Nine years is a long time to expect effects from QI for depression in primary care, but we have been surprised previously by observed direct and indirect long-term consequences of PIC interventions, and have documented the high magnitude of cumulative benefits for minorities across the follow-up years (Wells et al. 2007
). At the 9-year time-point, it is likely that the intervention effects reflect both consequences of initial exposure, such as patient learning or changes in attitudes, and of terminating the interventions or clients losing access to facilitated care through changing providers. PIC was not designed to look at the consequences of program termination versus continuation, so we cannot tease out exposure and termination effects except by speculating based on the particular pattern of results.
For “main” outcomes (MHI5 and unmet need for appropriate care), we found little evidence for overall intervention status effects (across all three intervention conditions) at 9 years, confirming with more complete data partial findings on mental health outcomes in recent studies (Wells et al. 2007
; Sherbourne et al. 2008
). However, we found that QI-meds relative to UC reduced mental health outcome at 9 years, a finding consistent with the similar observed effect (overall and among minorities) on reduced coping with stress at 9 years. These results could have several explanations. One could be a shift away from psychological coping strategies due to the emphasis during the intervention on medications—at 9 years we also found continuing higher rates of antidepressant medication use among whites under QI-Meds than UC. Another explanation could be that the distress and coping difficulty reflects the consequences of changes in access to treatments previously found to be valuable. Among whites, for example, it appears that there was a perception for those in the intervention clinics, particularly QI-Meds, of difficulties later with insurance coverage and finding providers. Lower rates of medical visits among whites under QI-Meds compared with UC could similarly reflect an access problem.
Given that early on the interventions improved access to treatments, it is difficult to know what may have created the perceptions and experiences of barriers at very long-term follow-up. One possibility could be an upward shift in expectations for ease of getting appropriate care, from having had a prior experience with QI that was not met when facing new health care systems. Alternatively, subjects may actually have had access difficulties, or were concerned about them, as a result of having had prior care. For example, a documented history of depression treatment could lead to being excluded from insurance coverage for depression treatment at the time of a subsequent job change under some employment or insurance policies (i.e., preexisting condition exclusion). By encouraging patients to consider new treatments that they might not otherwise have accepted, some patients could have affected their future eligibility, or could fear this consequence, which might also reduce their coping alternatives and cause psychological distress for persons in high need of services. Again, this is speculation based on an unusual pattern of results. We note that we cannot tie up this possible explanation tightly based on the data for two reasons. First, we did not obtain information on the occurrence of these specific insurance limitations. Second, different findings making up this story, were observed across different specific intervention and cultural groups in the study, rather than consistently across specific groups. Further, owing to data limitations such as not having data on preexisting condition exclusions, we cannot model this specific explanation through a more formal structural analytic approach. We do hope to explore this and other possible explanations for the long-term outcome findings subsequently through an extensive qualitative data set developed as part of this study, which is not yet completed.
Among underserved minorities, we found that both interventions relative to UC reduced the likelihood of respondents thinking they could handle their problem on their own and reduced perceived barriers to care due to racial discrimination. From the perspective of origins of health care disparities (Smedley and Nelson 2003
), this is an important outcome in its own right, that is, the interventions helped underserved minorities overcome culturally specific barriers, even though that did not result in reduced unmet need or greater access to treatments at 9 years, perhaps because of greater service availability problems for underserved minority groups. These are also issues for future studies including exploration of the PIC qualitative data.
There are important limitations to these findings, including use of particular health care systems in specific U.S. sites; moderate response rates; studying only certain minority groups; reliance on self-report measures although interviewers were blinded to intervention status; and limited sample sizes and power/precision for some comparisons, requiring grouping of African Americans and Latinos.
Overall we can conclude that the main, intended intervention effects are over by 9 years, after yielding many years of benefit especially for minorities; yet there is a picture at 9 years suggesting new unintended consequences for particular interventions or cultural groups, ranging from perceived barriers, difficulty coping, increased distress, lower access—but also lowering of attitudinal barriers for minorities. These findings could offer clues for needed longer-term intervention supports or system or policy changes that we hope may emerge from new studies and in-depth examination of qualitative data.