Sunday, September 20, 2009

Can Non-Nurse Professionals Coach Patients With Depression?

The Disease Management Care Blog is in San Diego on the eve of the annual DMAA Forum. What better way to prepare for all the learning that is going to happen tomorrow than to briefly share an important and recently published study on disease management for depression?

The article 'Case management for depression by health care assistants in small primary care practices' by Gensichen et al is in the latest Annals of Internal Medicine. You need a subscription to get to the entire manuscript, but the DMCB is ready to summarize the more important insights for you. The bottom line is that telephonic care management for depression may not require reliance on nurses.

This was a two year ‘pragmatic’ cluster randomized trial involving 74 small and often rural German primary care practices. The clinics, not the patients, were randomly assigned to having depression care for patients supplemented by specially trained ‘health care assistants’ (who were trained for a total of 17 hours) versus usual physician-only depression care. To be eligible for the trial, patients had to be referred into the study by their physician (presumably for suspected depression) and score high on a depression survey (the 27 point PHQ-9; ten points or higher suggests depression). 3051 patients were referred and 1671 scored high enough on the survey. For a variety of reasons (including withholding consent) 555 patients made it into the trial.

The health care assistants were non-physician non-nurse office ‘assistants’ who were described as first contact care workers who 'need not be college graduates.' They contacted patients twice a week for the first month and then once a month for the remaining year. Not only did they formally monitor the depression, but they monitored medication adherence, ‘encouraged self management activities’ and provided patient information back to the physician.

Twelve months later, the intervention group scored better on the follow-up PHQ-9 by 1.4 points (10.7 vs. 12.3) and had greater medication adherence according to a ‘Morisky Score.’ Over the year, both groups averaged about 6 visits with their primary care doctor and about 2 visits with psychiatrists.

The DMCB likes this study because it showed that success can be achieved with non-nurses. It always wondered if any caring and educated voice at the other end of the line was enough to shift patient behavior and medication adherence in the right direction. It suspects the same is true when it comes to other chronic illnesses. Ideally such a system in the U.S. would rely on nurse back-up and the right kind of attention to the U.S.' scope of practice laws and regulations.

Some other points to keep in mind:

The effect size was small (1.5 points on a 27 point scale and the means were still in the depressed range of greater than 9). We still have a long way to go.

Presumably, physicians only chose patients they thought were good candidates for the trial. We don't know if this would work on all patients with depression. Plus, if you run a disease management program and are stymied by poor recruitment and high drop out rates, welcome to the club. Even in a well run research program, patient leakage can be very high.

This study occurred in Germany. Differences in culture and how health care is regulated should be kept in mind while generalizing this to the U.S.

One problem among persons with depression is the occurence of suicidality. It's not clear how this was managed in this study, but imagine how thorny things can get if a patent expresses an intent to harm themselves over the phone.

There was no discussion of costs.

While the DMCB likes the study, it doesn't like how the authors 'framed' their manuscript and how the editors of the Annals let them get away with it. In fact, there is an accompanying editorial 'Progress on primary care management of depression' by Allen J. Dietrich of Dartmouth (which also needs a subscription). According to the authors and the editorialist, this use of non-nurse care management is further evidence of the merits of The Patient Centered Medical Home.

While the intervention did involve personnel that were physically located in the doctor's offices, the reason this worked is because someone was telephoning the patients. The DMCB doesn't understand why that function necessarily has to be physically located in each doctor's office; in fact, consolidating it may be more efficient. There is nothing in the manuscript that describes the linkages between the health care assistants and their assigned physicians, or why those linkages would better than those found in typical disease management programs.

The authors also conveniently and totally ignore the similarity of their intervention with traditional telephonic, disease management-based and insurer-sponsored patient coaching. The success of their non-physician supportive approach has been matched in the U.S. for years and in many respects, this Annals lead article is old news. In fact, the DMCB believes telephonic-based coaching and follow-up of patients with depression should be considered standard operating procedure.

Rather than compare their approach with usual care, the real question is whether non-nurses can perform as well as nurses in reducing depression symptoms and increasing medication compliance. Perhaps this should be a topic of investigation in comparative effectiveness research.

Deng Xiaoping, a former leader in Communist China, famously signalled his country's economic flexibility with the observation that it doesn't matter if a cat is black or white so long as it catches mice. The same may true when it comes to nurses vs. non-nurses and this part of reducing the burden of depression.

No comments: