title: Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care.
abstract: OBJECTIVE
  Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services.
  
  
  METHODS
  We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment.
  
  
  RESULTS
  Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers.
  
  
  CONCLUSIONS
  To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA. rhenke@post.harvard.edu
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Henke
authors.forename: Thomas G
authors.initials: TG
authors.lastname: McGuire
authors.forename: Alan M
authors.initials: AM
authors.lastname: Zaslavsky
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Ford
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Meredith
authors.forename: Jose J
authors.initials: JJ
authors.lastname: Arbelaez
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003865:Major Depressive Disorder / Q000628:therapy*; D019468:Disease Management; D017050:Episode of Care; D019317:Evidence-Based Medicine; D005260:Female; D006123:Group Practice / Q000145:classification; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D017749:Total Quality Management; D014481:United States
chemical_list: D000928:Antidepressive Agents