[show abstract][hide abstract] ABSTRACT: We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics.
We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization.
Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation.
Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.
American Journal of Public Health 04/2012; 102(6):e41-5. · 3.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis.
Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months.
Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests.
The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.
International Journal of Geriatric Psychiatry 05/2008; 23(11):1166-71. · 2.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the long-term effects on total healthcare costs of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program for late-life depression compared with usual care.
Randomized controlled trial with enrollment from July 1999 through August 2001. The IMPACT trial, conducted in primary care practices in 8 delivery organizations across the United States, enrolled 1801 depressed primary care patients 60 years or older. Data are from the 2 IMPACT sites for which 4-year cost data were available. Trial enrollment across these 2 health maintenance organizations was 551 patients.
Participants were randomly assigned to the IMPACT intervention (n = 279) or to usual primary care (n = 272). Intervention patients had access to a depression care manager who provided education, behavioral activation, support of antidepressant medication management prescribed by their regular primary care provider, and problem-solving treatment in primary care for up to 12 months. Care managers were supervised by a psychiatrist and a primary care provider. The main outcome measures were healthcare costs during 4 years.
IMPACT participants had lower mean total healthcare costs ($29 422; 95% confidence interval, $26 479-$32 365) than usual care patients ($32 785; 95% confidence interval, $27 648-$37 921) during 4 years. Results of a bootstrap analysis suggested an 87% probability that the IMPACT program was associated with lower healthcare costs than usual care.
Compared with usual primary care, the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period.
The American journal of managed care 03/2008; 14(2):95-100. · 2.12 Impact Factor