In previous research conducted by us in 2005, interviews with medical directors and quality improvement coordinators from Minnesota practices about barriers to improving depression care most frequently cited delivery system issues related to screening, diagnosis, follow-up, and education¹¹. Additional surveys of medical groups showed that in fact, with the exception of standardized symptom assessment tools, fewer practice system tools were in place to support depression care (e.g. registries, flow sheets, checklists, practice guidelines, performance feedback, case managers, or reminder systems) compared to other chronic conditions such as diabetes and coronary artery disease¹².

An email was sent to the physician identified as the medical leader at each of the 82 clinic sites participating in the DIAMOND Study in 2008 prior to the start of the initiative. The email requested completion of a questionnaire to evaluate practice systems for depression, and contained a link to an electronic version of the survey. A reminder email was sent up to three times if no response was received. Persistent non-respondents (approximately 30%) then received phone calls from the study manager and principal investigator (LS) to verify that they had received the survey, answer any questions, and encourage response.

The survey used to evaluate and monitor the changes in practice systems was a modification of a questionnaire that had been developed by the National Committee on Quality Assurance (NCQA), called Physician Practice Connections (PPC). This questionnaire was developed by an expert panel to measure the presence and function of chronic disease practice systems within the framework of the Chronic Care Model (CCM) for use in evaluating various pay-for-performance demonstrations. The development process built on an extensive literature review, input from experts and key stakeholders, and multiple pre-testing efforts with physician practices^17–19. The PPC addresses five of the six domains of the CCM: health systems (sometimes designated health care organization), delivery system redesign, clinical information systems, decision support, and self-management support.²⁰ This instrument was subsequently modified to become the basis for the NCQA recognition program for patient-centered medical homes nationally (as the PPC-PCMH).

In order to modify the original PPC for this study, 53 (out of 98) individual items relevant to depression care or the CCM were selected that were not specific for various other chronic conditions (and in some cases slightly modified only by adding the term depression to the current wording of the question to focus on depression as opposed to all chronic conditions). Nine other new items were added to cover specific practice systems required for the DIAMOND initiative, as well as a previously tested question asking for the organizational priority for improving depression (on a scale from 1–10). This revised version, called the Physician Practice Connections for Research in Depression (PPC-RD) thus consisted of a total of 63 items and took about 10 minutes to complete. The entire PPC-RD survey is included as an ^appendix (available online).

We classified the items in the PPC-RD survey into three categories: DIAMOND (21 items specific to depression and consistent with the DIAMOND care management approach), non-DIAMOND depression (20 items relevant for depression and the CCM but not specific for DIAMOND), and non-depression CCM (21 items relevant for any chronic condition). A Depression-Specific scale was comprised of the 21 DIAMOND and the 20 non-DIAMOND depression items; this scale did not include items unless they were directly relevant to practice systems for depression care (e.g. items about immunization and a care manager for asthma were not included). A CCM scale was comprised of the 20 non-DIAMOND depression and the 21 non-depression CCM items; this scale did not include practice systems that were highly specific to the DIAMOND intervention (e.g. measuring depression severity monthly, having a care manager for depression). Both scales were scored as the proportion (0-100%) of all items in the scale that were present. Most items asked if practice systems that were present “work well” or “need improvement”, and items reported as needing improvement only received half credit compared to those that worked well. In addition, the Depression-Specific and CCM scales were each subdivided into scores for each of the five domains of the CCM. Items from the original PPC, including those slightly modified to focus on depression, were assigned to the same CCM subscale they were assigned to in the original PPC. New items added to the PPC-RD to measure DIAMOND practice systems were assigned to the CCM subscales based on the judgment of the entire investigator team.

Table 2 displays responses to the 41 Depression-Specific scale items from the PPC-RD survey. Very few practice system tools were rated as present and functioning well for depression care. The majority of clinics did not have performance measurements or quality improvement initiatives for depression care, and these were rated as needing improvement when they were present. The delivery system redesign tools that were most often in place and functioning well for depression care were use of standing orders and medication reviews. Only a few clinics had practice systems for patient appointment reminders, pre-visit planning, and evaluation of alcohol/chemical dependency that were rated as well-functioning for depression care. A small minority of clinics had other key elements of care delivery systems that have been shown to improve depression care: involving non-physician staff, regular measurement of symptom severity, monitoring treatment response and adherence, follow-up of missed appointments, or a care manager. Most clinics did not have tracking systems for depression patients or their care.

A majority of clinics did have a depression care guideline and systems to assure that depression diagnostic codes were used and that treatment was intensified, but most reported that the latter did not function well. Few clinics had a well-functioning practice system for psychiatrists to review care for patients who were failing to improve. Self-management support systems were most often in place for individualized care management plans and treatment goals, and review of clinical measures (e.g. PHQ9 scores). Only rudimentary practice systems were in place to address loss to follow-up, failure to refill anti-depressants, barriers to treatment, relapse prevention or referral to self-management programs.

The composite score for Depression-Specific scale was 24, much lower than the more general CCM scale score of 44 (Table 3). The Depression-Specific subscale scores were also lower for Delivery System Redesign, Clinical Information Systems, and Decision Support. For both Depression-Specific and CCM scales, the highest subscale score was for Decision Support and the lowest for Health Systems. Correlations between the clinic priority for improving depression care and the depression and CCM PPC-RD scales and subscales were low, ranging from 0.02 – 0.19, and non-significant with the exception of the Depression-Specific Decision Support subscale (r=0.29, p=0.008).

While the literature on the relation between practice systems and quality of care is still developing, the evidence for this relationship is increasing^21–26. The CCM was developed based on that concept and its supporting evidence is largely focused on practice systems²⁰. The many randomized trials proving how to improve depression care were essentially tests of depression practice system interventions^2,3. Finally, we have previously shown that scores on the original PPC were correlated with measures of both process and outcome quality for diabetes among 40 medical groups in Minnesota²⁷. Unfortunately, these systems are still infrequently present, even in larger medical groups. In their study of 1,104 medical groups larger than 20 physicians, Casalino et al. demonstrated that even these larger organizations had relatively few practice systems for care management²⁸.

While metropolitan area clinics had somewhat higher scores for some practice systems for chronic disease care, metropolitan clinic location did not confer any advantage in having more practice systems for depression care. The association of small-to-medium size clinics with 3–5 adult primary care physicians with a higher CCM scale score suggests that larger clinics with more providers in Minnesota are not more likely to have advanced practice systems for chronic disease care. However, it is important to keep in mind that individual clinic size does not necessarily correlate with the size of its overall medical group or number of care sites. The inverse association of staffing by RNs with the presence of practice system tools for chronic care and depression care was quite surprising to us. Perhaps clinics relying primarily on medical assistants and licensed practical nurses have a greater need for well-established systems to guide them in the provision of care. Because about 10% of clinics lacked data on this variable, it should be interpreted somewhat cautiously.

In clinics with a fully functional EMR, there was some evidence for modestly higher overall scores on the CCM scale measuring chronic disease practice systems. Not surprisingly, the Clinical Information Systems subscales were associated with the presence of a fully functional EMR. However, given the remarkably high frequency of well-developed EMRs in this sample of clinics, it is noteworthy that presence of an EMR does not insure that other practice systems have been developed to facilitate consistent, high quality depression care.

In previous research in Minnesota medical groups in 2005 that included some but not all of the clinics in the current sample, we found far fewer practice systems for depression care than for other chronic diseases, especially compared to diabetes care for which practice systems are well-developed¹². Qualitative analysis of interviews with medical group leaders showed that barriers to improving depression care included the following factors: low reimbursement, competing demands by payors, internal change, difficulty measuring and diagnosing depression, the time and complexity of depression care, lack of provider and patient willingness to address depression, and problems in access and coordination with mental health care¹¹. Responses to similar questions on the current questionnaire regarding flow-sheets for depression care, adoption of depression practice guidelines, and the presence of care managers for depression showed little change on average over the ensuing 3 years. Although the Health Plan Employer Data and Information Set (HEDIS) benchmarks may not be ideal for measuring depression care, they provide a national standard for comparison. Mean HEDIS rates in 2005 and 2008 for anti-depressant medication continuation at 3 months (61% vs. 63%) and 6 months (45% and 46% ) have changed little for patients with commercial insurance, suggesting that the lack of progress that motivated the current depression initiative in Minnesota is mirrored in the rest of the nation^29,30.

Our study has a number of limitations. By design, our sample over-represents non-metropolitan area clinics. All of the study clinics were from medical groups that were members of ICSI and volunteered for DIAMOND; thus they may not be representative of Minnesota clinics in other ways as well. However, since this sample of clinics had few of the practice systems needed to improve depression care, it seems likely that typical clinics have even fewer. The scales used here have not yet been shown in a longitudinal study to predict better depression care, but ongoing work in the DIAMOND study will provide data to answer this question via periodic reassessment of the PPC-RD in these 82 clinics and measurement of depression care and symptoms in their patients.