The Effect of Adherence to Practice Guidelines on Depression Outcomes

Published in: Annals of Internal Medicine, v. 147, no. 5, Sep. 4, 2007, p. 320-329

Posted on RAND.org on January 01, 2007

by Kimberly A. Hepner, Melissa Rowe, Kathryn Rost, Scot Hickey, Cathy D. Sherbourne, Daniel Ford, Lisa S. Meredith, Lisa V. Rubenstein

Read More

Access further information on this document at www.annals.org

This article was published outside of RAND. The full text of the article can be found at the link above.

BACKGROUND: Few studies have assessed clinician adherence to depression practice guidelines and the relationship between clinician adherence and depression outcomes. OBJECTIVE: To estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes. DESIGN: Observational analysis of data collected from 1996 to 1998 in 3 randomized clinical trials. SETTING: 45 primary care practices in 13 U.S. states. PATIENTS: 1131 primary care patients with depression. MEASUREMENTS: Expert panel methods were used to develop a patient survey-based index that measured adherence to clinical practice guidelines on depression. Rates of adherence to the 20 indicators that form the index were evaluated. Multivariable regression that controlled for case mix was used to assess how index scores predicted continuous and dichotomous depression measures at 12, 18, and 24 months. RESULTS: Quality of care was high (clinician adherence 79%) for 6 indicators, including primary care clinician detection of depression. Quality of care was low (adherence, 20% to 38%) for 8 indicators, including management of suicide risk (3 indicators), alcohol abuse (2 indicators), and elderly patients; assessment of symptoms and history of depression; and treatment adjustment for patients who did not respond to initial treatment. Greater adherence to practice guidelines significantly predicted fewer depressive symptoms on continuous measures (P < 0.001 for 12 months, P < 0.01 for 18 months, and P < 0.001 for 24 months) and dichotomous measures (P < 0.05 for 18 and 24 months). LIMITATIONS: Data are based on patient self-report. Possible changes in practice since 1998 may limit the generalizability of the findings. CONCLUSIONS: Adherence to guidelines was high for one third of the recommendations that were measured but was very low for nearly half of the measures, pointing to specific needs for quality improvement. Guideline-concordant depression care appears to be linked to improved outcomes in primary care patients with depression.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit www.rand.org/about/principles.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.