title: Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial.
abstract: BACKGROUND
  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.
  
  
  METHODS
  Group-level randomized controlled trial conducted June 1996 to July 1999.
  
  
  METHODS
  Forty-six primary care clinics in 6 community-based managed care organizations.
  
  
  METHODS
  One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.
  
  
  METHODS
  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.
  
  
  METHODS
  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 $15 331 and $36 467 for QI-meds and $9478 and $21 478 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.
authors.affiliation: RAND, 1200 S Hayes St, Arlington, VA 22202, USA. mikels@rand.org
authors.forename: M
authors.initials: M
authors.lastname: Schoenbaum
authors.forename: J
authors.initials: J
authors.lastname: Unützer
authors.forename: C
authors.initials: C
authors.lastname: Sherbourne
authors.forename: N
authors.initials: N
authors.lastname: Duan
authors.forename: L V
authors.initials: LV
authors.lastname: Rubenstein
authors.forename: J
authors.initials: J
authors.lastname: Miranda
authors.forename: L S
authors.initials: LS
authors.lastname: Meredith
authors.forename: M F
authors.initials: MF
authors.lastname: Carney
authors.forename: K
authors.initials: K
authors.lastname: Wells
mesh_terms: D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003866:Depressive Disorder / Q000191:economics* / Q000628:therapy*; D004651:Employment; D005194:Family Practice / Q000191:economics* / Q000592:standards*; D017048:Health Care Costs / Q000706:statistics & numerical data; D006302:Health Services Research / Q000379:methods; D006801:Humans; D008329:Managed Care Programs / Q000191:economics / Q000592:standards*; D008605:Mental Health Services / Q000191:economics / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D011320:Primary Health Care / Q000191:economics / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000191:economics*; D019057:Quality-Adjusted Life Years; D014481:United States