Psychiatry and Primary CareDesign and implementation of the Telemedicine-Enhanced Antidepressant Management Study
Introduction
Intervention studies have demonstrated the effectiveness of collaborative care models designed to improve depression outcomes in primary care settings [1], [2], [3], [4], [5], [6], [7], [8], [9]. Collaborative care involves primary care providers (PCPs) working in conjunction with a depression care team comprising nonphysicians (e.g., nurses, pharmacists) and mental health specialists (e.g., psychologists, psychiatrists). The demonstrated cost-effectiveness of collaborative care has led to implementation efforts to promote adoption in routine practice [10], [11], [12].
Interventions designed and tested in large urban clinics are not necessarily applicable in small rural practices [13]. Implementing collaborative care in small rural primary care practices presents unique challenges because it is typically not feasible to employ mental health specialists on site. In fact, only 25% of primary care practices nationwide have on-site mental health specialists [14]. Although 21% of the U.S. population lives in rural areas according to the 2000 Census, only one previous study of collaborative care (QuEST) recruited a substantial number of rural primary care practices as study sites [4]. In the QuEST study, on-site primary care nurses were trained to provide depression care management, and psychiatrists were available for telephone consults [4]. The QuEST collaborative care model design has the advantage that nurse care managers have established therapeutic relationships with their patients, have access to on-site paper medical records and have open communication channels with PCPs. However, the QuEST design has the potential disadvantage that nurse care managers cannot specialize in depression treatment, lack meaningful access to mental health supervision/consultation and must incorporate care management activities into busy routines with competing demands.
The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to adapt the collaborative care model for small rural primary care practices using telemedicine technologies without altering the nature/content of the collaborative care model itself. Telemedicine (e.g., telephone, interactive video, electronic medical records, and internet) facilitates communication between a centrally located depression care team and PCPs practicing in geographically diverse clinic locations. We chose to conduct this first telemedicine-based collaborative care trial in rural areas served by the Veterans Administration (VA) healthcare system. The VA is a particularly suitable setting for telemedicine-based interventions because of the widespread standardized use of interactive video technology and electronic medical records [e.g., Computerized Patient Record System (CPRS)].
The objectives of the TEAM study are to compare processes and outcomes among patients with depression treated at intervention and matched control sites, and to determine whether the intervention was cost-effective in routine practice. The purpose of this paper is to describe the design of the TEAM study, including (1) methods used to enroll study participants, (2) usual depression care in the VA, (3) the TEAM intervention and (4) methods for evaluating the effectiveness/cost-effectiveness of the intervention. In addition, we describe the socioeconomic and clinical characteristics of the study participants and discuss our rational for the study design and the resulting strengths and weaknesses.
Section snippets
Study sites
Veterans Administration is organized into 21 Veterans Integrated Service Networks (VISNs). TEAM was conducted in VISN 16, one of the largest and most rural of the networks. The study was conducted in community-based outpatient clinics (CBOCs), of which there are 674 currently in operation across the nation and 34 in VISN 16. Community-based outpatient clinics are satellite facilities, usually located a long distance from their “parent” VA Medical Centers (VAMC) that maintain administrative
Results
The socioeconomic and clinical characteristics of the study participants are provided in Table 3. Eighty-two percent met criteria for major depressive disorder. Of particular note is the extremely high level of disease burden. Virtually, all (99.2%) of the study participants reported having at least one serious chronic health condition, and the average number was 5.5 [e.g., diabetes (32.9%), heart disease (32.2%), lung disease (20.3%), stroke (18.2%) and cancer (12.7%)]. SF12V physical health
Conclusions
The strengths and weaknesses of the TEAM study design were impacted by many decisions and tradeoffs. The first decision concerned the unit of randomization. We chose not to randomize at the patient level because of potential contamination among providers treating both intervention and usual care patients. We chose not to randomize at the provider level because of potential turnover and contamination across providers. By randomizing matched clinics, we avoid potential contamination problems. The
Acknowledgments
This research was supported by VA IIR 00-078-3 grant to Dr. Fortney, VA NPI-01-006-1 grant to Dr. Pyne, the VA HSR&D Center for Mental Health and Outcomes Research and the VA South Central Mental Illness Research Education and Clinical Center. Drs. Pyne and Edlund were supported by VA HSR&D Research Career Awards. Dr. Mittal was supported by VISN 16 South Central Network Research Career Development Grant Program. The authors would like to thank Dr. Kathryn Rost, Dr. Lisa Rubenstein, Dr. Greg
References (38)
- et al.
The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients
Gen Hosp Psychiatry
(2004) - et al.
Quality improvement in chronic illness care: a collaborative approach
Joint Comm J Qual Improv
(2001) - et al.
A three-component model for reengineering systems for the treatment of depression in primary care
Psychosomatics
(2002) - et al.
The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI
Eur Psychiatry
(1997) - et al.
The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability
Eur Psychiatry
(1997) - et al.
Associations among family support, family stress, and personal functional health status
J Clin Epidemiol
(1989) - et al.
Quality of life and functional health of primary care patients
J Clin Epidemiol
(1992) - et al.
Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial
Arch Gen Psychiatry
(1999) - et al.
A multifaceted intervention to improve treatment of depression in primary care
Arch Gen Psychiatry
(1996) - et al.
Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care
BMJ
(2000)