Our survey results show that few practice system tools were in place for depression in Minnesota clinical practices prior to the start of the DIAMOND Initiative, even among those clinics and medical groups with enough interest in improving depression to volunteer to participate in a major initiative on the topic. Only a small portion of those practice systems that were present were reported to be functioning well. Overall, the Depression-Specific composite scale score was much lower than the CCM composite scale score, suggesting that practice systems for depression care are less well-developed than general chronic disease practice systems.
While the literature on the relation between practice systems and quality of care is still developing, the evidence for this relationship is increasing21–26
. 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 interventions2,3
. 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 nation29,30
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.
We conclude that there is much room for improvement in practice systems for depression care. Such practice systems are needed for clinics to become accredited as medical homes, and it is likely that their implementation will result in much-needed improvements in care for patients with depression.