Monday, April 21
Grant Miller: Managerial Incentives in Public Service Delivery
Schoenbaum, Michael, J. Unutzer, C. Sherbourne, N.H. Duan, L.V. Rubenstein, J. Miranda, L.S. Meredith, and M.F. Carney. 2001. "Cost-Effectiveness of Practice-Initiated Quality Improvement for Depression - Results of a Randomized Controlled Trial." JAMA-Journal of the American Medical Association, 286(11): 1325-1330.
Context Depression is a leading cause of disability worldwide, but treatment rates in primary care are low. Objective To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment. Design Group-level randomized controlled trial conducted June 1996 to July 1999. Setting Forty-six primary care clinics in 6-community-based managed care organizations. Participants One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression. Interventions Matched practices were randomly assigned to provide usual care (n=443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n=424 patients) or trained local psychotherapists (QI-therapy; n=489). Practices could flexibly implement the interventions, which did not assign type of treatment. Main Outcome Measures Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions. Results Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P=.35) and $485 (13%) in QI-therapy (P=.28); estimated costs per QALY gained were between $15331 and $36467 for QI-meds and $9478 and $21478 for QI-therapy; and patients had 25 (P=.19) and 47 (P=.01) fewer days with depression burden and were employed 17.9 (P=.07) and 20.9 (P=.03) more days during the study period. Conclusions Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.