POPULATION HEALTH MANAGEMENT Volume 17, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2013.0057
Impact of Symptom Remission on Outpatient Visits in Depressed Primary Care Patients Treated with Collaborative Care Management and Usual Care Matthew R. Meunier, MD,1 Kurt B. Angstman, MS, MD,1 Kathy L. MacLaughlin, MD,1 Sara S. Oberhelman, MD,1 James E. Rohrer, PhD,1 David J. Katzelnick, MD,2 and Marc R. Matthews, MD1
Abstract
Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status ( > 8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460–0.805, P < 0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655–6.548, P < 0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. (Population Health Management 2014;17:180–184)
Introduction
D
epression contributes to significant morbidity in the US population, with 8% of persons aged 12 years or older reporting depressive symptoms within the last 2 weeks.1 Depression has a significant economic impact and is associated with increased absenteeism and decreased work productivity.2 Likewise, depression contributes to significant health care utilization, serving as the primary diagnosis of 7.9 million ambulatory medical visits annually.3 The Institute for Healthcare Improvement (IHI) triple aim states that health care reform should focus on improving patient outcomes, improving the experience of health care, and decreasing the total cost of care.4 Thus, changes in practice should consider improvements in clinical outcomes as well as decreased overall health care utilization as mechanisms to control health care costs. Studies have shown that collabo1 2
rative care management (CCM) has been effective in the treatment of depression by decreasing depression symptomatology.5–8 CCM also has been demonstrated to improve work-related outcomes (absenteeism and presenteeism) in primary care patients with depression.9 Multiple studies have demonstrated increased health care utilization for individuals with mental health disorders. In a 1996 study of health maintenance organization (HMO) patients who were high utilizers (based on medical costs), those diagnosed with depression were found to accrue greater costs than those without a depression diagnosis when controlling for medical comorbidities.10 In a US study of 3 HMO sites that identified high utilizers of outpatient health care (defined by greater than 6 ambulatory visits in each of the previous 2 years), 20% of the high utilizers were found to have current major depression or major depression in partial remission.11 After controlling for comorbidities, the
Department of Family Medicine, Mayo Clinic, Rochester, Minnesota. Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.
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IMPROVEMENT IN OUTPATIENT VISITS BY DEPRESSED PATIENTS
study found significantly more ambulatory office visits, hospitalized days, and percentage of individuals hospitalized for participants with current depression compared to those with past or no history of depression. In a 2009 study of depressed veterans, those with post-traumatic stress disorder (PTSD) and depression demonstrated significantly more outpatient utilization than those who only had depression.12 Although outcomes were not delineated, the group with PTSD had more severe depression symptoms and other comorbidities. In addition, a self-reported patient survey study of urban family medicine practices found a positive association between mental health conditions and increased utilization of health care services.13 The authors’ prior studies of primary care patients in CCM also have shown that those patients who have increased depression severity and other comorbidities tend to have worse clinical outcomes.14–16 Previous studies have demonstrated that depression treatment makes a positive impact on health care costs and outpatient utilization. A review of 9 studies in Washington State, including 1814 patients meeting criteria for depression, found mean health service costs 6 months after treatment to be significantly less for those achieving remission ($2012) compared to persistent depression ($3094, P < 0.001) or partial remission ($2571, P = 0.007).17 Of note, these studies utilized classic depression treatment strategies with no CCM. As the authors have noted in a prior study, those patients whose depression improved to remission while in CCM had decreased odds of outlier status for outpatient utilization at 6 months (defined as > 8 visits) and 12 months (defined as > 12 visits) compared to those who were not in remission. This was demonstrated while controlling for baseline severity of depression, clinical diagnosis, anxiety symptoms, and prior utilization patterns.18 Although CCM has been shown to be effective in the treatment of depression and that achieving depression remission is correlated with decreased outpatient utilization, some studies have demonstrated increased short-term costs after implementation of CCM. A randomized controlled study of 407 patients with depression demonstrated an increase in total medical costs 12 months after enrollment in a CCM program compared to usual care (UC).19 However, a more recent randomized controlled study of 551 patients diagnosed with major depressive disorder demonstrated a long-term cost reduction with CCM compared to UC over 4 years.20 The increase in short-term cost is thought to be related to patient ‘‘activation,’’ or increased patient engagement with treatment.20,21 In the present study, the authors compared outpatient visit counts of patients with depression in CCM to patients with depression receiving UC while controlling for comorbidities and prior outpatient visit patterns. Based on the authors’ prior results that clinical remission was associated with fewer outpatient visits at 6 and 12 months in patients enrolled in CCM,18 their hypothesis was that patients with poor depression outcomes at 6 months would have increased outpatient visit counts, regardless of treatment type. Methods
Primary care patients from 4 clinics in a large integrated practice (*100,000 adult patients) in Rochester, Minnesota
181
comprised the study group. Those who were diagnosed with major depressive disorder or dysthymia from March 1, 2008 through December 31, 2011, had a Patient Health Questionnaire (PHQ-9) 22 with a score of ‡ 10, and had a complete set of study data were included. The PHQ-9 is a 9-item patient assessment tool that scores each item from 0 to 3. A PHQ-9 score of < 5 is classified as asymptomatic; 5–9 as mild depressive symptoms; 10–14 as moderate depressive symptoms; 15–19 as moderately severe; and ‡ 20 as severe symptoms of depression. The study cohort included 1733 patients. Treatment was by UC with the patient’s primary care provider (PCP) or enrollment in CCM. The only exclusionary criterion was a clinical diagnosis of bipolar disorder. Patients in the UC arm were treated (medical and/or therapeutic) and had follow-up as directed by their PCP. For those enrolled in CCM, a registered nurse care manager reviewed the patient with the supervising psychiatrist, who met with the care managers on a weekly basis. Recommendations regarding therapeutic changes were communicated to the patient’s PCP. All treatment decisions were the responsibility of the PCP. Care manager to patient contact varied based on clinical need. Full details of the development and implementation of this study’s CCM have been described previously.21,23,24 The dependent variable for this study was outlier status ( > 80th percentile) for the number of outpatient visits at 6 months. Outpatient visits included those for all concerns, not just behavioral health visits. The independent demographic variables were age, sex, race, and marital status. The clinical predictor variables were baseline PHQ-9, clinical diagnosis, and remission status at 6 months (PHQ-9 < 5). Prior studies in the authors’ institution have demonstrated that outpatient visits were impacted by the individual patient’s prior visit counts.25–29 In order to control for this, the number of outpatient visits (primary, secondary, or tertiary care) for the 6 months prior to enrollment also was measured. The presence of high-risk clinical comorbidities also was recorded, as defined by Colla et al in 2012.30 A diagnosis of diabetes, cancer, chronic obstructive lung disease, dementia, or coronary artery disease was determined by screening of the electronic medical record. Following Rohrer et al, the number of comorbidities was categorized as none, 1, or ‡ 2.31 Categorical data were analyzed with chi-square testing while Mann-Whitney testing was utilized for statistical analysis of the continuous variables (because of non-normal distribution). Multiple logistic regression modeling for outpatient visit outlier status was performed while retaining all independent variables studied. Calculations were performed on MedCalc software ( < www.medcalc.org > , version 12.3.0.0). This study was reviewed and approved by the authors’ institutional review board. Results
Of the 1733 patients included in the study, 819 (47.3%) were in remission at 6 months and 914 (52.7%) were not (Table 1). At baseline, the remission group was slightly older, more likely married, with a diagnosis of first episode of major depression of moderate severity. The remission group had fewer outpatient visits compared to the group that
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Table 1. Characteristics of Primary Care Patients Diagnosed with Depression with or without Remission after Six Months, by Variable
Age Median years (range) Sex % female (N) Marital Status % married (N) Race % white (N) Clinical Diagnosis First episode of depression Recurrent depression Dysthymia Depression severity Moderate Moderately severe Severe Comorbidities None One Two or more Outpatient visit six months pre diagnosis: Median (range) Outpatient visit outlier ( > 6 visits) six months pre diagnosis: % outlier (N) Enrollment into CCM % enrolled (N) Outpatient visit six months post diagnosis: Median (range) Outpatient visit outlier ( > 8 visits) six months post diagnosis
PHQ-9 < 5 at six months (N = 819)
PHQ-9 ‡ 5 at six months (N = 914)
44.0 (18.0–89.6)
42.5 (18.0–92.3)
0.047
75.0% (614)
75.2% (687)
0.97
57.9% (474)
49.8% (455)
< 0.01
95.6% (783)
93.3% (853)
0.05
55.4% (454) 36.4% (298) 8.2% (67)
44.6% (408) 43.8% (400) 11.9% (106)
< 0.01
53.6% (439) 32.7% (268) 13.7% (112)
40.6% (371) 37.1% (339) 22.3% (204)
< 0.01
65.4% (536) 24.1% (197) 10.5% (86) 3.3 (1–20) 11.5% (94)
59.7% (546) 26.1% (239) 14.1% (129) 4.3 (1–32) 21.4% (196)
0.02 < 0.01 < 0.01
87.8% (719)
72.4% (662)
< 0.01
4.8 (1–27) 12.7% (104)
6.5 (1–42) 25.3% (231)
< 0.01 < 0.01
P value
PHQ-9, Patient Health Questionnaire; CCM, Collaborative Care Management.
was not in remission, and were less likely to be a prior outpatient visit outlier( > 6 visits) for the 6 months prior to diagnosis. For the 6 months after diagnosis, the remission group demonstrated a significantly lower number of outpatient
visits compared to those patients not in remission. Outpatient visit outlier status was defined as > 80th percentile ( > 8 visits) for the 6 months following diagnosis. Patients in remission were approximately 50% as likely to be an outlier as those who were not in remission (Table 1).
FIG. 1. Multiple regression model for odds ratio of outpatient visit outlier status ( > 8 visits) 6 months after diagnosis of depression, by variable. Multiple regression modeling with all other variables, controlling for age, sex, race, marital status, clinical diagnosis, medical comorbidity, enrollment into collaborative care management versus usual care, and clinical location (to control for site-to-site variability in outcomes). Model overall fit with null model - 2 log likelihood of 1701.742 (P < 0.0001). PHQ-9, Patient Health Questionnaire.
IMPROVEMENT IN OUTPATIENT VISITS BY DEPRESSED PATIENTS
Figure 1 demonstrates the multiple logistic regression analysis for outpatient visit outlier status ( > 8 visits) at 6 months after diagnosis. Severe depression (odds ratio [OR] 1.775, confidence interval (CI) 1.259–2.503, P < 0.01) and increased pre-diagnosis outpatient utilization outlier status (OR 4.892, CI 3.655–6.548, P < 0.01) were independent predictors for outpatient visit outlier status. In this model, remission at 6 months demonstrated an OR for outpatient visit outlier status of 0.609 (CI 0.461–0.805, P < 0.01), while controlling for age, sex, marital status, clinical diagnosis, enrollment into CCM versus UC, and clinical location (for site-to-site variability in outcomes). The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). Discussion
In patients diagnosed with depression, the number of allcause outpatient visits after the diagnosis of depression was significantly impacted by the severity of depression as well as the number of outpatient visits prior to diagnosis. Clinical remission at 6 months, as suggested by the original hypothesis, was associated with lower odds of having more than 8 visits during the 6 months after diagnosis. This finding was demonstrated while controlling for patient comorbidities, depression severity, and clinical diagnosis. It was noted that a simple variable with 3 categories proved to be useful for comorbidity adjustment, as was demonstrated previously in a study of polypharmacy.31 In addition, the authors adjusted for the likelihood to use medical care by including the number of visits in the previous year as a covariate, as was done in their previous work.25–29 This variable reflects both the biomedical need for services and any psychological inclination to seek care. By adjusting for prior use of service, the authors were able to separate out how much depression remission changes use of service above and beyond the normal pattern. This study is validated by its consistency with other studies that demonstrated similar findings. For instance, it was shown in a prior study that achieving remission status in CCM was inversely related to high outpatient visit counts 6 and 12 months after enrollment.18 In the present study, the authors find that this continues to be the case for all patients (CCM or UC) who had a 6-month follow-up PHQ-9 score for their depression. Further integration of behavioral health services continues to be strongly emphasized in Patient-Centered Medical Home standards32 and the results of the present study support early intervention and effective treatment of depression in primary care patients as a mechanism to improve clinical outcomes and decrease allcause outpatient visit utilization. Future studies could examine long-term effects of CCM for depression on outpatient visits, as previous studies have suggested economic benefits beyond this study’s follow-up time period. Future studies of the total health care costs by per member per month (PMPM) in individuals with depression within the CCM program also would be interesting. A 2011 study of PMPM costs for patients with bipolar disorder compared to other chronic conditions found that only those with both diabetes and coronary disease had higher total PMPM costs. Also, patients with depression had higher adjusted PMPM costs for primary care and nonpsychiatric in-
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patient services.33 In addition, further investigation into the effect of patient complexity on outpatient utilization may be made by examining alternative measures or study design. For example, the case-control design can be an efficient approach to studying the outcomes of practice innovations.34 Limitations of this study include the lack of racial and economic (such as health insurance coverage) diversity in the population. Because this study encompassed 1 large, midwestern US medical practice and the implementation of CCM may be different in other organizations, the results may not be generalizable to other clinical environments. However, patients in the present study were treated in several clinical locations, assuring some internal variation in practice styles, attitudes, and other unmeasured variables. An additional limitation could include potential referral bias because this cohort study did not randomize patients into CCM or UC. Also, CCM patients had more consistent depression severity follow-up than UC, which may have produced a bias in patient selection. Conclusions
In primary care patients treated for depression, successful treatment to remission (PHQ-9 score < 5) at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. This holds true even when controlling for the individual patient’s prior outpatient visit counts, health care comorbidities, and enrollment in CCM versus UC. Although this is encouraging for this developing model of care, future studies are encouraged. Acknowledgments
Isaac Johnson, MBA, and Julie Maxson, BA, assisted with abstraction and collection of the data. Author Disclosure Statement
Drs. Meunier, Angstman, MacLaughlin, Oberhelman, Rohrer, Katzelnick, and Matthews declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Angstman has a consulting agreement with Tamber Health; Tamber Health was not involved in study design, data analysis, or manuscript preparation. The other authors declared no conflicts of interest. Departmental funds were used for this study. References
1. Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev 2006;(3):CD004691. 2. Hees HL, Koeter MW, Schene AH. Longitudinal relationship between depressive symptoms and work outcomes in clinically treated patients with long-term sickness absence related to major depressive disorder. J Affect Disord 2013;148(2–3):272–277. 3. Henken HT, Huibers MJ, Churchill R, Restifo K, Roelofs J. Family therapy for depression. Cochrane Database Syst Rev 2007;(3):CD006728. 4. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: < http://www.ihi.org/offerings/Initiatives/ TripleAim/Pages/default.aspx > . Accessed March 24, 2013.
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5. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative metaanalysis and review of longer-term outcomes. Arch Intern Med 2006;166(21):2314–2321. 6. Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med May 2012;42(5):525–538. 7. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288(22): 2836–2845. 8. Hegerl U, Schonknecht P, Mergl R. Are antidepressants useful in the treatment of minor depression: a critical update of the current literature. Curr Opin Psychiatry 2012;25(1):1–6. 9. Shippee ND, Shah ND, Angstman KB, et al. Impact of collaborative care for depression on clinical, functional, and work outcomes: a practice-based evaluation. J Ambul Care Manage Jan–Mar 2013;36(1):13–23. 10. Henk HJ, Katzelnick DJ, Kobak KA, Greist JH, Jefferson JW. Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization. Arch Gen Psychiatry 1996;53(10): 899–904. 11. Pearson SD, Katzelnick DJ, Simon GE, Manning WG, Helstad CP, Henk HJ. Depression among high utilizers of medical care. J Gen Intern Med 1999;14(8):461–468. 12. Chan D, Cheadle AD, Reiber G, Unutzer J, Chaney EF. Health care utilization and its costs for depressed veterans with and without comorbid PTSD symptoms. Psychiatr Serv 2009;60(12):1612–1617. 13. Fogarty CT, Sharma S, Chetty VK, Culpepper L. Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med 2008;21(5):398–407. 14. Angstman KB, Dejesus RS, Rohrer JE. Correlation between mental health co-morbidity screening scores and clinical response in collaborative care treatment for depression. Ment Health Fam Med 2010;7(3):129–133. 15. Angstman KB, MacLaughlin KL, Williams MD, Rasmussen NH, DeJesus RS. Increased anxiety and length of treatment associated with depressed patients who are readmitted to collaborative care. J Prim Care Community Health 2011;2(2):82–86. 16. Angstman KB, Pietruszewski P, Rasmussen NH, Wilkinson JM, Katzelnick DJ. Depression remission after six months of collaborative care management: role of initial severity of depression in outcome. Ment Health Fam Med 2012;9(2): 99–106. 17. Simon GE, Khandker RK, Ichikawa L, Operskalski BH. Recovery from depression predicts lower health services costs. J Clin Psychiatry 2006;67(8):1226–1231. 18. Angstman KB, Oberhelman SS, Rohrer JE, Meunier MR, Rasmussen NH, Chappell DH. Depression remission decreases outpatient utilization at six and twelve months after enrollment into collaborative care management. Popul Health Manag 2013. In press. 19. Simon GE, Manning WG, Katzelnick DJ, Pearson SD, Henk HJ, Helstad CS. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry 2001;58(2):181–187. 20. Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14(2):95–100.
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21. Angstman KB, DeJesus RS, Williams MD. Collaborative care management for depression: comparison of cost metrics, clinical response to usual care. J Prim Care Community Health 2010;1(2):73–77. 22. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282(18):1737– 1744. 23. Angstman KB, DeJesus RS, Williams MD. Initial implementation of a depression care manager model: an observational study of outpatient utilization in primary care clinics. Popul Health Manag 2009;12:227–230. 24. Williams M, Angstman K, Johnson I, Katzelnick D. Implementation of a care management model for depression at two primary care clinics. J Ambul Care Manage 2011; 34(2):163–173. 25. Rohrer JE, Yapuncich KM, Adamson SC, Angstman KB. Do retail clinics increase early return visits for pediatric patients? J Am Board Fam Med 2008;21(5):475–476. 26. Rohrer JE, Angstman KB, Bartel GA. Impact of retail medicine on standard costs in primary care: a semiparametric analysis. Popul Health Manag 2009;12(6):333–335. 27. Rohrer JE, Angstman KB, Furst JW. Impact of retail walkin care on early return visits by adult primary care patients: evaluation via triangulation. Qual Manag Health Care 2009;18(1):19–24. 28. Angstman KB, Bernard ME, Rohrer JE, Garrison GM, Maclaughlin KL. Repeat retail clinic visits: impact of insurance coverage and age of patient. Popul Health Manag 2012;15:358–361. 29. Rohrer JE, Angstman KB, Garrison G. Early return visits by primary care patients: a retail nurse practitioner clinic versus standard medical office care. Popul Health Manag 2012;15:216–219. 30. Colla CH, Wennberg DE, Meara E, et al. Spending differences associated with the Medicare Physician Group Practice Demonstration. JAMA 2012;308(10):1015–1023. 31. Rohrer JE, Garrison G, Oberhelman SS, Meunier MR. Epidemiology of polypharmacy among family medicine patients at hospital discharge. J Prim Care Community Health 2013;4(2):101–105. 32. National Committee for Quality Assurance. Patient-centered medical home (PCMH) draft standards updated. Washington, DC: National COmmittee for Quality Assurance, 2013. 33. Williams MD, Shah ND, Wagie AE, Wood DL, Frye MA. Direct costs of bipolar disorder versus other chronic conditions: an employer-based health plan analysis. Psychiatr Serv 2011;62(9):1073–1078. 34. Rohrer JE, Angstman KB, Pecina JL. Application of a case-control design to the analysis of drop-outs from integrated behavioural health care. Qual Prim Care 2013; 21(1):33–37.
Address correspondence to: Kurt B. Angstman, MS, MD Department of Family Medicine Mayo Clinic 200 First Street SW Rochester, MN 55905 E-mail: [email protected]
Impact of Symptom Remission on Outpatient Visits in Depressed Primary Care Patients Treated with Collaborative Care Management and Usual Care Matthew R. Meunier, MD,1 Kurt B. Angstman, MS, MD,1 Kathy L. MacLaughlin, MD,1 Sara S. Oberhelman, MD,1 James E. Rohrer, PhD,1 David J. Katzelnick, MD,2 and Marc R. Matthews, MD1
Abstract
Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status ( > 8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460–0.805, P < 0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655–6.548, P < 0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. (Population Health Management 2014;17:180–184)
Introduction
D
epression contributes to significant morbidity in the US population, with 8% of persons aged 12 years or older reporting depressive symptoms within the last 2 weeks.1 Depression has a significant economic impact and is associated with increased absenteeism and decreased work productivity.2 Likewise, depression contributes to significant health care utilization, serving as the primary diagnosis of 7.9 million ambulatory medical visits annually.3 The Institute for Healthcare Improvement (IHI) triple aim states that health care reform should focus on improving patient outcomes, improving the experience of health care, and decreasing the total cost of care.4 Thus, changes in practice should consider improvements in clinical outcomes as well as decreased overall health care utilization as mechanisms to control health care costs. Studies have shown that collabo1 2
rative care management (CCM) has been effective in the treatment of depression by decreasing depression symptomatology.5–8 CCM also has been demonstrated to improve work-related outcomes (absenteeism and presenteeism) in primary care patients with depression.9 Multiple studies have demonstrated increased health care utilization for individuals with mental health disorders. In a 1996 study of health maintenance organization (HMO) patients who were high utilizers (based on medical costs), those diagnosed with depression were found to accrue greater costs than those without a depression diagnosis when controlling for medical comorbidities.10 In a US study of 3 HMO sites that identified high utilizers of outpatient health care (defined by greater than 6 ambulatory visits in each of the previous 2 years), 20% of the high utilizers were found to have current major depression or major depression in partial remission.11 After controlling for comorbidities, the
Department of Family Medicine, Mayo Clinic, Rochester, Minnesota. Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.
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IMPROVEMENT IN OUTPATIENT VISITS BY DEPRESSED PATIENTS
study found significantly more ambulatory office visits, hospitalized days, and percentage of individuals hospitalized for participants with current depression compared to those with past or no history of depression. In a 2009 study of depressed veterans, those with post-traumatic stress disorder (PTSD) and depression demonstrated significantly more outpatient utilization than those who only had depression.12 Although outcomes were not delineated, the group with PTSD had more severe depression symptoms and other comorbidities. In addition, a self-reported patient survey study of urban family medicine practices found a positive association between mental health conditions and increased utilization of health care services.13 The authors’ prior studies of primary care patients in CCM also have shown that those patients who have increased depression severity and other comorbidities tend to have worse clinical outcomes.14–16 Previous studies have demonstrated that depression treatment makes a positive impact on health care costs and outpatient utilization. A review of 9 studies in Washington State, including 1814 patients meeting criteria for depression, found mean health service costs 6 months after treatment to be significantly less for those achieving remission ($2012) compared to persistent depression ($3094, P < 0.001) or partial remission ($2571, P = 0.007).17 Of note, these studies utilized classic depression treatment strategies with no CCM. As the authors have noted in a prior study, those patients whose depression improved to remission while in CCM had decreased odds of outlier status for outpatient utilization at 6 months (defined as > 8 visits) and 12 months (defined as > 12 visits) compared to those who were not in remission. This was demonstrated while controlling for baseline severity of depression, clinical diagnosis, anxiety symptoms, and prior utilization patterns.18 Although CCM has been shown to be effective in the treatment of depression and that achieving depression remission is correlated with decreased outpatient utilization, some studies have demonstrated increased short-term costs after implementation of CCM. A randomized controlled study of 407 patients with depression demonstrated an increase in total medical costs 12 months after enrollment in a CCM program compared to usual care (UC).19 However, a more recent randomized controlled study of 551 patients diagnosed with major depressive disorder demonstrated a long-term cost reduction with CCM compared to UC over 4 years.20 The increase in short-term cost is thought to be related to patient ‘‘activation,’’ or increased patient engagement with treatment.20,21 In the present study, the authors compared outpatient visit counts of patients with depression in CCM to patients with depression receiving UC while controlling for comorbidities and prior outpatient visit patterns. Based on the authors’ prior results that clinical remission was associated with fewer outpatient visits at 6 and 12 months in patients enrolled in CCM,18 their hypothesis was that patients with poor depression outcomes at 6 months would have increased outpatient visit counts, regardless of treatment type. Methods
Primary care patients from 4 clinics in a large integrated practice (*100,000 adult patients) in Rochester, Minnesota
181
comprised the study group. Those who were diagnosed with major depressive disorder or dysthymia from March 1, 2008 through December 31, 2011, had a Patient Health Questionnaire (PHQ-9) 22 with a score of ‡ 10, and had a complete set of study data were included. The PHQ-9 is a 9-item patient assessment tool that scores each item from 0 to 3. A PHQ-9 score of < 5 is classified as asymptomatic; 5–9 as mild depressive symptoms; 10–14 as moderate depressive symptoms; 15–19 as moderately severe; and ‡ 20 as severe symptoms of depression. The study cohort included 1733 patients. Treatment was by UC with the patient’s primary care provider (PCP) or enrollment in CCM. The only exclusionary criterion was a clinical diagnosis of bipolar disorder. Patients in the UC arm were treated (medical and/or therapeutic) and had follow-up as directed by their PCP. For those enrolled in CCM, a registered nurse care manager reviewed the patient with the supervising psychiatrist, who met with the care managers on a weekly basis. Recommendations regarding therapeutic changes were communicated to the patient’s PCP. All treatment decisions were the responsibility of the PCP. Care manager to patient contact varied based on clinical need. Full details of the development and implementation of this study’s CCM have been described previously.21,23,24 The dependent variable for this study was outlier status ( > 80th percentile) for the number of outpatient visits at 6 months. Outpatient visits included those for all concerns, not just behavioral health visits. The independent demographic variables were age, sex, race, and marital status. The clinical predictor variables were baseline PHQ-9, clinical diagnosis, and remission status at 6 months (PHQ-9 < 5). Prior studies in the authors’ institution have demonstrated that outpatient visits were impacted by the individual patient’s prior visit counts.25–29 In order to control for this, the number of outpatient visits (primary, secondary, or tertiary care) for the 6 months prior to enrollment also was measured. The presence of high-risk clinical comorbidities also was recorded, as defined by Colla et al in 2012.30 A diagnosis of diabetes, cancer, chronic obstructive lung disease, dementia, or coronary artery disease was determined by screening of the electronic medical record. Following Rohrer et al, the number of comorbidities was categorized as none, 1, or ‡ 2.31 Categorical data were analyzed with chi-square testing while Mann-Whitney testing was utilized for statistical analysis of the continuous variables (because of non-normal distribution). Multiple logistic regression modeling for outpatient visit outlier status was performed while retaining all independent variables studied. Calculations were performed on MedCalc software ( < www.medcalc.org > , version 12.3.0.0). This study was reviewed and approved by the authors’ institutional review board. Results
Of the 1733 patients included in the study, 819 (47.3%) were in remission at 6 months and 914 (52.7%) were not (Table 1). At baseline, the remission group was slightly older, more likely married, with a diagnosis of first episode of major depression of moderate severity. The remission group had fewer outpatient visits compared to the group that
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Table 1. Characteristics of Primary Care Patients Diagnosed with Depression with or without Remission after Six Months, by Variable
Age Median years (range) Sex % female (N) Marital Status % married (N) Race % white (N) Clinical Diagnosis First episode of depression Recurrent depression Dysthymia Depression severity Moderate Moderately severe Severe Comorbidities None One Two or more Outpatient visit six months pre diagnosis: Median (range) Outpatient visit outlier ( > 6 visits) six months pre diagnosis: % outlier (N) Enrollment into CCM % enrolled (N) Outpatient visit six months post diagnosis: Median (range) Outpatient visit outlier ( > 8 visits) six months post diagnosis
PHQ-9 < 5 at six months (N = 819)
PHQ-9 ‡ 5 at six months (N = 914)
44.0 (18.0–89.6)
42.5 (18.0–92.3)
0.047
75.0% (614)
75.2% (687)
0.97
57.9% (474)
49.8% (455)
< 0.01
95.6% (783)
93.3% (853)
0.05
55.4% (454) 36.4% (298) 8.2% (67)
44.6% (408) 43.8% (400) 11.9% (106)
< 0.01
53.6% (439) 32.7% (268) 13.7% (112)
40.6% (371) 37.1% (339) 22.3% (204)
< 0.01
65.4% (536) 24.1% (197) 10.5% (86) 3.3 (1–20) 11.5% (94)
59.7% (546) 26.1% (239) 14.1% (129) 4.3 (1–32) 21.4% (196)
0.02 < 0.01 < 0.01
87.8% (719)
72.4% (662)
< 0.01
4.8 (1–27) 12.7% (104)
6.5 (1–42) 25.3% (231)
< 0.01 < 0.01
P value
PHQ-9, Patient Health Questionnaire; CCM, Collaborative Care Management.
was not in remission, and were less likely to be a prior outpatient visit outlier( > 6 visits) for the 6 months prior to diagnosis. For the 6 months after diagnosis, the remission group demonstrated a significantly lower number of outpatient
visits compared to those patients not in remission. Outpatient visit outlier status was defined as > 80th percentile ( > 8 visits) for the 6 months following diagnosis. Patients in remission were approximately 50% as likely to be an outlier as those who were not in remission (Table 1).
FIG. 1. Multiple regression model for odds ratio of outpatient visit outlier status ( > 8 visits) 6 months after diagnosis of depression, by variable. Multiple regression modeling with all other variables, controlling for age, sex, race, marital status, clinical diagnosis, medical comorbidity, enrollment into collaborative care management versus usual care, and clinical location (to control for site-to-site variability in outcomes). Model overall fit with null model - 2 log likelihood of 1701.742 (P < 0.0001). PHQ-9, Patient Health Questionnaire.
IMPROVEMENT IN OUTPATIENT VISITS BY DEPRESSED PATIENTS
Figure 1 demonstrates the multiple logistic regression analysis for outpatient visit outlier status ( > 8 visits) at 6 months after diagnosis. Severe depression (odds ratio [OR] 1.775, confidence interval (CI) 1.259–2.503, P < 0.01) and increased pre-diagnosis outpatient utilization outlier status (OR 4.892, CI 3.655–6.548, P < 0.01) were independent predictors for outpatient visit outlier status. In this model, remission at 6 months demonstrated an OR for outpatient visit outlier status of 0.609 (CI 0.461–0.805, P < 0.01), while controlling for age, sex, marital status, clinical diagnosis, enrollment into CCM versus UC, and clinical location (for site-to-site variability in outcomes). The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). Discussion
In patients diagnosed with depression, the number of allcause outpatient visits after the diagnosis of depression was significantly impacted by the severity of depression as well as the number of outpatient visits prior to diagnosis. Clinical remission at 6 months, as suggested by the original hypothesis, was associated with lower odds of having more than 8 visits during the 6 months after diagnosis. This finding was demonstrated while controlling for patient comorbidities, depression severity, and clinical diagnosis. It was noted that a simple variable with 3 categories proved to be useful for comorbidity adjustment, as was demonstrated previously in a study of polypharmacy.31 In addition, the authors adjusted for the likelihood to use medical care by including the number of visits in the previous year as a covariate, as was done in their previous work.25–29 This variable reflects both the biomedical need for services and any psychological inclination to seek care. By adjusting for prior use of service, the authors were able to separate out how much depression remission changes use of service above and beyond the normal pattern. This study is validated by its consistency with other studies that demonstrated similar findings. For instance, it was shown in a prior study that achieving remission status in CCM was inversely related to high outpatient visit counts 6 and 12 months after enrollment.18 In the present study, the authors find that this continues to be the case for all patients (CCM or UC) who had a 6-month follow-up PHQ-9 score for their depression. Further integration of behavioral health services continues to be strongly emphasized in Patient-Centered Medical Home standards32 and the results of the present study support early intervention and effective treatment of depression in primary care patients as a mechanism to improve clinical outcomes and decrease allcause outpatient visit utilization. Future studies could examine long-term effects of CCM for depression on outpatient visits, as previous studies have suggested economic benefits beyond this study’s follow-up time period. Future studies of the total health care costs by per member per month (PMPM) in individuals with depression within the CCM program also would be interesting. A 2011 study of PMPM costs for patients with bipolar disorder compared to other chronic conditions found that only those with both diabetes and coronary disease had higher total PMPM costs. Also, patients with depression had higher adjusted PMPM costs for primary care and nonpsychiatric in-
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patient services.33 In addition, further investigation into the effect of patient complexity on outpatient utilization may be made by examining alternative measures or study design. For example, the case-control design can be an efficient approach to studying the outcomes of practice innovations.34 Limitations of this study include the lack of racial and economic (such as health insurance coverage) diversity in the population. Because this study encompassed 1 large, midwestern US medical practice and the implementation of CCM may be different in other organizations, the results may not be generalizable to other clinical environments. However, patients in the present study were treated in several clinical locations, assuring some internal variation in practice styles, attitudes, and other unmeasured variables. An additional limitation could include potential referral bias because this cohort study did not randomize patients into CCM or UC. Also, CCM patients had more consistent depression severity follow-up than UC, which may have produced a bias in patient selection. Conclusions
In primary care patients treated for depression, successful treatment to remission (PHQ-9 score < 5) at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. This holds true even when controlling for the individual patient’s prior outpatient visit counts, health care comorbidities, and enrollment in CCM versus UC. Although this is encouraging for this developing model of care, future studies are encouraged. Acknowledgments
Isaac Johnson, MBA, and Julie Maxson, BA, assisted with abstraction and collection of the data. Author Disclosure Statement
Drs. Meunier, Angstman, MacLaughlin, Oberhelman, Rohrer, Katzelnick, and Matthews declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Angstman has a consulting agreement with Tamber Health; Tamber Health was not involved in study design, data analysis, or manuscript preparation. The other authors declared no conflicts of interest. Departmental funds were used for this study. References
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Address correspondence to: Kurt B. Angstman, MS, MD Department of Family Medicine Mayo Clinic 200 First Street SW Rochester, MN 55905 E-mail: [email protected]
