAND, Arlington, VA, USA. E-mail mikels@rand.org.

Ann Intern Med. 2002;136(3):116. doi:10.7326/ACPJC-2002-136-3-116
Text Size: A A A

Question: In patients with depression, are either of 2 quality-improvement (QI) interventions for improving the treatment of depression in managed care more cost-effective than usual care?

Design: Cost-effectiveness analysis from a societal perspective for a cluster-randomized {allocation concealed*}†, unblinded,* controlled trial with 2-year follow-up.

Setting: 46 primary care clinics in 6 community-based managed-care organizations (MCOs) in the United States.

Patients: 1356 patients who were ≥ 18 years of age {mean age 44 y, 71% women}‡, planned to use the primary care clinic over the next 12 months, and met the Composite International Diagnostic Interview criteria for depression. Follow-up at 2 years was 85%.

Intervention: Matched clinics were allocated to 1 of 2 QI interventions or to usual care (i.e., mailing of practice guidelines) (16 clinics, 443 patients). The QI interventions consisted of training for practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds, 12 clinics, 424 patients) or access to trained psychotherapists (QI-therapy, 15 clinics, 489 patients).

Main cost and outcome measures: Outcomes were quality-adjusted life-years (QALYs), days with depression burden, and days of employment. Intervention costs (screening, intervention materials, and professional time) and health care costs (consultations and psychotropic medications) were assessed in 1998 U.S. dollars. Indirect costs for patient time were included.

Main results: Intention-to-treat analyses were adjusted for baseline patient characteristics and practice randomization blocks. Patients in the QI-therapy group had more QALYs (P = 0.006), fewer days of depression burden (P = 0.01), and more days of employment (P = 0.03) than did those receiving usual care (Table). QI-meds and usual care did not differ for any outcome (Table). The groups did not differ for health care costs (including patient time) (Table).

Conclusion: 1 of 2 quality-improvement interventions for depression in managed care was more effective but cost more than usual care.

2 quality-improvement (QI) interventions vs usual care for depression in primary care§

Outcomes at 2 yUsual care totalIncremental effect of QI-meds (95% CI)Incremental effect of QI-therapy (CI)
Quality-adjusted life-years1.70.01 (−0.00 to 0.03)0.02 (0.01 to 0.04)¶
Days of depression burden419.9−25.0 (−63.1 to 13.2)−46.7 (−83.1 to −10.3)¶
Days of employment279.217.9 (−1.6 to 37.4)20.9 (2.4 to 39.3)¶
Health care costs‖ (U.S. $)**3835419 (−467 to 1306)485 (−393 to 1363)

§QI-meds = QI intervention and medication follow-up by nurses; QI-therapy = QI intervention and access to psychotherapists.

||Includes patient time.

¶Comparison with usual-care group is statistically significant.

**A correction was made at this point in the table. See Notices and Corrections for details.





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Depression in primary care: quality improvement and economics. Manag Care 2008;17(3 Suppl 2):22-4; discussion 25-6.
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.