Patients in a Depression Collaborative Care Model of Care

A collaborative care model (CCM) has been implemented for management of depression. This paper studies the impact that the CCM had on cost measures for the period of six months after initial diagnosis of depression compared to patients receiving usual care (UC). There was a significant increase in the CPT costs for the six months following diagnosis in the CCM group ($451.35 vs.$323.50, P < 0.001). The average CPT cost rank and CPT cost differential were also significantly increased in the CCM group. The adjusted means of the CPT costs were (when controlling for prior utilization) $452.11 for the CCM group and$322.09 for UC (P < 0.001). In the CCM group; there were 161 patients (73.5%) that achieved a clinical response for their depression compared to the UC group, which had a 15.1% (18/119) response rate (P < 0.001). There also was a significant difference between the groups in those who were symptoms free of their depression (PHQ-9 score < 5), with the CCM having 59.4% of the patients symptom-free compared to 10.9% of the UC group (P < 0.001). In this group of patients, CCM is associated with markedly improved clinical outcomes for depression, however with a modest short-term increase in CPT costs

PHQ-9 Response Curve

Major depressive disorder is common in primary care. Depression Improvement Across Minnesota—Offering a New Direction (DIAMOND), using a collaborative care model, was first implemented in March 2008 starting with 5 clinics and expanding to more than 70 clinics statewide by 2010. This was intended to improve depression management and to augment the relationship between the patient, the primary care provider, and the psychiatrist. Prior retrospective studies have demonstrated the clinical effectiveness of our program. This study was designed to examine those patients who were in clinical remission (defined as a Patient Health Questionnaire–9 [PHQ-9] score <5) at 6 months (180 days) after enrollment in collaborative care management. By determining the subsequent PHQ-9 data that were obtained, a PHQ-9 response curve was developed for those patients who did improve. The pilot study demonstrated that there appeared to be rapid response to depression treatment, evident by the first month of treatment and more pronounced in severely depressed patients. Also, it demonstrated that in the patients who did respond, there was no any difference in the remission rates over the study period when evaluated by the initial severity of the depression

Cellulitis in Obesity

Purpose: Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI); however, patients have not been extensively studied in the outpatient environment or stratified based on range of obesity and associated risk factors. This study looked at antibiotic dosing and treatment failure in the obese population from the primary care perspective and accounts for BMI range, weight, comorbid diabetes, and tobacco use. Methods: This study was a retrospective chart review of 637 adult primary care patients designed to evaluate rates of treatment failure of outpatient cellulitis among patients of varying BMI. Treatment failure was defined as ( a ) hospital admission for intravenous antibiotics, ( b ) prolonged antibiotic course, or ( c ) requiring a different antibiotic after initial course. Results: Adverse outcomes were not statistically significant between normal BMI and those with BMI ≥40 kg/m 2 . A subset of patients with a BMI ≥50 kg/m 2 was noted to have approximately twice the rate of adverse outcomes as the normal BMI group. While controlling for age, gender, race, diagnosis of diabetes mellitus, and tobacco use, a BMI of ≥50 kg/m 2 and a weight ≥120 kg was associated with adverse outcomes with an odds ratio of 2.440 (95% CI, 1.260-4.724; P = .008) and 2.246 (95% CI, 1.154-4.369; P = .017), respectively. Conclusions: Patients with cellulitis weighing >120kg or with a BMI ≥50 kg/m 2 were at greatest risk for treatment failure in the outpatient setting, even when controlling for comorbid diabetes and tobacco use. As morbid obesity continues to become more prevalent, it becomes imperative that primary care physicians have better antibiotic dosing guidelines to account for the physiologic effects of obesity to minimize the risk of increased morbidity, health care costs, and antibiotic resistance

Prolonged Care Management for Depression

Introduction: Collaborative care management (CCM) for the treatment of depression has been shown to be an effective therapy. CCM can be seen as a resource intensive treatment. Early identification of patients who would not be effectively treated with CCM could allow for alteration of therapy or change in modality. Methods: A retrospective case-controlled study used 132 patients with prolonged enrollment (>1 year) in CCM (cases) and 396 randomized CCM patients who achieved remission within 6 months (controls). The hypothesis was that by studying the epidemiology of patients in prolonged care management (PCM), characteristics could be determined to help define this group. Results: With regression modeling, the odds of a patient having PCM at 1 year was highly significant for those unmarried patients (odds ratio [OR] = 1.736, confidence interval [CI] = 1.115-2.703, P = .015) with dysthymia (OR = 2.362, CI = 1.104-5.052, P = .027) and severe depression (OR = 2.856, CI = 1.551-5.260, P = .001). The adjusted baseline Patient Health Questionnaire–9 (PHQ-9) score showed a difference of 16.0 for the cases versus 14.8 for the controls ( P < .001). By 10 weeks, the difference is much larger at (10.7 vs 4.9, P < .001). At 26 weeks, the control group had an adjusted average PHQ-9 score of 2.0, whereas the case group was still elevated at 10.2 ( P < .001). Conclusions: Case-controlled analysis of PCM patients demonstrated independent predictors (such as unmarried status, diagnosis of dysthymia or severe depression), however, no baseline data was of sufficient clarity to suggest changes in clinical practice. The trend of the patient’s PHQ-9 over time was strongly suggestive of allowing differentiation between the groups

Impact of gestational diabetes diagnosis on concurrent depression in pregnancy

Background Gestational diabetes mellitus (GDM) affects nearly 5% of US pregnancies and is associated with poor outcomes. Perinatal depression is also associated with substantial risks to both the fetus and mother. There is limited data about the relationship between GDM and antenatal depression. Therefore, we looked at whether a GDM diagnosis would be associated with an increased risk of depression during pregnancy. Methods We studied 562 pregnant women from 1 July 2013 to 30 June 2015, in a prospective multi-part survey on clinical obstetrical outcomes. Results Of the 562 patients, 46 patients (8.0%) were diagnosed with GDM. There was no statistical difference between the groups for either history of prior or post-partum depression. Diagnosis of depression was present in 15.2% of the GDM group but only 6.2% of the control group. Regression modeling demonstrated an adjusted odds ratio (AOR) of 2.46 for a diagnosis of depression when the patient had a diagnosis of GDM (95% CI 1.01–6.03, p=.049). Conclusions The diagnosis of GDM was associated with an elevated risk of concomitant pregnancy diagnosis of depression. Given the elevated risk to patients diagnosed with GDM, a more frequent depression screening interval could be considered during the remainder of the pregnancy, such as each prenatal visit

Obesity and Symptom Burden in Family Medicine Patients

Background: Medical visits are initiated by patients in search of symptom relief. The extent to which obesity independently increases the risk of common symptoms is unknown. Objectives: To assess how obesity affects symptom burden among family medicine patients, after adjustment for severity of illness, via retrospective analysis of electronic medical records pertaining to 1738 adult family medicine patients treated in a large family medicine department in Rochester, Minnesota, USA. Methods: A symptom index was used to measure symptom burden. Body mass index (BMI; kg/m2) was measured during clinic visits. Multiple logistic regression analysis was used to test for an independent relationship between BMI category and the presence of three or more common symptoms. Results: Adjusting for co-morbidity and other confounders using multiple logistic regression analysis revealed that having a BMI >=35 kg/m2 was independently related to symptom burden (adjusted odds ratio [OR]_=_1.80; 95% CI 1.24, 2.63). Patients with low and moderate co-morbidities (as measured by the Charlson Co-morbidity Index) also had higher odds of reporting more symptoms (OR_=_1.60; 95% CI 1.17, 2.17 and OR_=_1.87; 95% CI 1.36, 2.56, respectively). Symptom burden increased with age. Odds of having three or more symptoms were lower for married patients (OR 0.63; 95% CI 0.47, 0.83). Conclusions: In our sample of family medicine patients, increased symptom burden may be associated with a BMI >=35 kg/m2. Lower levels of obesity do not appear to be related to symptom burden. DOI: 10.2165/1312067-200801030-00003Obesity, Obesity-therapies, Weight-loss

Collaborative Care Management for Depression

The collaborative care management (CCM) model has been demonstrated to be significantly more effective compared to usual care (UC) in depression management although an initial increase in cost measures was seen. In this paper, cost measures as well as clinical response were analyzed on patients with available follow-up data at six months. Records of 219 patients with follow-up data in CCM group and 119 in UC group were reviewed. At six months, there was a statistically significant clinical response rate among patients in CCM compared to UC group ( P < 0.0001). Likewise, 65% in CCM group was “symptom-free” at 6 months vs. 31.9% in UC group ( P < 0.0001). Among the responders in both groups, there was no statistical difference in cost measures. However, cost measures were significantly higher among non-responders compared to responders within CCM. Between the two models, the non-responders in UC had lower cost measures than the non-responders under CCM

Personality Disorders in Primary Care: Impact on Depression Outcomes Within Collaborative Care

Background: Individuals with personality disorders (PDs) are high utilizers of primary care and mental health services; however, they struggle to utilize the care effectively and studies have shown a strong association between having a PD and higher impairment in social role functioning. This is especially important because PDs are highly comorbid with a wide range of other mental health disorders. The collaborative care model (CCM) for depression was developed with an emphasis on patient engagement and aimed to reduce health care utilization, while improving treatment outcomes in primary care. We hypothesized that the diagnosis of a personality disorder in primary care patients will negatively affect 6-month depression outcomes after enrollment into a CCM. Methods: This retrospective chart review study was conducted on patients enrolled into CCM over a period of 7 years with collection of 6-month follow-up data. A total of 2826 patients were enrolled into CCM with a clinical diagnosis of depression and a baseline Patient Health Questionnaire–9 (PHQ-9) ≥10 were included in the study cohort. Using the depression database, baseline and 6-month follow-up data were obtained. Adjusted odds ratios (AORs) were determined for both remission and persistent depressive symptoms using logistic regression modeling for the 6-month PHQ-9 outcome; while retaining all the study variables. Results: Of the 2826 CCM patients with depression in our study, 216 (7.6%) were found to have a PD. Patients with PD were younger (37.7 vs 42.5 years, P < .001) and more likely to be unmarried (36.1% vs 55.6%, P < .001) than patients without a PD. While age, marital status, clinical diagnosis, and Mood Disorders Questionnaire (MDQ) score were significant predictors of remission; anxiety symptoms, gender, and race were not. The presence of a PD diagnosis was associated with a 60% lower likelihood of remission at 6 months (AOR = 0.39; 95% CI 0.28-0.54). Conversely, patients without a PD were 2.5 times as likely to experience remission at 6-month remission compared to patients with PD (AOR =2.57; 95% CI 1.85-3.56). Conclusion: Patients with a personality disorder were more likely to have a recurrent depressive disorder diagnosis, an abnormal MDQ score, increased anxiety symptoms, and higher baseline PHQ-9 score. Patients with PD had worse CCM outcomes at 6 months with only 25.0% able to achieve remission versus 54.3% ( P < .001) without a PD. The presence of a PD with depression was associated with poor outcomes (reduced remission rates and increased persistent depressive symptoms rates) in comparison to patients without a diagnosis of PD, while treated within CCM