Clinical Effectiveness of Integrated Primary Care
Summaries of evidence on the effectiveness of integrated or collaborative care are starting to spring up all over the web.
Excellent summary of the evidence on collaborative care done by the Canadian Collaborative Care Project.
There are now models based on well proven research protocols that are available on the web for other sites to use. The IMPACT program for elderly patients with depression, and the STAR*D program are excellent examples.
See Alexander Blount's lead article, "Integrated Primary Care: Organizing the Evidence" in the Summer 2003 issue of Families, Systems and Health.
The Bureau of Primary Health Care has a page with their evidence for Integrated Primary Care.
Team care doubles the effectiveness of depression care for elderly patients.
Is Collaborative Care Better in Treatment of Panic Disorders?
Collaborative Care Can Improve the Health Status of Elderly Patients
Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. Am J Prev Med 2002;22(4):267-84.
Evidence from Australia. A whole issue of the Medical Journal of Australia on Integrated Primary Care 2008.
Pioneering Work in Integrated Primary Care Effectiveness Research
Common mental disorders in primary care, such as
depression, are associated with significant loss of day to day functioning by
patients. This impairment is as great or greater than the impairment of
chronic medical conditions such as diabetes or arthritis. Wayne Katon and his collaborators at the
University of Washington have done some of the most exhaustive controlled
research on interventions that can help primary care physicians manage mental
disorders, particularly depression, more effectively. Their research has focused
on the problem of depression. Katon
conceives his studies, as well as similar ones by other researchers, as
comprising three "generations." The
first generation involves implementing screening procedures in primary care to
more accurately identify depressed patients so that the physician can plan
appropriate treatment. The second
generation consists of a diagnostic interview with a psychiatrist for patients
who are identified as depressed; the psychiatrist consults with the primary
physician in developing a treatment plan for the patient.
Patients were recruited to the study and then randomly assigned to the
intervention or the control (usual care by their usual physician).
In both generations, the diagnosis and sometimes the treatment of studied
patients were more appropriate in the intervention cases than in the controls,
but the outcomes in terms of patient functioning were not different (Katon et
al., 1992b; Katon et al., 1995)
In the third generation studies (Katon, 1995;
Katon et al., 1995), the intervention shifted from helping the physician (who
did all the treatment) to integrating a mental health clinician into the
treatment. An integrated
protocol of patient education about depression and brief treatment (2 to 4
sessions) with a psychiatrist or psychologist was part of the treatment in the
primary care setting. The visits
with the biomedical provider alternated with the visits with the mental health
provider. Outcomes began to change
significantly. Table 1 is a summary
of the study by Katon and his colleagues of an
integrated approach to treating depression in primary care. The most powerful result is the difference in the patients
with major depression who showed significant symptom reduction under the two
conditions studied: 74% of the
people with major depression in the integrated treatment plan showed significant
symptom reduction while only 44% of the patients who had physician treatment and
referral to mental health services at a separate site showed similar
improvement.
See table of data: Impact
of integrated approach on depression in primary care.
Katon's summary of his team's findings was, "First, we know that a model of collaborative management with people with major depression dramatically improves adherence, satisfaction with treatment, and depressive outcomes" (1995, p 364). Similar results have been reported in the United Kingdom. Balestrieri, Williams & Wilkinson (1988) performed a meta-analysis of studies comparing treatment provided by mental health counselors in primary care and by general practitioners, and estimated that counselors achieve a 10% greater success rate.
Katon's work has lead to an evolution of depression treatment in primary care.
James C. Coyne, Ph.D., offers a provocative discussion of the trend toward "Depression Specialists" in primary care in his article, DEPRESSION IN PRIMARY CARE: Depressing News, Exciting Research Possibilities.
The Rand Corporation Partners in Care program, based on a study showing equal effectiveness of medication and psychotherapy for depressed patients in primary care settings, offers ways of developing programs to actively address this population.
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