Collaborative Psychiatric Care in a Rural Family Medicine Setting Reduces Health Care Utilization in Depressed Patients

January 2007 | Back to Table of Contents

Clinical and Health Affairs

Collaborative Psychiatric Care in a Rural Family Medicine Setting Reduces Health Care Utilization in Depressed Patients

By Bruce Sutor, M.D., and David C. Agerter, M.D.

Abstract
Collaborative care by primary care physicians and psychiatrists has been shown to improve adherence to treatment and symptoms in patients with major depression. The authors examined whether such a care model would alter health care utilization by depressed patients. Ambulatory visits and inpatient hospital days were compared for 49 patients with depression and 49 matched patients (age/gender/severity of co-morbid conditions) who were not depressed. Use of health care services was measured 1 year before intervention and 1 year after intervention and compared with that of the control patients. The authors concluded that depressed patients make fewer visits to health care providers when a psychiatrist is involved in their care.

It has long been recognized that depression is associated with increased morbidity and mortality.^1-4 Depressed patients are less likely to adhere to treatment recommendations and suffer more somatic symptoms that lead to more medical visits and evaluations.⁵ Research into depression’s effects on health care utilization indicates that depressed patients may use more services than individuals who are not depressed, thus increasing their overall health care costs. ^6-8

Most people with depression are treated exclusively by primary care clinicians who, as a group, tend to underdiagnose and undertreat depression.⁹The possible reasons why include length of clinic visits, inadequate training, and confounding somatic presentations of depressed patients. Access to psychiatrists and other mental health professionals also can prevent patients from receiving effective treatment for their depression. This is especially problematic in rural areas where there are fewer practicing psychiatrists and where patients often must travel long distances for a specialty evaluation.

Katon and colleagues have developed a collaborative care model in which primary care clinicians and psychiatrists work together to evaluate and treat patients with depressive and anxiety disorders.^10,11 Collaborative care has been shown to improve adherence to treatment and symptoms in patients with major depression. These results come with a modest increase in cost.¹²

At the Mayo Family Clinic Kasson, a rural family medicine clinic that serves as a teaching facility for physicians in Mayo Clinic’s family medicine residency program, we developed and implemented a program that provides psychiatric consultation, follow-up, and collaboration. Patients referred for psychiatric evaluation are seen in the clinic and are often introduced to the psychiatrist by the referring clinician. Ongoing care is then shared by the psychiatrist and family physician, depending on the patient’s needs. Patients with more severe psychiatric illness, medical co-morbidity, or treatment-refractory illness might be seen more frequently by the psychiatrist; those with less severe illness or who respond quickly might be seen by the psychiatrist for consultation only, with all additional follow-up provided by a family physician. The goals of the program are to improve patient access to psychiatric care, develop better working relationships between family physicians and psychiatrists, and improve educational experiences for family medicine residents and staff physicians.

The following is a summary of our findings regarding health care utilization by depressed patients who were treated collaboratively in our primary care clinic. The goals of the study were to examine health care utilization patterns of patients with depression and to explore what effect psychiatric consultation and collaborative care have on these patients’ overall usage.

Patients and Methods
Ours was a clinically based, retrospective study. We selected the medical charts of the 197 patients at Mayo Family Clinic Kasson who were referred for psychiatric consultation between 2000 and 2003. We reviewed the charts of those patients who received a primary diagnosis of a depressive disorder (major depression, dysthymia, depressive disorder NOS). Two patients who had not provided consent for use of their medical charts in research were eliminated from the study, as were 146 who did not meet DSM-IV-TR criteria for a depressive disorder as their primary psychiatric diagnosis.¹³

The chart analysis for each of the 49 patients selected for the study covered 26 months—the 12 months before consultation, the 2 months of treatment, and a 12-month follow-up comparison period. Ambulatory visits to primary care and specialty care providers as well as inpatient hospital days were tabulated for each patient.

Medical co-morbidity at the time of consultation was rated on a scale of 0 to 3:
0 = trivial or no medical conditions (eg, an upper respiratory infection);
1 = mild; a single well-controlled medical condition (eg, diabetes under good control);
2 = moderate; 2 well-controlled medical conditions or a single medical condition causing functional debility (eg, diabetes under somewhat poor control);
3 = severe; 3 or more well-controlled medical conditions, or 1 or more medical condition causing great functional debility (eg, diabetes that is difficult to control and sequelae such as neuropathic pain or diabetic retinopathy).

Patients with depression were matched (age, gender, medical condition severity) with control patients who were not depressed but were treated at the clinic during the same time period. Matching metrics were obtained and tabulated for the control subjects. Paired 2-tail t-testing utilizing SPSS statistical programming was used to compare data from the groups.

Study Setting
The Mayo Family Clinic Kasson is located in a community of 4,500 people in southeastern Minnesota. Eight full-time family physicians staff the facility and supervise 24 family medicine residents and 2 nurse practitioners. Approximately 40,000 patient visits take place at the facility each year. A limited amount of specialty care (physical therapy, dietician services, psychiatry, psychology, and diabetes care) is available at the facility. Patients are referred to Mayo Medical Center in Rochester for tertiary services, diagnostic testing, emergency services, and inpatient hospital care.

Results
The mean age of the patients enrolled in the study at the time of initial consultation was 44 years for those with depression and 45 years for those without. Forty-one percent of the patients in each group were male and 59% were female. More than half (57%) had trivial-to-mild medical co-morbidity, and 43% had moderate-to-severe medical co-morbidity. Mean mental health care provider visits were tabulated for the 2-month intervention interval and the 12-month follow-up period. Mean mental health care visits during the 14-month period was 2.7, with a range of 1 to 11 total visits.

Our initial goal was to examine health care utilization for the entire sample (Figure 1). We considered the number of ambulatory outpatient visits to primary care and specialty care providers, total ambulatory visits, and hospitalization days for each group. We found that when compared with the control group, the depressed patients tended to utilize both primary care and specialty care more frequently than their counterparts who were not depressed. However, we saw a statistically significant decline in primary care visits and in total health care visits for depressed patients after the intervention. This indicates that depressed patients make fewer visits to health care providers if a psychiatrist has been involved in their care.

Our second goal was to see if the severity of co-morbid medical illness made a difference in overall health care utilization. Figure 2 compares the number of ambulatory visits and inpatient hospital days for depressed patients with trivial-to-mild medical problems with those of patients who are not depressed. Among this population, primary care visits and total ambulatory care visits declined significantly following the psychiatric intervention. After the intervention, use of services by depressed patients with trivial-to-mild medical problems was similar to that of the control group.

Among depressed patients with moderate-to-severe medical co-morbidity, we did see a substantial but not statistically significant decrease in hospitalization days and primary care visits following psychiatric intervention (Figure 3). However, despite intervention, this group still utilized ambulatory medical services significantly more than their counterparts who were not depressed.

Discussion
Our original hypothesis was that using a collaborative care model for treating patients with depression would result in decreased health care utilization. The results of our study support this hypothesis, regardless of whether the patient had mild or severe co-morbidities in addition to their depression. One possible explanation for the decrease in usage is that patients with improved mood require fewer health care visits for depression itself, thus decreasing total health care visits. Successful treatment of depression also may reduce patient perception of physical symptoms, reduce incapacity as a result of those symptoms, improve efficacy of medical interventions, and improve patient compliance with medical treatment.

Despite such findings, we noticed that depressed patients continue to use the health care system more frequently than nondepressed patients, even after intervention. The overall trend, however, is for collaborative care patients to utilize health care more like nondepressed patients. Perhaps a larger study group would have shown this trend to be statistically significant.

Our study had a number of limitations. It was small and retrospective with unblinded raters. There was a selection bias in that more severely depressed or treatment refractory patients were likely to be referred for collaborative care. The rating of medical severity is somewhat subjective and relies on clinical documentation, which can vary among providers. Although most of the patients received their medical care exclusively within the Mayo system, undoubtedly some will have received care at other facilities or from nontraditional providers, thus making our tabulations of health care utilization incomplete. Also, given the retrospective nature of this study, standardized depression rating scales were not utilized and no standard criteria beyond that of the psychiatric evaluation were applied to support or verify the diagnosis of a depressive disorder.

Conclusion
Several roadblocks stand in the way of implementing a collaborative care model for the treatment of depression. Given the shortage of psychiatrists, particularly in rural areas and the inner city, it is not feasible for most primary care clinics to have a psychiatrist working on site. Limited reimbursement models for psychiatric care also serve as a disincentive for primary care clinics to employ a psychiatrist. Additionally, although telephonic and electronic consultations are an important part of collaborative care, such activity takes time and effort for which providers are not financially compensated in most systems.

Despite the limitations, we believe that the results of our study support the hypothesis that collaborative care involving psychiatrists and family physicians in the evaluation and treatment of patients with depression can reduce overall health care utilization. Larger prospective studies with objective depression rating scales are needed to further support our conclusions. MM

Bruce Sutor is an assistant professor in the department of psychiatry and psychology and David Agerter is an associate professor in the department of family medicine at Mayo Clinic.

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