Focus on Depression

Introduction

Depression is a significant medical condition requiring care over the long term. Important advances in the management of depression have been made, including the increased availability of useful screening tools and more effective treatments. Still, depression continues to impose significant personal, social, and financial burdens. It is a serious and prevalent chronic disease, equivalent in its impact on health to such conditions as asthma and diabetes.

Numerous randomized controlled clinical studies have demonstrated the effectiveness of both pharmacologic and psychotherapeutic interventions for the management of depression. In addition, many studies assessing the management of depression have demonstrated substantial and sustained improvements in both clinical and economic outcomes through systematic screening and use of effective interventions that are now widely available. However, these treatments and interventions must be both implemented and sustained by health care systems and practitioners. Although primary care physicians are usually the first point of contact for patients with depression, there are still gaps in the expertise, experience, and time available in many primary care practices to adequately identify and assess behavioral issues or to initiate and maintain the best treatment approaches on the longitudinal basis. Research has shown that successful screening, diagnosis, and management of patients with depression is best achieved through a multifaceted approach, with use of standardized screening and assessment tools, and in most cases a combination of medication and counseling with close ongoing cooperation between primary care and mental health professionals. Moreover, the capacity to sustain successful diagnosis and treatment approaches often include integration of clinical and economic systems at multiple levels, and engagement of multiple stakeholders including patients, providers, practices, health plans, and purchasers.

Many of the opportunities for improvement in the treatment of depression arise from a need for integration between physical and behavioral health care, and a need to remove the stigma related to a diagnosis of depression or other behavioral illnesses. Challenges facing the improved treatment of depression range from limited insurance coverage for mental and addictive disorders to a lack of communication between primary care physicians and psychiatrists. It is vital that we address these challenges to improving care for persons with depression. A critical first step is to assist primary care physicians in using the most efficient and effective approaches to diagnosis and care for patients with depression. One proven means of fostering enhanced physician practice is through interventions in the form of quality improvement activities that focus on system changes. These activities can become models for improvement of the overall health care of patients with depression, which can be implemented at the health plan, group practice, or individual office level.

Currently, many health care organizations do not foster the programs and system changes that would assist physicians in primary care to ensure success in the identification and ongoing care of patients with depression. This edition of Quality Profiles is a tool that health care organizations and behavioral health care providers can utilize to select and guide implementation of interventions and to review and redefine systems that can lead to optimal management of patients with depression. It is also a celebration of the successes that have been achieved, as well as a beacon for those to come. Implementation of local adaptation of these approaches will help move mental health into the mainstream of medicine. More importantly, it will greatly benefit individuals with depression, their families, and society.

The National Committee for Quality Assurance (NCQA) and Pfizer are pleased to provide the second installment of Quality Profiles: The Leadership Series. This series of publications is intended to help health care organizations move further along the quality continuum toward optimal patient care.

NCQA’s Health Plan Employer Data and Information Set (HEDIS^®) has driven substantial improvements in the delivery of health care by leveraging the power of performance measurement and accountability. However, far too many people still suffer and die because the health care system has failed to consistently deliver care that we know to be effective.

The key to further progress, which must be anchored by the health care industry, is a fundamental paradigm shift from tertiary to secondary and primary prevention of disease. Health plans, disease management organizations, and medical groups should continue to use their unique access to key health care stakeholders (e.g., practitioners, patients, employers) to lead the transformation of health care into a coordinated, patient-centered, evidence-based system.

The initial publication of Quality Profiles: The Leadership Series marked a new direction for the Quality Profiles program. In contrast to earlier publications, which compiled model QIAs across different clinical areas, each edition of Quality Profiles: The Leadership Series examines an important clinical issue in detail. As a result, the implications of quality improvement (QI), the rationale for chance, and the barriers to improved quality can be placed in the context of an expanded discussion of the personal, social, and economic impact of the disease conditions under review. The overall goal of this series is to provide employers and health care organizations with a rich selection of QI resources, illustrated by case studies, which can be used as the foundation for new program development.

This installment of Quality Profiles: The Leadership Series addresses the management of depression, which has a profound direct impact on productivity and health care cost, as well as substantial effects on other disease states. Individual QIA profiles are integrated into the clinical discussion of depression to better highlight their specific contributions to disease management.

In Quality Profiles: Focus on Depression, we have provided comprehensive descriptions of two QIAs, along with condensed summaries of two additional activities. As in previous publications, we have used a presentation format designed to make the profiles easy to understand, adapt, and implement, comprising the following information:

• Selecting the activity: Analysis of a quality issue and its effect on the covered population; identification of activity and anticipated impact.
• Setting activity parameters: Establishment of QIA methods defining the population, specifying data sources and collection, identifying goals and barriers)
• Implementing the initiative: Review of specific interventions and outcomes; analysis of interventions with respect to QIA goals and barriers
• Epilogue: Analysis of overall QIA organizational impact, sustainability, and future directions

Each QIA profile also incorporates “Quality Lessons,” a summary of key points and observations about the QIA, and “Quality Options,” examples of other companies’ QIAs that address similar issues in comparable populations. These are intended to emphasize the important conclusions from the implementation of the QIA under review and to provide plan managers and employers with the tools to build programs with similar goals. Finally, specific tools and templates used for implementation, such as surveys, screening tools, treatment guidelines, and newsletters, are presented as appendices.

METHODOLOGY

Quality improvement activities relating to depression management from health plans and managed behavioral healthcare organizations (MBHOs) that received NCQA Accreditation between May 2000 and January 2004 were considered for inclusion in Quality Profiles: Focus on Depression. Eligible QIAs were screened in a two-step selection process. The first phase evaluated QIAs against the following criteria:

• Accreditation status: The organization must have attained a status of Excellent, Commendable, or Accredited; or, in the case of MBHOs, Full Accreditation
• Meaningful improvement: NCQA’s Review Oversight Committee must have determined that the QIA under review demonstrated meaningful improvement (with regard to better outcomes for the affected population and/or impact on high-volume, high-risk, or high-cost conditions) that was directly attributable to the strength, quality, and duration of the activity
• Health care area: The QIA must have addressed a quality issue specific to the management of depression or anxiety

The second phase of the selection process involved review by specially trained, independent consultants of QIAs meeting the above criteria, on the basis of the following: :

• Nature of the QIA
• Health impact of the QIA
• Evidence of QIA sustainability

This two-phase process yielded the four highest-scoring initiatives. The organizations that developed these plans were then interviewed to gather additional information on QIA methodology, barriers to the initiative, adjustments to interventions (if any), and progress and results of the initiative since the original submission. This information was integrated into the original submission to develop the reviews included in Quality Profiles: Focus on Depression. Note that the quantitative graphs and tables included in the reviews are based solely on information and data that was reviewed or validated during the NCQA Accreditation process and was subject to the full two-phase selection process.

NCQA AND PFIZER: Quality Profiles Partnership

Quality Profiles: The Leadership Series has been developed to provide a useful resource for organizations undertaking QI initiatives by providing both a clinical rationale for improvement and examples of challenges and successes involved in specific QIA implementation. The series is the product of a partnership between two organizations that share a deep commitment to advancing quality in health care.

NCQA, which for over a decade has strived for improvements in health care delivery via accreditation, certification, and recognition programs and the development of HEDIS^® measures

and

Pfizer Inc, which works with health plans, medical groups, and other organizations to facilitate clinical excellence.

Pfizer has also sponsored the publication of this volume by NCQA in electronic and print format to provide examples of successful QI activities for other organizations.

Contributing Health Care Organizations

Quality Profiles Peer Reviewers

Patricia Beauvais
Mark Bloomberg, MD
Erick Davis, MD
Marie Howson, MBA, RN
Patricia Meyer, RN, BS

NCQA Staff Members

Kathleen C. Mudd, MBA, RN
Vice President for Product Delivery

L. Gregory Pawlson, MD, MPH
Executive Vice President

Barry A. Scholl
Vice President for Communications and Marketing

Elizabeth Usher
Director, Customer Relations

Pfizer Staff Members

Benjamin Eng, MD, MA
Senior Medical Director, Group Leader
Customer and Market Development/Medical

Jeff Henderson
Senior Director, National Accounts, HMDS

Lindsay S. Rosen
Senior Manager, Quality Improvement
Initiatives and Customer Collaborations Team
Payer/Provider Management Group

David Schaaf, MD
Medical Director
Customer and Market Development/Medical


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