RESEARCH ARTICLE DISSEMINATION
Volume 2, March 2017
The CFHA Research and Evaluation Committee is pioneering a new member benefit. We have created a subcommittee devoted to sending quarterly updates on research relevant to the mission of CFHA. This will be distributed through the CFHA listserv. Any members who have research that they would like to submit for consideration are welcome to email it to Elizabeth Banks at firstname.lastname@example.org. The following inclusion criteria are used to select research articles and a panel of committee members review the articles and select a few that reflect the clinical, operational, financial, and educational worlds of integrated care. Articles must be empirically based and have strong methodology.
Campbell‐Sills, L., Roy‐Byrne, P. P., Craske, M. G., Bystritsky, A., Sullivan, G., & Stein, M. B. (2016). Improving outcomes for patients with medication‐resistant anxiety: effects of collaborative care with cognitive behavioral therapy. Depression and Anxiety, 33(12), 1099-1106.
BACKGROUND: Many patients with anxiety disorders remain symptomatic after receiving evidence-based treatment, yet research on treatment-resistant anxiety is limited. We evaluated effects of cognitive behavioral therapy (CBT) on outcomes of patients with medication-resistant anxiety disorders using data from the Coordinated Anxiety Learning and Management (CALM) trial.
METHODS: Primary care patients who met study entry criteria (including DSM-IV diagnosis of generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or social anxiety disorder) despite ongoing pharmacotherapy of appropriate type, dose, and duration were classified as medication resistant (n = 227). Logistic regression was used to estimate effects of CALM's CBT program (CALM-CBT; chosen by 104 of 117 medication-resistant patients randomized to CALM) versus usual care (UC; n = 110) on response [≥ 50% reduction of 12-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptom score] and remission (BSI-12 < 6) at 6, 12, and 18 months. Within-group analyses examined outcomes by treatment choice (CBT vs. CBT plus medication management) and CBT dose.
RESULTS: Approximately 58% of medication-resistant CALM-CBT patients responded and 46% remitted during the study. Relative to UC, CALM-CBT was associated with greater response at 6 months (AOR = 3.78, 95% CI 2.02-7.07) and 12 months (AOR = 2.49, 95% CI 1.36-4.58) and remission at 6, 12, and 18 months (AORs = 2.44 to 3.18). Patients in CBT plus medication management fared no better than those in CBT only. Some evidence suggested higher CBT dose produced better outcomes.
CONCLUSIONS: CBT can improve outcomes for patients whose anxiety symptoms are resistant to standard pharmacotherapy.
Keeley, R. D., Brody, D. S., Engel, M., Burke, B. L., Nordstrom, K., Moralez, E., ... & Emsermann, C. (2016). Motivational interviewing improves depression outcome in primary care: A cluster randomized trial. Journal of Consulting and Clinical Psychology, 84(11), 993-1007.
OBJECTIVE: To examine the effects of Motivational Interviewing (MI) conducted by primary care providers on rates of improvement over time for depressive symptoms and remission among low-income patients with newly diagnosed Major Depressive Disorder.
METHOD: Ten care teams were randomized to MI with standard management of depression (MI-SMD; 4 teams, 10 providers, 88 patients) or SMD alone (6 teams, 16 providers, 80 patients). Patients were assessed at 6, 12 and 36 weeks with the Patient Health Questionnaire-9 (PHQ-9). Treatment receipt was ascertained through patient inquiry and electronic records. Audio-recorded index encounters were evaluated for mediators of improved depressive symptoms (providers' MI ability and patient language favoring participating in treatment or other depression related mood-improving behaviors).
RESULTS: In Intention-To-Treat analyses, MI-SMD was associated with a more favorable trajectory of PHQ-9 depressive symptom scores than SMD alone (randomization group × time interaction estimate = 0.13, p = .018). At 36 weeks, MI-SMD was associated with improved depressive symptoms (Cohen's d = 0.41, 95% CI [0.11, 0.72]) and remission rate (Success Rate Difference = 14.53 [1.79, 27.26]) relative to SMD alone. MI-SMD was not associated with a significant group x time interaction for remission, or with increased receipt of antidepressant medication or specialty mental health counseling. The providers' ability to direct clinical discussions toward treating depression, and the patients' language favoring engagement in mood-improving behaviors, mediated the effects of MI-SMD on depressive symptoms (ps < .05).
DISCUSSION: Training providers to frame discussions about depression using MI may improve upon standard management for depression.
Hall, K. S., Harris, L. H., & Dalton, V. K. (2016). Women's preferred sources for primary and mental health care: Implications for reproductive health providers. Women's Health Issues, 27 (2). 196-205.
OBJECTIVE: To describe women's preferences for reproductive health providers as sources of primary and mental health care.
METHODS: This is secondary data analysis of the Women's Health Care Experiences and Preferences Study, an Internet survey conducted in September 2013 of 1,078 women aged 18 to 55 randomly sampled from a U.S. national probability panel. We estimated women's preferred and usual sources of care (reproductive health providers, generalists, other) for various primary care and mental health care services using weighted statistics and multiple logistic regression.
RESULTS: Among women using health care in the past 5 years (n = 981), 88% received primary and/or mental health care, including a routine medical checkup (78%), urgent/acute (48%), chronic disease (27%), depression/anxiety (21%), stress (16%), and intimate partner violence (2%) visits. Of those, reproductive health providers were the source of checkup (14%), urgent/acute (3%), chronic disease (6%), depression/anxiety (6%), stress (11%), and intimate partner violence (3%) services. Preference for specific reproductive health-provided primary/mental health care services ranged from 7% to 20%. Among women having used primary/mental health care services (N = 894), more women (1%-17%) preferred than had received primary/mental health care from reproductive health providers. Nearly one-quarter (22%) identified reproductive health providers as their single most preferred source of care. Contraceptive use was the strongest predictor of preference for reproductive health-provided primary/mental health care (odds ratios range, 2.11-3.30).
CONCLUSIONS: Reproductive health providers are the sole source of health care for a substantial proportion of reproductive-aged women-the same groups at risk for unmet primary and mental health care needs. Findings have implications for reproductive health providers' role in comprehensive women's health care provision and potentially for informing patient-centered, integrated models of care in current health systems.
Resnik, L., Ekerholm, S., Johnson, E.E., Ellison, M.L., & O'Toole, T.P. (2016). Which homeless veterans benefit from a peer mentor and how. Journal of Clinical Psychology, Advanced online edition. doi: 10.1002/jclp.22407.
OBJECTIVE: Veterans Affairs (VA) is expanding peer support. Research is limited on Veterans' perspective on benefits from peer services. We describe homeless Veteran perceptions of value and examine characteristics associated with benefit.
METHOD: From a sample of Veterans in a multisite randomized control trial, we studied addition of peers in VA Primary Care and homeless-oriented primary care clinics. We used qualitative methods to study the perceptions of peer services among a subsample of homeless Veterans. Quantitative methods were used to validate findings in both samples.
RESULTS: Sixty-five percent of the subsample and 83% of the full sample benefited from a peer mentor. Participants who benefited had more peer visits and minutes of intervention (p<.05), were more likely to be minority, and were less likely to have posttraumatic stress disorder.
CONCLUSION: The majority of Veteran participants in this study benefited from receiving peer mentor intervention. African American Veterans were more likely to benefit and Veterans with PTSD were less likely to benefit. Client endorsement of the peer's role influenced outcomes.
Anderson, D. R., Zlateva, I., Coman, E. N., Khatri, K., Tian, T., & Kerns, R. D. (2016). Improving pain care through implementation of the Stepped Care Model at a multisite community health center. Journal of Pain Research, 9, 1021-1029. doi: 10.2147/JPR.S117885
OBJECTIVE: Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center.
METHODS: The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 pre-intervention and 4,385 post-intervention) cared for at Community Health Center, Inc.
RESULTS: Providers' pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing.
CONCLUSIONS: Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.
Krupski, A., West, I. I., Scharf, D. M., Hopfenbeck, J., Andrus, G., Joesch, J. M., & Snowden, M. (2016). Integrating primary care into community mental health centers: impact on utilization and costs of health care. Psychiatric Services, 67(11), 1233-1239.
OBJECTIVE: This evaluation was designed to assess the impact of providing integrated primary and mental health care on utilization and costs for outpatient medical, inpatient hospital, and emergency department treatment among persons with serious mental illness.
METHODS: Two safety-net, community mental health centers that received a Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) grant were the focus of this study. Clinic 1 had a ten-year history of providing integrated services whereas clinic 2 began integrated services with the PBHCI grant. Difference-in-differences (DID) analyses were used to compare individuals enrolled in the PBHCI programs (N=373, clinic 1; N=389, clinic 2) with propensity score-matched comparison groups of equal size at each site by using data obtained from medical records.
RESULTS: Relative to the comparison groups, a higher proportion of PBHCI clients used outpatient medical services at both sites following program enrollment (p<.003, clinic 1; p<.001, clinic 2). At clinic 1, PBHCI was also associated with a reduction in the proportion of clients with an inpatient hospital admission (p=.04) and a trend for a reduction in inpatient hospital costs per member per month of $217.68 (p=.06). Hospital-related cost savings were not observed for PBHCI clients at clinic 2 nor were there significant differences between emergency department use or costs for PBHCI and comparison groups at either clinic.
CONCLUSIONS: Investments in PBHCI can improve access to outpatient medical care for persons with severe mental illness and may also curb hospitalizations and associated costs in more established programs.
Camacho, E. M., Ntais, D., Coventry, P., Bower, P., Lovell, K., Chew-Graham, C., ... & Davies, L. M. (2016). Long-term cost-effectiveness of collaborative care (vs usual care) for people with depression and comorbid diabetes or cardiovascular disease: a Markov model informed by the COINCIDE randomised controlled trial. BMJ Open, 6(10), 1-11. doi: http://dx.doi.org/10.1136/bmjopen-2016-012514
OBJECTIVES: To evaluate the long-term cost-effectiveness of collaborative care (vs usual care) for treating depression in patients with diabetes and/or coronary heart disease (CHD).
METHODS: 387 participants completed baseline assessment (collaborative care: 191; usual care: 196) and full or partial 4-month follow-up data were captured for 350 (collaborative care: 170; usual care: 180). 62% of participants were male, 14% were non-white. Participants were aged ≥18 years, listed on a Quality and Outcomes Framework register for CHD and/or type 1 or 2 diabetes mellitus, with persistent depressive symptoms. Collaborative care consisted of evidence-based low-intensity psychological treatments, delivered over 3 months and case management by a practice nurse and a Psychological Well Being Practitioner. As planned, the primary measure of cost-effectiveness was the incremental cost-effectiveness ratio (cost per quality-adjusted life year (QALY)).
RESULTS: The mean cost per participant of collaborative care was £317 (95% CI 284 to 350). Over 24 months, it was estimated that collaborative care was associated with greater healthcare usage costs (net cost £674 (95% CI -30 953 to 38 853)) and QALYs (net QALY gain 0.04 (95% CI -0.46 to 0.54)) than usual care, resulting in a cost per QALY gained of £16 123, and a likelihood of being cost-effective of 0.54 (willingness to pay threshold of £20 000).
CONCLUSIONS: Collaborative care is a potentially cost-effective long-term treatment for depression in patients with comorbid physical and mental illness. The estimated cost per QALY gained was below the threshold recommended by English decision-makers. Further, long-term primary research is needed to address uncertainty associated with estimates of cost-effectiveness.