title: A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care.
abstract: OBJECTIVE
  Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials.
  
  
  METHODS
  Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes.
  
  
  RESULTS
  There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P <.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94).
  
  
  CONCLUSIONS
  Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement.
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota leif.i.solberg@healthpartners.com.
authors.forename: Leif I
authors.initials: LI
authors.lastname: Solberg
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota.
authors.forename: A Lauren
authors.initials: AL
authors.lastname: Crain
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota.
authors.forename: Michael V
authors.initials: MV
authors.lastname: Maciosek
authors.affiliation: University of Washington Medical Center, Seattle, Washington.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Unützer
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota.
authors.forename: Kris A
authors.initials: KA
authors.lastname: Ohnsorg
authors.affiliation: Kaiser Permanente Colorado, Denver, Colorado.
authors.forename: Arne
authors.initials: A
authors.lastname: Beck
authors.affiliation: RAND Corporation, Santa Monica, California.
authors.forename: Lisa
authors.initials: L
authors.lastname: Rubenstein
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota.
authors.forename: Robin R
authors.initials: RR
authors.lastname: Whitebird
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota.
authors.forename: Rebecca C
authors.initials: RC
authors.lastname: Rossom
authors.affiliation: Institute for Clinical Systems Improvement, Minneapolis, Minnesota.
authors.forename: Pamela B
authors.initials: PB
authors.lastname: Pietruszewski
authors.affiliation: Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Crabtree
authors.affiliation: Private practice, Minneapolis, Minnesota.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Joslyn
authors.affiliation: University of Minnesota, Minneapolis, Minnesota.
authors.forename: Andrew
authors.initials: A
authors.lastname: Van de Ven
authors.affiliation: University of Colorado, Denver, Colorado.
authors.forename: Russell E
authors.initials: RE
authors.lastname: Glasgow
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003299:Cooperative Behavior; D003863:Depression / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D017060:Patient Satisfaction; D011320:Primary Health Care / Q000191:economics*; D058996:Quality Improvement; D011795:Surveys and Questionnaires
chemical_list: D000928:Antidepressive Agents
keywords: collaborative care; depression; health care delivery; primary care; quality