Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions
Science Update •
People with diabetes or heart disease plus depression fare better if their medical care is coordinated by a care manager who also educates patients about their condition and provides motivational support, compared to those who receive care from their primary care physician only, according to an NIMH-funded study published December 30, 2010, in the New England Journal of Medicine.
Coexisting depression is common among patients with diabetes or heart disease, especially if their medical conditions are poorly controlled. Having depression puts these patients at higher risk for poor self-care and more medical complications, and a higher risk for death. Patients dealing with multiple chronic conditions also tend to incur higher medical costs.
Wayne Katon, M.D., of the University of Washington, and colleagues at Group Health Research Institute in Seattle developed a team-based intervention approach—TEAMcare—that aimed to improve medical outcomes and ease depression symptoms among these patients. They tested the intervention in a randomized controlled trial of 214 participants in 14 primary care clinics in Washington state. The participants all had poorly controlled diabetes and/or heart disease with coexisting depression.
Half of the patients were randomized to a 12-month trial of TEAMcare, in which a medically supervised nurse care manager coordinated their care with their primary care provider (PCP) and other medical professionals. The nurse care manager also helped patients set goals for controlling their medical conditions, provided motivation and education about taking their medications correctly, consulted with patients' PCPs about changes in medications recommended by supervisors, and encouraged better self-care. The other half of the participants received usual care, in which their PCP consulted with them about depression care and medical disease control, but they did not have a nurse care manager coordinating their care.
Results of the Study
Overall, patients in the TEAMcare intervention fared better than those in usual care. Symptoms of depression eased in the TEAMcare group more so than in the usual care group. Patients in the TEAMcare intervention also showed greater improvements in blood glucose levels, blood pressure and "bad" cholesterol levels, compared to patients in usual care. Patients in TEAMcare were also more likely to have their medications adjusted, indicating a desire to fine-tune their care to achieve better results. TEAMcare patients also reported greater satisfaction with their medical care and a higher quality of life.
Previous research suggests that patients who are more satisfied with their medical care tend to be more motivated to take better care of themselves and therefore have better outcomes. According to the researchers, TEAMcare offers a promising way of improving outcomes in patients with multiple medical illnesses and depression because it provides systematic patient support as well as assistance to PCPs.
The researchers also note that patients with multiple medical conditions tend to have high health care costs. The study results suggest that a proactive, coordinated intervention like TEAMcare may facilitate better, more efficient care of these patients in particular.
TEAMcare was tested among a specific population enrolled in one health plan, using highly trained nurse care managers. Further study is needed to determine whether the approach can be cost-effectively applied to broader populations, and whether less experienced nurse care managers could be used without sacrificing quality of care.
Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Multi-condition collaborative care for chronic illnesses and depression. New England Journal of Medicine. Dec. 30, 2010.