comparative effectiveness study of practice based vs telemedicine based depression collaboratives
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Comparative Effectiveness Study of Practice-Based vs. Telemedicine-Based Depression Collaboratives. John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD Division of Health Services Research Department of Psychiatry University of Arkansas for Medical Sciences.

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comparative effectiveness study of practice based vs telemedicine based depression collaboratives

Comparative Effectiveness Study of Practice-Based vs. Telemedicine-BasedDepression Collaboratives

John Fortney, PhD

Jeff Pyne, MD

Dinesh Mittal, MD

Teresa Hudson, PharmD

Division of Health Services Research

Department of Psychiatry

University of Arkansas for Medical Sciences

funding
Funding
  • National Institute of Mental Health
    • R01 MH076908
partnership
Partnership
  • Community Health Centers of Arkansas
    • Boston Mountain Rural Health Centers Inc.
    • Community Clinic at St Francis House
    • Corning Area Healthcare Inc.
    • East Arkansas Family Health Center Inc.
    • Jefferson Comprehensive Healthcare System Inc.
  • University of Arkansas for Medical Sciences
    • Department of Psychiatry
      • Division of Health Services Research
practice based depression collaborative
Practice-Based Depression Collaborative
  • 20/28 randomized trials of depression collaboratives significantly improved outcomes1:
    • Median effect for response: +18%
    • Median effect for remission: +16%

1) Williams J et. al. Systematic review of multifaceted interventions to improve depression care. General Hospital Psychiatry, 29, 91-116, 2007

components of practice based depression collaborative
Components of Practice-Based Depression Collaborative
  • Provider education
  • Screening
  • Patient education, activation, and self-management
  • Regularly scheduled follow-up assessments
  • Use of clinical information systems and TX guidelines
  • Delegation of key clinical activities to non-physician members of a practice team
  • Ready access to mental health specialists
  • Stepped care
barriers to implementing practice based depression collaborative in chcs
Barriers to Implementing Practice-Based Depression Collaborative in CHCs
  • On-site mental health specialists are typically unavailable.
  • Linkages to off-site mental health specialists are weak.
  • Depression Collaboratives are more effective if they include MH services1.
  • Depression Collaborative is effective in urban practices, but NOT rural practices.2

1) Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine 2006;166:2314-21.

2) Adams S, Xu S, Dong F, Fortney J, Rost K. Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients, Journal of Rural Health, 2006 22(4):343-50.

telemedicine based depression collaborative
Telemedicine-Based Depression Collaborative
  • Offsite depression care team at UAMS Dept. of Psychiatry
    • Nurse care manager
    • Pharmacist
    • Psychologist
    • Psychiatrist
  • Telephones
    • Care manager encounters with patients at home
  • Interactive Video
    • Evidence-Based Psychotherapy with patients at CHC
    • Psychiatric evaluations with patients at CHC
  • Web-based Decision Support System for Care Manager
    • NetDSS
netdss https www netdss net
NetDSS - https://www.NetDSS.net/
  • NetDSS has the following functional capabilities:
    • patient registry and panel management
    • trial and phase management
    • encounter scheduler
    • decision support
    • progress note generator
    • Workload/Outcomes report generator
  • NetDSS guides the care manager through a self-documenting and evidence-based patient encounter using scripts and self-scoring instruments which support:
    • patient education and activation
    • barrier assessment
    • comorbidity assessment
    • depression severity monitoring
    • suicide risk assessment
    • adherence monitoring
    • side-effect monitoring
    • self-management activities
research question
Research Question
  • Compare outcomes of telemedicine-based depression collaborative to practice-based depression collaborative.
exclusion criteria
Exclusion Criteria
  • Self-reported treatment with MH specialist
  • Self-reported Schizophrenia
  • Self-reported bereavement
  • Self-reported pregnancy/post partum
  • Bipolar Disorder (MDQ)
  • Substance Dependence (MINI)
  • Cognitive Impairment (Blessed)
  • Acute Suicide Ideation (HRSA risk assessment)
  • No phone
enrollment flowchart

9 Primary Care Practices

54,145 Patient Visits

PHQ9 Screens

19,285 (36%)

Positive Screens

2,863 (15%)

Eligible/enrolled

364 (55%)

Consented

829 (62%)

6-Month Follow-Up

316 (87%)

Ineligible

316 (45%)

12-Month Follow-Up

271 (82%)

Not located/refused

134 (16%)

18-Month Follow-Up

193 (88%)

Enrollment Flowchart
face to face service utilization
Face to Face Service Utilization

Specialty MH Encounters

Depression PC Encounters

tele mental health utilization
Tele-Mental Health Utilization
  • Tele - Cognitive Behavioral Therapy
    • 30 (17%) had an interactive video encounter
      • 33% Completed CBT manual
      • 47% Attended ≥ 8 sessions
      • 53% Dropped out and attended <8 sessions
    • 422 scheduled interactive-video sessions
      • 57% Interactive-video sessions attended
      • 40% Interactive-video sessions canceled by patients
      • 3% Canceled due to technical difficulties
  • Tele - Psychiatric Evaluations
    • 22 (12%) following two failed trials
      • 45% had an interactive video encounter
      • 55% had a telephone encounter
    • 5 (3%) for telephone suicide risk assessment
care manager fidelity telemedicine based depression collaborative
Care Manager FidelityTelemedicine-Based Depression Collaborative
  • Completed Baseline Assessments – 94.5%
  • Completed Follow-ups
    • Acute Stage – 1,191 (74%)
      • Mean days between assessments = 24 days
    • Continuation Stage – 295 (86%)
      • Mean days between assessments = 32 days
  • Final Disposition
    • 49% - Remitted and completed continuation phase
    • 12% - Responded and completed continuation phase
    • 12% - Did not respond within twelve months or relapsed
    • 2% - Requested deactivation
    • 25% - Baseline assessment not completed or lost to follow-up
care manager fidelity practice based depression collaborative
?Care Manager Fidelity?Practice-Based Depression Collaborative
  • NetDSS
    • Only 3 sites Used NetDSS
  • HRSA Patient Electronic Care System
    • Only 4 Sites Reporting Data
  • Patient Self-Report
    • Inaccurate
  • Chart Review
    • Currently underway
eighteen month follow up response and remission rates n 192
Eighteen Month Follow-upResponse and Remission Rates (n=192)

OR=16.7

p<0.0001

OR=10.8

P<0.0001

conclusions
Conclusions
  • Telemedicine-based depression collaborative required few PC visits than practice-based depression collaborative.
  • Telemedicine-based depression collaborative is more clinically effective than practice-based depression collaborative.
  • CHCs and CHCA should consider pooling resources to fund off-site depression care team.
future research
Future Research
  • Partnership for Implementation of Evidence-Based Practices (EBPs)
    • NIMH R24 MH085104
  • Objectives
    • Develop and sustain an Implementation Partnership to promote the adaptation, adoption, and evaluation of EBPs
    • In two Demonstration Projects, use QI methods to implement EBPs for Bipolar Disorder and Alcohol Use Disorders
ad