Providing individualized, multidisciplinary care to individuals with both depression and diabetes improves outcomes for these patients and cuts the cost of their care, according to findings reported today in the Archives of General Psychiatry.
Many patients with diabetes struggle with the demands of self care, which may require taking frequent blood glucose measurements, reliably taking medication, and making frequent follow-up visits with their clinician. But those who also have depression face additional difficulties following through on their own diabetes care while also managing their depression. As a result, individuals who have both disorders often have poorer treatment outcomes and may rack up considerable health care costs.
Recognizing that traditional care often fails these patients, Wayne Katon, MD, and his colleagues at the University of Washington in Seattle teamed up with the Group Health Research Institute, the research arm of Group Health Cooperative, a nonprofit health system serving more than 600 000 members in Washington and northern Idaho, to probe whether interdisciplinary team-based care might be a better option. They conducted a randomized trial of 215 patients with poorly controlled diabetes and depression from 14 primary care offices within Group Health Cooperative’s integrated care system. Patients were randomized to receive either usual care or team care. Patients in the team care group were assigned a nurse manager, who was supervised by psychiatric and endocrine specialists and who shared these specialists’ care recommendations with each patient’s primary care physician.
Dr Katon discussed the results of the study with news@JAMA.
news@JAMA: What do these latest findings add to results you previously published from this study in 2010?
Dr Katon: [In the 2010 study], we found that team care not only improved patients’ depression but also dramatically improved LDL cholesterol levels, blood pressure, and hemoglobin A1c. Patients were more satisfied with their care, their functioning was better, and they reported a higher quality of life. This study adds 24 months of follow-up data and an analysis of cost-effectiveness.
news@JAMA: What do the findings you’re reporting today tell you about the costs of team care vs traditional care for these patients?
Dr Katon: These are expensive patients. The baseline cost of their care was $11 000 to $12 000 over two years. The cost of the team care intervention was about $1200 over two years, but these patients incurred about $1800 less in medical costs than those receiving traditional care, so there was a net savings of about $600 per patient. These savings were based on the Group Health system model, where practices are paid a set fee per year to care for a particular patient and they can’t bill separately for the nurse manager’s time. If you could bill for the nurse manager’s services, you could save more.
news@JAMA: What would the savings be in a fee-for-service setting, which is typical for most primary care practices in the United States?
Dr Katon: We estimated that the savings in a fee-for-service setting would be $1100 to $1200 per patient over two years.
news@JAMA: Why do you think the intervention worked and helped cut costs?
Dr Katon: People with comorbid depression and other medical conditions do poorly in our health care system. It’s hard to get mental health care. People who are depressed have trouble just taking their medication every day and they don’t manage their condition well. A lot of these folks fall through the cracks [in traditional primary care]. They miss appointments. Their appointments take longer. They are very frustrating for physicians. These are the most expensive patients, and that’s where you can save the most health care costs.
In a team care setting, the nurse is in frequent contact with the patient. If the patient doesn’t show up, the nurse follows up with them. If the patient needs extra resources, the nurse tries to get them those resources. The nurse is teaching them about how to manage their illness and is really developing a relationship with them. The nurse also acts a bridge between the specialists and primary care physician. When the patients get their depression under control, they are better able to manage their diabetes. The team model helps the health care system take better care of these patients.