title: Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.
abstract: BACKGROUND
  Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown.
  
  
  OBJECTIVE
  To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up.
  
  
  METHODS
  A group-level randomized controlled trial.
  
  
  METHODS
  Forty-six primary care practices in 6 managed care organizations.
  
  
  METHODS
  Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up.
  
  
  METHODS
  Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months.
  
  
  METHODS
  Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care.
  
  
  RESULTS
  Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder).
  
  
  CONCLUSIONS
  Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.
authors.affiliation: Health Program, RAND, Santa Monica, CA 90407-2138, USA. kwells@ucla.edu
authors.forename: Kenneth
authors.initials: K
authors.lastname: Wells
authors.forename: Cathy
authors.initials: C
authors.lastname: Sherbourne
authors.forename: Michael
authors.initials: M
authors.lastname: Schoenbaum
authors.forename: Susan
authors.initials: S
authors.lastname: Ettner
authors.forename: Naihua
authors.initials: N
authors.lastname: Duan
authors.forename: Jeanne
authors.initials: J
authors.lastname: Miranda
authors.forename: Jürgen
authors.initials: J
authors.lastname: Unützer
authors.forename: Lisa
authors.initials: L
authors.lastname: Rubenstein
mesh_terms: D000328:Adult; D003866:Depressive Disorder / Q000628:therapy*; D004502:Education, Medical, Continuing; D004509:Education, Nursing, Continuing; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D010353:Patient Education as Topic; D011320:Primary Health Care / Q000592:standards*; D011785:Quality Assurance, Health Care; D017749:Total Quality Management