These results offer a promising direction for improving care and outcomes for depressed, ethnic minority primary care patients. We found that when managed care practices implemented a feasible quality improvement program following their own practical goals and largely within their existing resources, they were able to improve by 8 to 20 percentage points the rate of appropriate care for depression. The Latino, African American, and white participants all improved rates of receiving appropriate care as a result of the intervention, to a roughly similar degree. These gains were made in spite of the modest extent of modification of the basic intervention design to accommodate ethnic minority patients. The major modifications were: including experts in treating ethnic minorities among the intervention team, making information relevant to treatment of ethnic minorities available for providers, and translating patient materials into Spanish.
The intervention specifically improved clinical outcomes among the ethnic minorities. Since the minorities were at substantially greater risk of receiving less appropriate care and having poor outcomes (especially Latinos) without the intervention, this led to a reduction in health disparity by ethnic status among depressed, minority patients. In our knowledge, this is the first evidence that a general quality improvement program is effective for diverse medical patients.
The QI intervention improved clinical outcomes among ethnic minorities but not among whites. This could mean that the populations differ, such that the minorities include a higher proportion of initial treatment responders who have not already been treated and improved. Consistent with this explanation, we found in exploratory analyses that the intervention effects for all ethnic groups were qualitatively stronger among persons not previously receiving care, compared to those previously receiving care. An alternative explanation would be that factors such as social or family support or diet-related metabolic responsiveness to care differed between the ethnic minorities and whites resulting in improved responsiveness to care in the ethnic minority samples.
In contrast, the QI intervention increased employment for white patients, although we did not have the precision to conclude that the response, like the descriptive results, was weaker for minorities. Thus, both groups benefit, but we have the most confidence that the minorities did so clinically while the whites did so functionally through employment. The relationship between depression, its treatment, and employment is poorly understood and it is interesting to note that improvement in one outcome is possible without improvement in the other. Because the whites were more likely to have prior treatment, they may have already improved clinically and the intervention provided further improvement leading to better employment; or the whites may have had better opportunities to respond to any improvement through increasing employment. It is possible that a more sustained intervention or ethnic-focused adaptation would be needed to accomplish a similar employment benefit among minorities. This study raises new questions about the effects of medical interventions on multiple components of need and disparities.
Several limitations should be noted in this study. First, there was sample loss during enrollment, a factor that could result in under- or overreport of the interventions effects. All measures are self-report, including race or ethnicity. The African American sample was small; generalizations cannot be made to sites serving large numbers of African American patients or to sites with less diversity. The results suggest there may be ethnic differences in outcomes in response to the interventions. The clinical outcomes were primarily among minorities whereas the employment outcomes were primarily among the white patients. These results were not anticipated and, therefore, cannot be clearly interpreted. One possibility is that changes in clinical outcomes associated with QI interventions would only be effective in ethnically diverse settings. However, we would caution against interpreting these findings to indicate that clinical improvements will not be found in white patients when organizations implement these QI interventions. Factors such as prior experience with care may have been associated with ethnic status and could account for the differential response. If this is true, underserved whites, such as those in rural areas, may also show differential clinical response to care. These ethnic findings clearly need replication. Finally, all changes noted as a result of the interventions should be attributed to the QI interventions rather than to depression treatments.
These results suggest that practice-initiated quality improvement programs may offer an approach to improve quality of care equitably with respect to ethnic groups, without increasing disparities in health outcomes, a risk that is common for diffusion of social innovations (Rogers 1996
). Moreover, this same approach has the potential to reduce disparities in health-specific outcomes. In this respect, medicine may have a feasible strategy to overcoming some disparities within the context of managed care. This is encouraging news because it implies that some progress on reducing disparities could proceed without much larger changes in public policy. A similar level of implementation and outcome improvement seems feasible for similar practices, which span private and public, rural and urban, network and staff/group practices. Although the intervention in this study provided improved care for the minority patients, minority patients continued to receive lower quality care and incurred poorer health outcomes than did white patients. Even with improved opportunities for care, minorities may face substantial barriers, such as need for child care, demanding work environments, lack of Spanish-speaking providers, failure to include families in treatment decisions, and so on. Despite the promise of quality improvement interventions, development of interventions specifically to improve care for depressed minorities is needed. For example, strategies to educate and activate minority communities regarding depression care may be necessary to close the gap in care for these populations. Similarly, given the substantial number of patients who were depressed at one year, improvements beyond those achieved via this modest intervention are needed for all depressed medical patients. Nonetheless, these results offer an important initial step in improving the quality of health care for our nation's growing ethnic minority community.