Gender patterns in cost effectiveness of quality improvement for depression: Results of a randomized, controlled trial

Background: Little is known about gender differences in the costs and outcomes of primary care quality improvement strategies for depression. Methods: Intent-to-treat analysis of data from a group-level controlled trial, in which matched primary care clinics in the US were randomized to usual care or to one of two interventions designed to increase the rate of effective depression treatment. One intervention facilitated medication management ("QI-Meds") and the other psychotherapy ("QI-Therapy"), but patients and clinicians could choose the type of treatment, or none. The study involved 46 clinics in 6 non-academic, managed care organizations; 181 primary care providers; and 375 male and 981 female patients with current depression. Outcomes are health care costs, quality-adjusted life years (QALY), depression burden, employment, and costs/QALY, over 24 months of follow-up. Results: Relative to usual care, QI-Therapy significantly reduced depression burden and increased employment, for men and women; but QI-Meds significantly reduced depression burden only among women. Average health care costs increased $429 in QI-Meds and $983 in QI-Therapy among men; corresponding cost increases were $424 and $275 for women. The estimated cost per QALY for men ranged between $16,600 and $42,600 under QI-Therapy. For women, estimated costs per QALY were $23,600 or below for QI-Meds and $12,500 or below under QI-Therapy. Limitations: This study may be underpowered for some relevant outcomes, particularly costs. The study population is limited to patients who sought health care in primary care settings. Conclusions: Both men and women can benefit substantially from quality improvement interventions for depression in primary care. Results are particularly favorable for the QI-Therapy intervention.