Collaborative care versus screening and follow-up for patients with diabetes and depressive symptoms: results of a primary care-based comparative effectiveness trial

A systematic review of randomized controlled trials in a general practice setting aiming to reduce excess all-cause mortality and enhance cardiovascular health in patients with severe mental illness

OBJECTIVE

People with severe mental illness (SMI) have a reduced life expectancy, primarily due to chronic somatic diseases like cardiovascular disorders. Integrated care in general practice addressing mental and physical health may reduce excess mortality in this population. This review assessed the effectiveness of collaborative care, general integrated care, and physical health interventions in reducing overall mortality in patients with SMI. Secondary outcomes included disease-specific mortality, cardiovascular health indicators, and health-related quality of life.

METHODS

We searched PubMed, PsycINFO, Cochrane Library, and Embase for randomized controlled trials published before April 24, 2024. Eligible studies focused on integrated care interventions targeting somatic health in patients with SMI. Two reviewers independently conducted data extraction and risk of bias assessment. The study was registered with PROSPERO (CRD42022328464).

RESULTS

Of 2904 identified publications, 17 were included (covering 13 studies). Seven studies reported mortality data, with one showing reduced mortality in patients with major depressive disorder receiving collaborative care. No studies examined disease-specific mortality. Nine studies assessed cardiovascular outcomes, with three reporting reduced cardiovascular risk in collaborative care interventions simultaneously targeting depression and cardiovascular factors. Seven studies reported on quality of life, with three finding improvements. Study quality was rated moderate to high.

CONCLUSION

We found low-certainty evidence that collaborative care reduces mortality in depression. There was moderate evidence that collaborative care models, simultaneously addressing mental and cardiovascular health could potentially improve cardiovascular health in depression. The limited number of studies and their focus on depression limit the generalizability of these findings to other SMIs.

Effect of Community-Based Integrated Care for Patients With Diabetes and Depression (CIC-PDD) in China: A Pragmatic Cluster-Randomized Trial

OBJECTIVE

To develop a care model for patients with both diabetes and depression and assess the model's effectiveness.

RESEARCH DESIGN AND METHODS

In this pragmatic cluster randomized trial, we allocated eight community health centers into two groups: the enhanced usual care group and the intervention group. A comprehensive care plan was developed for the intervention group based on the integrated care model. We recruited individuals aged ≥18 years with type 2 diabetes and depression (Patient Health Questionnaire-9 score ≥10). The primary outcome was the between-group difference in the percentage of patients who had at least a 50% reduction in depressive symptoms and a reduction of at least 0.5 percentage points in HbA1c. The outcome analysis was conducted within the intention-to-treat population; missing data were multiply imputed.

RESULTS

We enrolled 630 participants, with 275 in the intervention group and 355 in the control group. A significantly greater percentage of patients in the intervention group met the primary outcome at 12 months (for depressive symptoms: risk difference [RD] 31.03% [62.06% vs. 31.02%, respectively; 95% CI 21.85-40.21]; for HbA1c: RD 19.16% [32.41% vs. 13.25%, respectively; 95% CI 11.35-26.97]). The patients in the intervention group showed significant enhancements in mental quality of life (mean difference [MD] 6.74 [46.57 vs. 39.83, respectively; 95% CI 3.75-9.74]), diabetes self-care activities (MD 0.69 [3.46 vs. 2.78, respectively; 95% CI 0.52-0.86]), medication adherence (MD 0.72 [6.49 vs. 5.78, respectively; 95% CI 0.37-1.07]), and experience of care (MD 0.89 [3.84 vs. 2.95, respectively; 95% CI 0.65-1.12]) at 12 months. Rural participants benefited more from the intervention.

CONCLUSIONS

The implementation strategy can serve as a valuable blueprint for the identification and treatment of patients with physical and mental multimorbidity in primary health care settings.

Effects of Integrated Care Approaches to Address Co-occurring Depression and Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

Depressive symptoms frequently co-occur with diabetes and, when unaddressed, can function to worsen diabetes control and increase the risk of diabetes-related morbidity. Integrated care (IC) approaches aim to improve outcomes among people with diabetes and depression, but there are no current meta-analyses examining their effects.

PURPOSE

In our study we summarize the effects of IC approaches to address depression and diabetes and examine moderating effects of IC approaches (e.g., behavioral intervention used; type of IC approach).

DATA SOURCES

A systematic search was conducted of PubMed, PsycInfo, CINAHL, and ProQuest.

STUDY SELECTION

Two reviewers triaged abstracts and full-text articles to identify relevant articles. Randomized controlled trials with enrollment of participants with diabetes and depressive symptoms and with provision of sufficient data on depression scores and hemoglobin A1c were included.

DATA EXTRACTION

Two reviewers extracted demographic information, depression scores, diabetes outcomes, intervention details, and the risk of bias for each study.

DATA SYNTHESIS

From 517 abstracts, 75 full-text reports were reviewed and 31 studies with 8,843 participants were analyzed. Among 26 studies with reporting of HbA1c, IC approaches were associated with a significant between-group difference regarding the percent decrease of HbA1c (d = -0.36, 95% CI -0.52 to -0.21). Studies that included a combination of behavioral interventions (behavioral activation with cognitive behavioral therapy) showed greater reductions in HbA1c. Among 23 studies with reporting of depressive symptoms, the pooled effect of IC approaches lowered depressive scores by 0.72 points (95% CI -1.15 to -0.28).

LIMITATIONS

The inclusion of a wide range of IC approaches increased study heterogeneity. A random effects model and sensitivity analyses mitigated this limitation.

CONCLUSIONS

IC approaches are associated with improved glycemia and depressive symptoms in comparison with treatment as usual.

The Significance of Disease Knowledge as a Risk Factor for Depression and Anxiety in Diabetic Patients

Background

Diabetes mellitus is a chronic disease that can lead to depression and anxiety disorders if it is not controlled and managed properly. This study aimed to estimate the prevalence of depression and anxiety disorders among diabetic patients and to determine whether patient knowledge is a risk factor.

Methods

The study included 220 patients with diabetes who attended the Diabetic Care Center. Socio-demographic data on the patients was collected. The Hospital Anxiety and Depression Scale questionnaire was used to assess patients' depression and anxiety levels. The Diabetes Knowledge Test 2 was used to assess the patients' knowledge of diabetes.

Results

From 220 patients with diabetes, anxiety was detected in 78.2%. From the recordings of these patients with diabetes, it was observed that 32.7%, 29.5%, and 15.9% suffered from mild, moderate, and severe anxiety, respectively. Depression was diagnosed in 170 patients (77.2%), with the majority sowing a moderate degree (32.3%) of depression. Furthermore, 29.5% and 15.5% patients had recorded mild and severe degrees of depression, respectively. Patients' understanding of diabetes was inadequate in this study, with the majority of patients (70.5%) having a low level of overall diabetes knowledge. In terms of general knowledge of diabetes, 64.1% patients had a low knowledge level, whereas 74.5% patients had a low knowledge level related to insulin therapy.

Conclusion

The patients' diabetes knowledge is significantly correlated with their anxiety and depression symptoms. Patients with diabetes should be regularly screened for anxiety and depression symptoms. Our findings indicate that the educational diabetes program could be a useful intervention for reducing depression and anxiety.

Program ACTIVE II: 6- and 12-month outcomes of a treatment approach for major depressive disorder in adults with type 2 diabetes

AIMS

To evaluate the long-term effects of behavioral treatments on glycemic and psychological outcomes for patients with major depressive disorder (MDD) and type 2 diabetes (T2D).

METHODS

Program ACTIVE II was a multicenter randomized controlled comparative effectiveness trial of cognitive behavioral therapy (CBT), exercise (EXER), combination treatment (CBT + EXER) and usual care (UC) for adults with MDD and T2D.

RESULTS

Primary outcomes: change in A1c and depressive symptoms at 6- (N = 87) and 12-months (N = 75) from baseline. In those with a baseline A1c ≥7.0 %, CBT + EXER showed lasting A1c benefit at 6- (-1.2 %; SE: 0.6; p = 0.032) and 12-months (-1.4 %; SE: 0.6; p = 0.025) compared to UC. All groups had clinically significant improvements in depressive symptoms. At 6 months, CBT + EXER had significant improvements in diabetes-related distress regimen burden (p = 0.005); and social support (CIRS, p = 0.043) compared to UC.

CONCLUSIONS

The Program ACTIVE II CBT + EXER intervention demonstrated a sustained improvement in A1c for a subgroup of study participants with a baseline A1c ≥7.0 %. However, this finding should be considered preliminary because of small sample size. All 3 behavioral intervention groups demonstrated improvements in psychosocial outcomes one-year post-intervention. These findings point to the enduring benefits of community-based interventions to extend the availability of depression treatment for T2D patients.

Diabetes and Depression: Strategies to Address a Common Comorbidity Within the Primary Care Context

Diabetes and depression represent a prevalent, bidirectional, and impactful comorbidity that affects patient and family quality of life, glycemic self-management, long-term diabetes complications, usage of medical services, medical costs, and early mortality. Primary care providers (PCPs) are frequently the first medical providers to observe changes in mood and diabetes management, as well as the primary point of contact for making referrals to specialty providers (e.g. endocrinology, psychiatry). PCPs play a critical role in screening, evaluating, and treating these conditions. Critical to fostering and maintaining a position of trust and patient engagement in medication recommendations is the use of person-centered, nonjudgmental language used by the provider within the clinical encounter. Key strategies for the management of these conditions include the following: routine screening for depressive symptoms, securing access to behavioral health professionals, either within or beyond the primary care setting, collaboration with diabetes care and education specialists to support problem-solving of diabetes self-management, and monitoring the use and effectiveness of antidepressant medications.

Exploring quality improvement for diabetes care in First Nations communities in Canada: a multiple case study

BACKGROUND

Indigenous peoples in Canada experience higher rates of diabetes and worse outcomes than non-Indigenous populations in Canada. Strategies are needed to address underlying health inequities and improve access to quality diabetes care. As part of the national FORGE AHEAD Research Program, this study explores two primary healthcare teams' quality improvement (QI) process of developing and implementing strategies to improve the quality of diabetes care in First Nations communities in Canada.

METHODS

This study utilized a community-based participatory and qualitative case study methodology. Multiple qualitative data sources were analyzed to understand: (1) how knowledge and information was used to inform the teams' QI process; (2) how the process was influenced by the context of primary care services within communities; and (3) the factors that supported or hindered their QI process.

RESULTS

The findings of this study demonstrate how teams drew upon multiple sources of knowledge and information to inform their QI work, the importance of strengthening relationships and building relationships with the community, the influence of organizational support and capacity, and the key factors that facilitated QI efforts.

CONCLUSIONS

This study contributes to the ongoing calls for research in understanding the process and factors affecting the implementation of QI strategies, particularly within Indigenous communities. The knowledge generated may help inform community action and the future development, implementation and scale-up of QI programs in Indigenous communities in Canada and globally.

Case management interventions in chronic disease reduce anxiety and depressive symptoms: A systematic review and meta-analysis

BACKGROUND

There is no systematic insight into the effect of case management on common complications of chronic diseases, including depressive symptoms and symptoms of anxiety. This is a significant knowledge gap, given that people with a chronic disease such as Parkinson Disease or Alzheimer's Disease have identified care coordination as one of their highest priorities. Furthermore, it remains unclear whether the putative beneficial effects of case management would vary by crucial patient characteristics, such as their age, gender, or disease characteristics. Such insights would shift from "one size fits all" healthcare resource allocation to personalized medicine.

OBJECTIVE

We systematically examined the effectiveness of case management interventions on two common complications associated PD and other chronic health conditions: Depressive symptoms and symptoms of anxiety.

METHODS

We identified studies published until November 2022 from PubMed and Embase databases using predefined inclusion criteria. For each study, data were extracted independently by two researchers. First, descriptive and qualitative analyses of all included studies were performed, followed by random-effects meta-analyses to assess the impact of case management interventions on anxiety and depressive symptoms. Second, meta-regression was performed to analyze potential modifying effects of demographic characteristics, disease characteristics and case management components.

RESULTS

23 randomized controlled trials and four non-randomized studies reported data on the effect of case management on symptoms of anxiety (8 studies) or depressive symptoms (26 studies). Across meta-analyses, we observed a statistically significant effect of case management on reducing symptoms of anxiety (Standardized Mean Difference [SMD] = - 0.47; 95% confidence interval [CI]: -0.69, -0.32) and depressive symptoms (SMD = - 0.48; CI: -0.71, -0.25). We found large heterogeneity in effect estimates across studies, but this was not explained by patient population or intervention characteristics.

CONCLUSIONS

Among people with chronic health conditions, case management has beneficial effects on symptoms of depressive symptoms and symptoms of anxiety. Currently, research on case management interventions are rare. Future studies should assess the utility of case management for potentially preventative and common complications, focusing on the optimal content, frequency, and intensity of case management.

Effectiveness of health literacy interventions on anxious and depressive symptomatology in primary health care: A systematic review and meta-analysis

Background

Affective disorders are a debilitating and very prevalent problem throughout the world. Often these are associated with the onset of comorbidities or a consequence of chronic diseases. Anxiety and depression are associated with poor social and personal relationships, compromised health. We aimed to synthesize evidence from studies measuring the impact of a health literacy (HL) intervention on the improvement of affective disorders.

Methods

For this systematic review and meta-analysis, we searched PubMed/MEDLINE, Embase, Web of Science, Ibecs, Cuiden, Scielo, Science Direct and Dialnet for exclusively randomized controlled trial studies (RCTs) published between 1 Jan 2011, and 31 May 2022. The search terms employed were "health literacy," "health knowledge," "anxiety," "anxiety disorder," "depression," "depressive disorder," and "adult." The risk of bias assessment was performed using the Cochrane Collaboration Revised Risk of Bias tool (RoB2). We conducted random-effects meta-analyses and explored heterogeneity using meta-regression and a stratified survey.

Results

Of 2,863 citations found through the initial screening, 350 records were screened by the title and abstract for their themes and relevance. Finally, nine studies complied with the inclusion criteria for the meta-analysis. 66.66% of studies (n = 6) were rated as having a low risk of bias and 33.33% (n = 3) were judged to raise some concerns. The health literacy interventions were associated with -1.378 reduction in depression and anxiety questionnaires scores [95% CI (-1.850, -0.906)]. Low mood disorder scores are associated with better mental health and wellbeing.

Conclusion

Our findings demonstrate that an HL intervention in relation to the symptoms associated with affective disorders improves the emotional state of patients in PHC, with a moderately positive effect in reducing depression and anxiety.

Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a scoping review

AIM

To map integrated and non-integrated self-management support interventions provided by primary care nurses to persons with chronic diseases and common mental disorders and describe their characteristics.

DESIGN

A scoping review.

DATA SOURCES

In April 2020, we conducted searches in several databases (Academic Research Complete, AMED, CINAHL, ERIC, MEDLINE, PsycINFO, Scopus, Emcare, HealthSTAR, Proquest Central) using self-management support, nurse, primary care and their related terms. Of the resulting 4241 articles, 30 were included into the analysis.

REVIEW METHODS

We used the Rainbow Model of Integrated Care to identify integrated self-management interventions and to analyze the data and the PRISMS taxonomy for the description of interventions. Study selection and data synthesis were performed by the team. Self-management support interventions were considered integrated if they were consistent with the Rainbow model's definition of clinical integration and person-focused care.

RESULTS

The 30 selected articles related to 10 self-management support interventions. Among these, five interventions were considered integrated. The delivery of the interventions showed variability. Strategies used were education, problem-solving therapies, action planning, and goal setting. Integrated self-management support intervention characteristics were nurse-person relationship, engagement, and biopsychosocial approach. A framework for integrated self-management was proposed. The main characteristics of the non-integrated self-management support were disease-specific approach, protocol-driven, and lack of adaptability.

CONCLUSION

Our review synthesizes integrated and non-integrated self-management support interventions and their characteristics. We propose recommendations to improve its clinical integration. However, further theoretical clarification and qualitative research are needed.

IMPLICATION FOR NURSING

Self-management support is an important activity for primary care nurses and persons with chronic diseases and common mental disorders, who are increasingly present in primary care, and require an integrated approach.

IMPACT

This review addresses the paucity of details surrounding integrated self-management support for persons with chronic diseases and common mental disorders and provides a framework to better describe its characteristics. The findings could be used to design future research and improve the clinical integration of this activity by nurses.

Specific content for collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care

BACKGROUND

In primary care (PC) many patients suffer from multimorbidity involving depression and/or anxiety. Collaborative care (CC) has shown promising results for patients with depression, anxiety, and multimorbidity involving depression. However, specific content in CC for patients with multimorbidity involving depression and/or anxiety is unknown.

OBJECTIVE

(i) To examine the effect of CC interventions in patients with multimorbidity involving depression and/or anxiety compared with usual care; (ii) to identify specific content of CC.

METHODS

We conducted a systematic literature review of randomized controlled trial studies evaluating CC models for adults with multimorbidity involving depression and/or anxiety in PC settings. PubMed, CINAHL, Web of Science, and PsycInfo were searched in December 2019. We conducted a qualitative synthesis using an existing framework and developed a new framework to map the content for each studied intervention.

RESULTS

We identified 1,447 studies. Twelve publications were included. Eleven had medium-to-high quality of CC for patients with multimorbidity involving depression. Specific content of CC in these studies is: A stepped care model, involving medication and psychotherapy delivered by a nurse or psychologist Care Manager (CM) focusing on problem-solving techniques; follow-up including monitoring of symptoms and function, and relapse prevention strategies; scheduled CM supervision.

CONCLUSIONS

Specific content for CC for patients with multimorbidity involving depression is identified from current research. Research gaps were found regarding CC for patients with multimorbidity and anxiety, depression and anxiety, and depression and/or anxiety and more than 2 diseases.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

Effect of routinely assessing and addressing depression and diabetes distress on clinical outcomes among adults with type 2 diabetes: a systematic review

OBJECTIVES

This study examined the effect of using patient-reported outcome measures (PROMs) routinely to assess and address depressive symptoms and diabetes distress among adults with type 2 diabetes.

DESIGN

A systematic review of published peer-reviewed studies.

DATA SOURCES

Medline, Embase, CINAHL Complete, PsycINFO, The Cochrane Library and Cochrane Central Register of Controlled Trials were searched.

ELIGIBILITY CRITERIA

Studies including adults with type 2 diabetes, published in English, from the inception of the databases to 24 February 2022 inclusive; and where the intervention included completion of a PROM of depressive symptoms and/or diabetes distress, with feedback of the responses to a healthcare professional.

DATA EXTRACTION AND SYNTHESIS

Using Covidence software, screening and risk of bias assessment were conducted by two reviewers independently with any disagreements resolved by a third reviewer.

RESULTS

The search identified 4512 citations, of which 163 full-text citations were assessed for eligibility, and nine studies met the inclusion criteria. Five studies involved assessment of depressive symptoms only, two studies assessed diabetes distress only, and two studies assessed both. All studies had an associated cointervention. When depressive symptoms were assessed (n=7), a statistically significant between-group difference in depressive symptoms was observed in five studies; with a clinically significant (>0.5%) between-group difference in HbA1c in two studies. When diabetes distress was assessed (n=4), one study demonstrated statistically significant difference in depressive symptoms and diabetes distress; with a clinically significant between-group difference in HbA1c observed in two studies.

CONCLUSION

Studies are sparse in which PROMs are used to assess and address depressive symptoms or diabetes distress during routine clinical care of adults with type 2 diabetes. Further research is warranted to understand how to integrate PROMs into clinical care efficiently and determine appropriate interventions to manage identified problem areas.

PROSPERO REGISTRATION NUMBER

CRD42020200246.

Modifying the quality-adjusted life year calculation to account for meaningful change in health-related quality of life: insights from a pragmatic clinical trial

BACKGROUND

We propose a modified quality-adjusted life year (QALY) calculation that aims to be consistent with guidance for interpreting change in patient-reported outcomes. This calculation incorporates the minimally important difference (MID) in generic preference-based health-related quality of life (HRQL) change scores to reflect what might be considered meaningful HRQL improvement/deterioration. In doing so, we review common issues in QALY calculations such as adjustment for baseline scores and standardizing for between-group differences.

METHODS

Using EQ-5D-5L outcome data from the Alberta TEAMCare-Primary Care Network trial in the management of depression for patients with type 2 diabetes (n = 98), this study compared results from different QALY calculation methods to investigate the impact of (i) adjusting for baseline HRQL score, (ii) standardizing between-group differences at baseline, and (iii) adjusting for 'meaningful' HRQL changes. The following QALY calculation methods are examined: area under curve (QALY-AUC), change from baseline (QALY-CFB), regression modelling (QALY-R), and incorporating an MID for HRQL changes from baseline (QALY-MID).

RESULTS

The incremental QALY-AUC estimate favoured the Collaborative Care group (0.031) while the incremental QALY-CFB (-0.028) estimate favoured Enhanced Care. Adjusting for meaningful HRQL changes resulted in a crude incremental QALY-MID of -0.023; however, after adjusting for between-group differences at baseline, QALY-R and adjusted incremental QALY-MID estimates were -0.007 and -0.001, respectively. In addition, recursive regression analyses showed that very low baseline HRQL scores impact incremental QALY estimates.

CONCLUSIONS

Uncertainty in incremental QALY estimates reflects uncertainty in the value of small within-individual change as well as the impact of small differences between groups at baseline. Applying a responder-definition approach yielded crude and adjusted QALY-MID estimates that were more in favour of Collaborative Care than QALY-CFB and QALY-R estimates, respectively, suggesting that ambiguous small changes in HRQL scores have the potential to influence QALY outcomes used in economic or non-economic applications.

The economic burden of anxiety and depression on the working age population with diabetes in Spain

Diabetes mellitus (DM) is a complex, chronic, multifactorial, and costly health problem representing 8% of total public health expenditures in Spain. The objective of this study was to analyse the prevalence and costs of Anxiety (AX) and Depression (DP) in the Spanish working population with DM. Data were obtained from the National Health Survey of Spain 2017. A multivariate analysis was conducted to predict the use of resources and absenteeism/presenteeism. Direct and indirect costs were calculated. The final population analysed contained 15,822 subjects (18-65 years old). DM prevalence was 4.8%, and AX-DP 10.6% (50.5% were men). Self-diagnosed health was rated as regular, poor or very poor in 89% of DM subjects with DP-AX. The average costs estimated were €24,643.41 for DM subjects with AX-DP and €20,059.53 for those with only DM. The total estimated 2017 economic impact of DM was 2.4% of Spanish gross domestic product (13% directly related to DP-AX). Indirect costs represented 72.7% of total DP-AX costs. Spanish society is paying a considerable price for the incidence of DP-AX levels with DM in the working population. This global challenge has important repercussions for individuals' quality of life, health systems, and countries' development and economic growth.

Exploring the impact of pharmacist comprehensive annual care plans on perceived quality of chronic illness care by patients in Alberta, Canada

Background:

In 2012, the Government of Alberta introduced a funding program to remunerate pharmacists to develop a comprehensive annual care plan (CACP) for patients with complex needs. The objective of this study is to explore patients’ perceptions of the care they received through the pharmacist CACP program in Alberta.

Methods:

We invited 3442 patients who received a pharmacist-billed CACP within the previous 3 months and 6888 matched controls across Alberta to complete an online questionnaire. The questionnaire consisted of the short version Patient Assessment of Chronic Illness Care (PACIC-11), with 3 additional pharmacy-specific assessment questions added. Additional questions related to health status and demographics were also included.

Results:

Overall, most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls. Of note, controls reported higher quality of care for 5 domains within the adapted PACIC-like tool compared with CACP patients (p < 0.05 for all). Interestingly, only 79 (44%) of CACP patients reported that they had received a CACP, whereas only 192 (66%) of control patients reported that they did not receive a care plan. In a sensitivity analysis including only these respondents, individuals who received a CACP perceived a significantly higher quality of chronic illness care across all PACIC domains.

Conclusion:

Overall, chronic illness care incentivized by the pharmacist CACP program in Alberta is perceived to be moderate to low. When limited to respondents who explicitly recognized receiving the service or not, the perceptions of quality of care were more positive. This suggests that better implementation of CACP by pharmacists may be associated with improved quality of care and that some redesign is needed to engage patients more. Can Pharm J (Ott) 2021;154:xx-xx.

The TELE-DD project on treatment nonadherence in the population with type 2 diabetes and comorbid depression

Diabetic patients have increased depression rates, diminished quality of life, and higher death rates due to depression comorbidity or diabetes complications. Treatment adherence (TA) and the maintenance of an adequate and competent self-care are crucial factors to reach optimal glycaemic control and stable quality of life in these patients. In this report, we present the baseline population analyses in phase I of the TELE-DD project, a three-phased population-based study in 23 Health Centres from the Aragonian Health Service Sector II in Zaragoza, Spain. The objectives of the present report are: (1) to determine the point prevalence of T2D and clinical depression comorbidity and treatment nonadherence; (2) to test if HbA1c and LDL-C, as primary DM outcomes, are related to TA in this population; and (3) to test if these DM primary outcomes are associated with TA independently of shared risk factors for DM and depression, and patients' health behaviours. A population of 7,271 patients with type-2 diabetes and comorbid clinical depression was investigated for inclusion. Individuals with confirmed diagnoses and drug treatment for both illnesses (n = 3340) were included in the current phase I. A point prevalence of 1.9% was found for the T2D-depression comorbidity. The prevalence of patients nonadherent to treatment for these diseases was 35.4%. Multivariate analyses confirmed that lower diabetes duration, increased yearly PCS visits, HbA1c and LDL-C levels were independently related to treatment nonadherence. These findings informed the development of a telephonic monitoring platform for treatment of nonadherence for people with diabetes and comorbid depression and further trial, cost-effectiveness, and prognostic studies (phases II and III).

Cost-effectiveness of Community-Based Depression Interventions for Rural and Urban Adults With Type 2 Diabetes: Projections From Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II

OBJECTIVE

We estimated the cost-effectiveness of the Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II community-based exercise (EXER), cognitive behavioral therapy (CBT), and EXER+CBT interventions in adults with type 2 diabetes and depression relative to usual care (UC) and each other.

RESEARCH DESIGN AND METHODS

Data were integrated into the Michigan Model for Diabetes to estimate cost and health outcomes over a 10-year simulation time horizon from the health care sector and societal perspectives, discounting costs and benefits at 3% annually. Primary outcome was cost per quality-adjusted life-year (QALY) gained.

RESULTS

From the health care sector perspective, the EXER intervention strategy saved $313 (USD) per patient and produced 0.38 more QALY (cost saving), the CBT intervention strategy cost $596 more and gained 0.29 more QALY ($2,058/QALY), and the EXER+CBT intervention strategy cost $403 more and gained 0.69 more QALY ($585/QALY) compared with UC. Both EXER and EXER+CBT interventions dominated the CBT intervention. Compared with EXER, the EXER+CBT intervention strategy cost $716 more and gained 0.31 more QALY ($2,323/QALY). From the societal perspective, compared with UC, the EXER intervention strategy saved $126 (cost saving), the CBT intervention strategy cost $2,838/QALY, and the EXER+CBT intervention strategy cost $1,167/QALY. Both EXER and EXER+CBT interventions still dominated the CBT intervention. In comparison with EXER, the EXER+CBT intervention strategy cost $3,021/QALY. Results were robust in sensitivity analyses.

CONCLUSIONS

All three Program ACTIVE II interventions represented a good value for money compared with UC. The EXER+CBT intervention was highly cost-effective or cost saving compared with the CBT or EXER interventions.

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association at the Association's 80th Scientific Sessions, which was held online as a result of coronavirus disease 2019. Dr. de Groot is an Associate Professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism at Indiana University (IU) School of Medicine. She serves as the Acting Director of the IU Diabetes Translational Research Center. Dr. de Groot is the 2020 recipient of the Rachmiel Levine Medal for Leadership from the American Diabetes Association.In the year 2020, we marked the 50th anniversary of the field of behavioral science in diabetes in the modern era. Over this relatively short period of time, this field has charted the psychosocial landscape of prediabetes and diabetes by establishing the prevalence and impact of emotional and behavioral aspects of diabetes. Interventions to address these conditions have been developed that span the T2 to T4 translational research spectrum ranging from the intrapsychic to population-based interventions. Policies ranging from standards of care to Medicare benefits have been implemented. A review of research in the area of diabetes and depression is provided as an example of innovations in this field. Behavior is the foundation of all interventions we make in diabetes and prediabetes. As a mature science, it is critical to stemming the tide of diabetes and its outcomes. To make additional strides, we must rebalance our focus and augment funding for behavioral interventions for individuals, communities, and health care systems in conjunction with other forms of treatment.

Treatment for comorbid depressive disorder or subthreshold depression in diabetes mellitus: Systematic review and meta-analysis

OBJECTIVE

To provide an estimate of the effect of interventions on comorbid depressive disorder (MDD) or subthreshold depression in type 1 and type 2 diabetes.

METHODS

Systematic review and meta-analysis. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomized controlled trials evaluating the outcome of depression treatments in diabetes and comorbid MDD or subthreshold symptoms published before August 2019 compared to care as usual (CAU), placebo, waiting list (WL), or active comparator treatment as in a comparative effectiveness trial (CET). Primary outcomes were depressive symptom severity and glycemic control. Cohen's d is reported.

RESULTS

Forty-three randomized controlled trials (RCTs) were selected, and 32 RCTs comprising 3,543 patients were included in the meta-analysis. Our meta-analysis showed that, compared to CAU, placebo or WL, all interventions showed a significant effect on combined outcome 0,485 (95% CI 0.360; 0.609). All interventions showed a significant effect on depression. Pharmacological treatment, group therapy, psychotherapy, and collaborative care had a significant effect on glycemic control. High baseline depression score was associated with a greater reduction in HbA1 c and depressive outcome. High baseline HbA1 c was associated with a greater reduction in HbA1 c.

CONCLUSION

All treatments are effective for comorbid depression in type 1 diabetes and type 2 diabetes. Over the last decade, new interventions with large effect sizes have been introduced, such as group-based therapy, online treatment, and exercise. Although all interventions were effective for depression, not all treatments were effective for glycemic control. Effective interventions in comorbid depressive disorder may not be as effective in comorbid subthreshold depression. Baseline depression and HbA1 c scores modify the treatment effect. Based on the findings, we provide guidance for treatment depending on patient profile and desired outcome, and discuss possible avenues for further research.

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

Editor's Note: This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association. She delivered her address at the Association's 80th Scientific Sessions, which was held online as a result of the coronavirus disease 2019.

Validity of the patient health questionnaire-2 (PHQ-2) for the detection of depression in primary care in Colombia

BACKGROUND

The PHQ-2 is a screening test for major depressive disorder (MDD) derived from PHQ-9, which has shown to be useful in the detection of cases of clinical significance in previous studies. The psychometric properties of PHQ-2 in the Colombian population are unknown.

METHODS

PHQ-2 were assessed in 243 patients in general medical consultations using the Mini-International Neuropsychiatric Interview (MINI) as the gold standard. Internal consistency, convergent validity and criterion validity were calculated by analyzing the Receptor Operating Characteristics (ROC) and the area under the curve (AUC).

RESULTS

Cronbach's alpha and McDonald's omega coefficients were 0.71. Spearman's rho coefficients for correlations with PHQ-9 and HADS-D scores were 0.63 and 0.59 (p<0.01). AUC was 0.89. The optimal cut point was ≥2 with the following indicators: sensitivity 0.87 specificity 0.74; Youden index 0.60; PPV 0.47; NPV 0.95; (LR+) 3.24; (LR-) 0.18 (95% CI 0.09-0.37). Kappa coefficient between PHQ-2 and MINI for depression was .458 and 0.46 for HADS-D.

LIMITATIONS

Since this study was done with people attending hospital, which could has implications for the prevalence of depression, affecting the validity indicators of the instrument.

CONCLUSIONS

PHQ-2 show an acceptable test performance in the context of the study. However, the test could yield a considerable amount of false positives that would require specialized evaluation to establish a reliable diagnosis.

Factors associated with the onset of major depressive disorder in adults with type 2 diabetes living in 12 different countries: results from the INTERPRET-DD prospective study

AIMS

To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries.

METHODS

People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables.

RESULTS

In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS.

CONCLUSION

This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Anxiety and depression in diabetes care: longitudinal associations with health-related quality of life

Anxiety and depression are commonly found in patients with diabetes, but little is known about how the anxiety and depression symptoms of diabetes patients and the health-related quality of life (HRQoL) over time influence each other. Therefore, we conducted a survey among patients with diabetes (T1) and repeated the survey after 3 months (T2). Linear regression models and cross-lagged structural equation models were used to analyze the associations between anxiety and depression symptoms and HRQoL within and across time intervals. Correcting for baseline index and potential confounders, the HRQoL index at T2 reflected the change in anxiety/depression between T1 and T2 more than anxiety/depression at T1 (P < 0.05). Similarly, anxiety and depression at T2 reflected the change in the EQ-5D index over time more than the index at baseline (P < 0.05). Our longitudinal data fitted well in a cross-lagged model with bi-directional pathways of associations between anxiety and HRQoL, as well as depression and HRQoL, among adult patients with diabetes (x²/df = 1.102, P = 0.256; CFI = 1.000, RMSEA = 0.030). Our findings support early detection of anxiety and depression, as well as comprehensive efforts improving HRQoL for patients with diabetes.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Effectiveness of psychoeducational interventions for the treatment of diabetes-specific emotional distress and glycaemic control in people with type 2 diabetes: A systematic review and meta-analysis

AIMS

Psychological comorbidity, such as depression and/or diabetes-specific emotional distress (DSD), is highly prevalent in people with type 2 diabetes (T2DM) and associated with poorer treatment outcomes. While treatments for depression are well established, interventions specifically designed for DSD are sparse. The aim of this study was to determine interventions that successfully address DSD and HbA1c in people with T2DM.

METHODS

Seven databases were searched to identify potentially relevant studies. Eligible studies were selected and appraised independently by two reviewers. Multiple meta-analyses and meta-regression analyses were performed to synthesise the data; the primary analyses determined the effect of interventions on DSD, with secondary analyses assessing the effect on HbA1c.

RESULTS

Thirty-two studies (n = 5206) provided sufficient DSD data, of which 23 (n = 3818) reported data for HbA1c. Meta-analyses demonstrated that interventions significantly reduced DSD (p = 0.034) and HbA1c (p = 0.006) compared to controls, although subgroup meta-analyses and meta-regression to explore specific intervention characteristics that might mediate this effect yielded non-significant findings.

CONCLUSIONS

The findings demonstrate that existing interventions successfully reduce DSD and HbA1c in people with T2DM. While promising, deductions should be interpreted tentatively, highlighting a stark need for further focused exploration of how best to treat psychological comorbidity in people with T2DM.

Program ACTIVE II: Outcomes From a Randomized, Multistate Community-Based Depression Treatment for Rural and Urban Adults With Type 2 Diabetes

OBJECTIVE

Depression (major depressive disorder [MDD]) in adults with type 2 diabetes mellitus (T2DM) is associated with worsened diabetes complications, increased health care costs, and early mortality. Program ACTIVE II was a randomized, controlled, multicenter treatment trial designed to test the comparative effectiveness of cognitive behavioral therapy (CBT) and/or community-based exercise (EXER) on diabetes and depression outcomes compared with usual care (UC).

RESEARCH DESIGN AND METHODS

Using a 2 × 2 factorial randomized controlled trial design, adults with T2DM for ≥1 year who met DSM-IV-TR criteria for MDD were randomized to CBT (10 sessions occurring over 12 weeks; N = 36), EXER (12 weeks of community-based exercise including six sessions with a personal trainer; N = 34), CBT+EXER (concurrent over a 12-week period; N = 34), and UC (N = 36). Primary outcomes were depression remission rate (assessed by psychiatric interviewers blind to assignment) and change in glycemic control (HbA_1c).

RESULTS

The mean age was 56.0 years (SD 10.7). Participants were female (77%), white (71%), and married (52%). After controlling for education and antidepressant use, odds of achieving full MDD remission in the intervention groups were 5.0-6.8 times greater than UC (P < 0.0167). The CBT+EXER group demonstrated improved HbA_1c compared with UC. For participants with a baseline HbA_1c ≥7.0%, exploratory post hoc subgroup analysis showed that the CBT+EXER group had a 1.1% improvement in HbA_1c (P < 0.0001) after controlling for covariates.

CONCLUSIONS

The Program ACTIVE behavioral treatment interventions demonstrated clinically meaningful improvements in depression outcomes in adults with T2DM and MDD. These community-based interventions are complementary to medical care and extend access to those in rural and urban areas.

An interview study of the care manager function-Opening the door to continuity of care for patients with depression in primary care

AIM

To explore experiences among patients with depression of contact with a care manager at a primary care centre.

DESIGN

A qualitative explorative study.

METHODS

During spring and summer 2016, 20 individual face-to-face interviews were conducted with patients with experience of care manager contact. The material was analysed using systematic text condensation.

RESULTS

The participants described that having contact with a care manager was a support in their recovery process. Care became more available, and the structured continuous contact and the care manager's availability contributed to a trusting relationship. Having someone to share their burden with was a relief. However, it was described as negative when the care manager was perceived as inflexible and not open to issues that the participants felt a need to discuss. For the care manager contact to be successful, there is a need for flexibility and individually tailored contact.

The use of the Patient Assessment of Chronic Illness Care (PACIC) instrument in diabetes care: a systematic review and meta-analysis

Purpose

The Patient Assessment of Chronic Illness Care (PACIC) was created to assess whether provided care is congruent with the Chronic Care Model, according to patients. We aimed to identify all studies using the PACIC in diabetic patients to explore (i) how overall PACIC scores varied across studies and (ii) whether scores varied according to healthcare delivery, patient and instrument characteristics.

Data sources

MEDLINE, Embase, PsycINFO, CINAHL and PubMed Central (PMC), from 2005 to 2016.

Study selection

Studies of any design using the PACIC in diabetic patients.

Data extraction and synthesis

We extracted data on healthcare delivery, patient, and instrument characteristics, and overall PACIC score and standard deviation. We performed random-effects meta-analyses and meta-regressions.

Results

We identified 34 studies including 25 942 patients from 13 countries, mostly in North America and Europe, using different versions of the PACIC in 11 languages. The overall PACIC score fluctuated between 1.7 and 4.2, with a pooled score of 3.0 (95% confidence interval 2.8-3.2, 95% predictive interval 1.9-4.2), with very high heterogeneity (I2 = 99%). The PACIC variance was not explained by healthcare delivery or patient characteristics, but by the number of points on the response scale (5 vs. 11) and the continent (Asia vs. others).

Conclusion

The PACIC is a widely used instrument, but the direct comparison of PACIC scores between studies should be performed with caution as studies may employ different versions and the influence of cultural norms and language on the PACIC score remains unknown.

Depression in primary care: part 1-screening and diagnosis

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis

Interprofessional primary care (IPPC) teams are promoted as an alternative to single profession physician practices in primary care with focus on preventive care and chronic disease management. Characteristics of teams can have an impact on their performance. We synthesized quantitative, qualitative or mixed-methods evidence addressing the design of IPPC teams. We searched Ovid MEDLINE, Embase, CINAHL, and PAIS using search terms focused on IPPC teams. Studies were included if they discussed the influence of team structure, organization, financial arrangements, or policies and procedures, or either health care processes or outputs, health outcomes, or costs, and were conducted in Australia, Canada, the United Kingdom or New Zealand between 2003 and 2016. We screened 11,707 titles, 5366 abstracts, and selected 77 full text articles (38 qualitative, 31 quantitative and 8 mixed-methods). Literature focused on the implications of team characteristics on team processes, such as teamwork, collaboration, or satisfaction of patients or providers. Despite heterogeneity of contexts, some trends are observable: shared space, common vision and goals, clear definitions of roles, and leadership as important to good teamwork. The impacts of these on health care outputs or patient health are not clear. To move the state of knowledge beyond perception of what works well for IPPC teams, researchers should focus on quantitative causal inference about the linkages between team characteristics and patient health.

Patient Engagement in ACO Practices and Patient-reported Outcomes Among Adults With Co-occurring Chronic Disease and Mental Health Conditions

BACKGROUND

Accountable care organizations (ACOs) have increased their use of patient activation and engagement strategies, but it is unknown whether they achieve better outcomes for patients with comorbid chronic physical and mental health conditions.

OBJECTIVES

To assess the extent to which practices with patient-centered cultures, greater shared decision-making strategies, and better coordination among team members have better patient-reported outcomes (PROs) for patients with diabetes and/or cardiovascular and comorbid mental health diagnoses.

RESEARCH DESIGN

Sixteen practices randomly selected from top and bottom quartiles of a 39-item patient activation/engagement implementation survey of primary care team members (n=411) to assess patient-centered culture, shared decision-making, and relational coordination among team members. These data were linked to survey data on patient engagement and on emotional, physical, and social patient-reported health outcomes.

SUBJECTS

Adult patients (n=606) with diabetes, cardiovascular, and comorbid mental health conditions who had at least 1 visit at participating primary care practices of 2 ACOs.

MEASURES

Depression/anxiety, physical functioning, social functioning; patient-centered culture, patient activation/engagement implementation, relational coordination.

RESULTS

Patients receiving care from practices with high patient-centered cultures reported better physical functioning (0.025) and borderline better emotional functioning (0.059) compared with less patient-centered practices. More activated patients reported better PROs, with higher activation levels partially mediating the relationship of patient-centered culture and better PROs.

CONCLUSIONS

ACO patients with comorbid physical and mental health diagnoses report better physical functioning when practices have patient-centered cultures. More activated/engaged patients report better patient emotional, physical, and social health outcomes.

Nurse-delivered interventions for mental health in primary care: a systematic review of randomized controlled trials

BACKGROUND

Mental health issues are increasingly prevalent within the community. Many people experiencing mental health issues have established relationships with primary care providers, including general practice nurses (GPNs). With the recent growth of general practice nursing, it is timely to explore the evidence for GPNs to provide mental health interventions for adults with mental illness within their scope of practice.

OBJECTIVE

To synthesize the evidence about nurse-delivered interventions in primary care for adults with mental illness.

METHODS

A systematic review of randomized control trials (RCTs) retrieved from the CINAHL, Ovid MEDLINE and EBSCO electronic databases between 1998 and 2017.

RESULTS

Nine randomized controlled trials were identified, which reported nurse-delivered interventions in primary care for the management of mental health in adults with mental illness. The heterogeneity of interventions and outcomes made comparison of studies difficult. Seven studies demonstrated significant improvement in at least one outcome following the intervention. In some studies, these improvements were sustained well beyond the intervention. Additionally, consumers were satisfied with the interventions and the role of the GPN.

CONCLUSION

There is currently limited evidence of the impact of nurse-delivered interventions in primary care for adults with mental illness. Given the significant improvements in symptoms and the acceptability of interventions seen in included studies, there is a need for further robust research exploring the role of the GPN both individually and within the multidisciplinary team. Such research will enable stronger conclusions to be drawn about the impact of nurse-delivered interventions in primary care for adults with mental illness.

Treatment of Depression in Integrated Care: Implementation of the Nurse Care Manager

The collaborative care model is an effective model for improving depression symptoms in patients in a primary care (PC) setting. An essential role in this model is the care manager (CM), and nurses have been effective in this role. However, there remains a question of how to best design, train, and implement this nurse CM role in PC. The purpose of this review is to provide readers with a critical description of what processes for training and implementation of a collaborative nurse CM role have been be successful in the literature, specifically as it pertains to supporting patients with depression and chronic medical illnesses in an integrated PC setting. A literature review of PubMed, CINAHL, PsychINFO, Scopus, and the Cochrane Collaborative was conducted in October 2018. Successful nurse CM interventions have included regular patient follow-up, symptom check-in, treatment monitoring, goal setting, and education. Psychological support techniques such as Problem-Solving Therapy, behavioral activation, and motivational interviewing have been useful in supporting patient care-plan engagement and goal achievement. Nurse CM training should support the successful implementation of the designed role. Nurse CMs have an opportunity to significantly impact depressive outcomes of patients with depression and long-term health conditions. Further research is needed to explore the potential that this nursing role has as well as how to best operationalize this role.

Association between different types of comorbidity and disease burden in patients with diabetes

BACKGROUND

This study examined the association between different types of comorbidities and the quality of diabetes care, health-related quality of life (HRQoL), and total health care expenditure.

METHODS

Adult patients with diabetes were identified from the 2011 to 2013 Medical Expenditure Panel Survey, a nationally representative survey of the civilian non-institutionalized US population. Twenty different chronic conditions were captured and categorized as: (i) diabetes only; (ii) diabetes plus concordant (diabetes-related) comorbidity only; and (iii) diabetes plus one or more discordant (non-diabetes-related) comorbidities. Disease burden outcomes included the process of diabetes care (eye and foot examinations, HbA1c and cholesterol tests, influenza vaccination), HRQoL, and total health care expenditure. Multivariable models were used to examine associations between the type of comorbidity and outcomes.

RESULTS

A sample of 8292 patients with diabetes was identified, of which 11.4% had diabetes only, 40.5% had concordant comorbidity only, and 48.1% reported one or more discordant comorbidities. Patients with diabetes and either type of comorbidity received better quality of diabetes care than those without a comorbidity. However, patients with discordant comorbidity showed significantly lower HRQoL measures and higher health care expenditure than those with concordant comorbidity. Adjusted total mean annual expenditure was US$4891, $6326, and $9210 for those with diabetes only and those with diabetes with one concordant or one discordant comorbidity, respectively.

CONCLUSIONS

Higher disease burden in patients with diabetes was associated with discordant rather than concordant comorbidity. Future interventional studies evaluating patient-centered care models addressing different types of comorbidity are necessary to better manage these complex patients.

Creating a safety net for patients with depression in primary care; a qualitative study of care managers' experiences

OBJECTIVE

The aim of this study was to explore nurses' experiences and perceptions of working as care managers at primary care centers.

DESIGN

Qualitative, focus group study. Systematic text condensation was used to analyze the data.

SETTING

Primary health care in the region of Västra Götaland and region of Dalarna in Sweden.

SUBJECTS

Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support.

MAIN OUTCOME MEASURES

The nurses' experiences and perceptions of working as care managers at primary care centers.

RESULTS

The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression.

CONCLUSION

The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points   The care managers described their role as an additional support to the already existing care at the primary care center.  •  They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression.  •  Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful.  •  Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.

Screening for Anxiety and Depressive Symptoms in Type 2 Diabetes Using Patient-Reported Outcome Measures: Comparative Performance of the EQ-5D-5L and SF-12v2

Objective. To evaluate the performance of EQ-5D-5L (EuroQol Five-Dimension, Five-Level Questionnaire) and SF-12-v2 (12-item Medical Outcomes Health Survey–Short Form, Version 2) in screening for anxiety and depressive symptoms in adults with type 2 diabetes. Methods. Cross-sectional data from a population-based study of type 2 diabetes in Alberta, Canada, were used. Anxiety symptoms (using the 2-item Generalized Anxiety Disorder questionnaire) were categorized into absent (<3) versus present (≥3). Depressive symptoms (using the 8-item Patient Health Questionnaire) were categorized according to two severity cut-points: absent (<10) versus mild (≥10), and absent (<15) versus moderate-severe (≥15). The performance of the measures in screening for anxiety and depressive symptoms was evaluated using receiver operating curve (ROC) analysis. Results. Average age of participants (N = 1,391) was 66.8 years (SD 10.2), and 47% were female. Seventeen percent of participants screened positive for mild and 5.9% for moderate-severe depressive symptoms, and 11.3% for anxiety symptoms. For comorbid symptoms, 8.6% screened positive for anxiety and any depressive symptoms, and 4.6% for anxiety and moderate-severe depressive symptoms. The EQ-5D-5L anxiety/depression dimension and the SF-12 mental composite summary score had the best performance in screening for anxiety (area under ROC: 0.89, 0.89, respectively), depressive symptoms (any: 0.88, 0.92; moderate-severe: 0.90, 0.90), and comorbid anxiety and depressive symptoms (any: 0.92, 0.91; moderate-severe: 0.92, 0.90). These were followed by SF-12 feeling downhearted/depressed item (range = 0.83–0.85), while the lowest performance was for the EQ-5D-5L index score (0.80–0.84) and the SF-12 mental health domain (0.81–0.82). Conclusion. The EQ-5D-5L and the SF-12 are suitable tools for screening for anxiety and depressive symptoms in adults with type 2 diabetes. These tools present a unique opportunity for a standardized approach for routine mental health screening within the context of routine outcome measurement initiatives, where screening is recommended.

Integrated Care for Depression in Older Primary Care Patients

For decades, depression in older adults was overlooked and not treated. Most treatment was by primary care providers and typically poorly managed. Recent interventions that integrate mental health services into primary care have increased the number of patients who are treated for depression and the quality of that treatment. The most effective models involve systematic depression screening and monitoring, multidisciplinary teams that include primary care providers and mental health specialists, a depression care manager to work directly with patients over time and the use of guideline-based depression treatment. The article reviews the challenges and opportunities for providing high-quality depression treatment in primary care; describes the 3 major integrated care interventions, PRISM-E, IMPACT, and PROSPECT; reviews the evidence of their effectiveness, and adaptations of the model for other conditions and settings; and explores strategies to increase their scalability into real world practice.

Successfully Managing Diabetes in a Community Setting: Evidence From the YMCA of Greater Richmond Diabetes Control Program

Purpose The purpose of this study was to describe how a community-academic partnership developed and implemented a shared goal of evaluating the impact of a large community-based diabetes self-management program on diabetes care and mental health outcomes. Methods Data came from the YMCA of Greater Richmond Diabetes Control Program (DCP), a 12-week, group-format self-management program led by lay health coaches. Adults with type 2 diabetes (N = 312) completed baseline assessments of sociodemographic characteristics, diabetes history, and mental health. Four outcomes were assessed pre- and post-DCP on 141 participants who completed the program: hemoglobin A1C (A1C), weight, depressive symptoms (Patient Health Questionnaire-8), and glucose monitoring. The team worked with a Community Advisory Board throughout the research process. Results The DCP had wide geographic reach, including lower-income neighborhoods. The average age of the participants was 53.9 years, 71.4% were female, and 69% were African American. During the DCP, A1C declined from 8.4% to 7.6% (P < .001), but weight was unchanged (229.2 vs 227.9, P < .282). During the DCP, the proportion of participants with clinically significant depressive symptoms declined from 32.4% to 15.5% (P < .001), and frequency of glucose monitoring significantly increased. Conclusions The YMCA of Greater Richmond DCP has wide reach into underserved populations throughout the metropolitan area. This program is effective at improving diabetes self-management and mental health. Findings have implications for supporting academic-community partnerships to address diabetes disparities.

Impact of Collaborative Shared Medical Appointments on Diabetes Outcomes in a Family Medicine Clinic

Purpose

The purpose of this study is to evaluate the impact of a collaborative diabetes shared medical appointment on patient outcomes in an urban family medicine practice.

Methods

Fifty-nine patients were enrolled to participate in multiple shared medical appointments (SMAs) over 12 months. Baseline data included hemoglobin (A1C), lipids, systolic blood pressure (SBP), weight, adherence to American Diabetes Association (ADA) guidelines, and surveys, including the Problem Areas in Diabetes (PAID-2) scale and the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD). A1C and SBP were evaluated at each visit. Lipid control was assessed at baseline and at 6 and 12 months. Adherence to ADA guidelines, SKILLD and PAID-2 survey scores, and number of antihyperglycemic and antihypertensive medications were also evaluated at 12 months.

Results

Thirty-eight patients completed the study. Compared with baseline, A1C and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly over 12 months ( P < .001 and P = .004, respectively). More patients became compliant with the ADA guidelines throughout the course of the study. Specifically, more patients achieved the LDL-C goal of ≤100 mg/dL (2.59 mmol/L; P < .001), were prescribed appropriate antihypertensive medications ( P < .001) and aspirin ( P < .001), and received the pneumonia vaccine ( P < .001). PAID-2 and SKILLD survey scores also significantly improved over the course of the study ( P ≤ .001 and P = .003, respectively).

Conclusion

Short-term interdisciplinary SMAs decreased A1C and LDL-C, improved patient adherence to ADA guidelines, improved emotional distress related to diabetes, and increased knowledge of diabetes.

Walk-in clinics versus physician offices and emergency rooms for urgent care and chronic disease management

BACKGROUND

Walk-in clinics are growing in popularity around the world as a substitute for traditional medical care delivered in physician offices and emergency rooms, but their clinical efficacy is unclear.

OBJECTIVES

To assess the quality of care and patient satisfaction of walk-in clinics compared to that of traditional physician offices and emergency rooms for people who present with basic medical complaints for either acute or chronic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers on 22 March 2016 together with reference checking, citation searching, and contact with study authors to identify additional studies. We applied no restrictions on language, publication type, or publication year.

SELECTION CRITERIA

Study design: randomized trials, non-randomized trials, and controlled before-after studies.

POPULATION

standalone physical clinics not requiring advance appointments or registration, that provided basic medical care without expectation of follow-up. Comparisons: traditional primary care practices or emergency rooms.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

The literature search identified 6587 citations, of which we considered 65 to be potentially relevant. We reviewed the abstracts of all 65 potentially relevant studies and retrieved the full texts of 12 articles thought to fit our study criteria. However, following independent author assessment of the full texts, we excluded all 12 articles.

AUTHORS' CONCLUSIONS

Controlled trial evidence about the mortality, morbidity, quality of care, and patient satisfaction of walk-in clinics is currently not available.

A qualitative study examining healthcare managers and providers' perspectives on participating in primary care implementation research

BACKGROUND

Primary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research.

METHODS

Guided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts.

RESULTS

Two major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues.

CONCLUSIONS

Healthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.

Cost-Effectiveness Evaluation of Collaborative Care for Diabetes and Depression in Primary Care

INTRODUCTION

Information is limited on the cost effectiveness of strategies to improve depressive symptoms in patients with Type 2 diabetes in primary care outside of the U.S.

METHODS

Using patient data from a 12-month controlled implementation trial, outcomes and healthcare costs determined through administrative database linkages were compared for a strategy of family physician notification and follow-up ("enhanced care") versus collaborative care. Two measures of effectiveness were used: depression-free days (DFDs) based on Patient Health Questionnaire, and quality-adjusted life years (QALYs) based on EQ-5D. Data were collected November 2010 to January 2013 with analyses completed in May 2015. Incremental cost-effectiveness ratios were also compared against true usual care patients.

RESULTS

Among 227 patients, mean age was 58 years, 55% were female, and mean diabetes duration was 12 years. Compared with total 12-month cost per usual care patient (C$5,889), the incremental cost was C$450 for patients in enhanced care and C$1,021 for collaborative care. Both enhanced and collaborative care strategies improved outcomes compared with usual care, with incremental DFDs of 65.9 and 117.6, and incremental QALYs of 0.006 and 0.042, respectively. Compared with enhanced care, collaborative care yielded incremental cost-effectiveness ratios of C$11/DFD and C$15,861/QALY. Compared with usual care, the incremental cost-effectiveness ratios were C$7/DFD or C$76,271/QALY for enhanced care and C$9/DFD or C$24,368/QALY for collaborative care.

CONCLUSIONS

In primary care patients with Type 2 diabetes who screened positive for depression, physician notification and follow-up was a clinically effective strategy compared with usual care, but investing more resources in collaborative care yielded the most cost-effective strategy.