Pathways and TEAMcare Studies (Text Version)

On September 27, 2010, Wayne Katon, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (530 KB). 

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Slide 1

Pathways and TEAMcare Studies

Wayne Katon, MD¹
Mike VonKorff, ScD²
Elizabeth Lin, MD, MPH²
Paul Ciechanowski, MD, MPH¹
Evette Ludman, PhD²
Carolyn Rutter, PhD²
Bessie Young, MD, MPH¹
Do Peterson, MS²
David McCulloch, MD²

¹University of Washington School of Medicine
²Group Health Research Institute NIMH Grants MH 41739 and MH 01643 (Dr. Katon)

Slide 2

Health Services Models

TEAMcare approaches have been shown to improve quality of care and outcomes of patients with depression, diabetes, asthma and CHF.

The most complex and medical costly patients often have multiple comorbidities including at least one mental health diagnosis.

Slide 3

Medicare Patients

• Depression, diabetes and heart disease are among the most common illnesses in aging populations but fewer than 4% of Medicare beneficiaries with any of these three illnesses have no other chronic medical conditions.
• 80% of those with CHF, 71% with depression and 56% with diabetes have 4 or more chronic conditions.

Partnership for Solutions 2001.

Slide 4

161,697 Patients with Diabetes were Examined to Estimate Rates and Reasons for Poor Disease Control (HbA1c, SBP, LDLs)

• 20% to 23% poor adherence.
• Among those with adequate adherence, 30% to 47% had no evidence of treatment intensification.
• Poor adherence and lack of treatment intensification were found in 53% to 68% of patients with poor disease control.

Schmittdiel J, et al. 2008

Slide 5

Challenge: Development of Health Services Models for "Natural" Clusters of Illness

Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions.

• Examples:
  • Diabetes, CAD, depression
  • Depression, chronic pain, substance abuse

Slide 6

New NIMH-Funded Study: TEAMcare Inclusion Criteria

• Evidence via automated date (ICD-9) of having diabetes and/or coronary artery disease (CAD).
• Evidence of poor disease control (HbA_1c >8.5, blood pressure >140/90, LDL >130).
• PHQ-9 ≥10.

Slide 7

Recruitment

• 14 GH clinics (e.g. Olympia, Everett, Silverdale, and BVU).
• 150 primary care physicians signed consent.
• 9,838 PHQ-2 screeners mailed.
• 214 Patients randomized:
  • 106 Intervention (106)
  • 108 Control

Slide 8

TEAMcare Intervention Goals

• Improve depression care: behavioral activation and antidepressants.
• Improve medical disease control: HbA_1c, HTN, LDL.
• Improve self-care (diet, exercise, cessation of smoking, glucose checks).

Slide 9

Core Elements

• Nurse Care Management:
  • Identify Goals—specific, measurable (BP, HbA_1c, PHQ-9, # steps).
  • Monitor Progress of Targets—systematic, pro-active.
  • Treat-to-Target—relentless adjustment, Individualized.
  • Support Self-Care—adherence to medication adjustments.
  • Regular Clinical Review—supervised case reviews, Tx recommendations.

Slide 10

TEAMcare Interventionists

• 3 diabetes nurse educators
• Caseload supervision:
  • Depression: 2 psychiatrists
  • Diabetes and CAD: nephrologist, family doctor
  • E-Mail to diabetologist for complex cases

Slide 11

Nurse Training

• Motivational interviewing
• Problem solving
• Behavioral activation
• Antidepressants
• Treat-to-Target: blood glucose, HTN, LDLS

Slide 12

TEAMcare Summary Report

Initial	Clinic	Enroll Date	PHQ		BP		HbA1c		LDL
			BL	Now	BL	Now	BL	Now	BL	Now
	NSH	5/19/2008	19	19	141/69	127/77	7.3	6.8	168	138
	NSH	1/9/2008	15	2	118/80	130/80	9.2	8.3	138	124
	EVM	11/12/2007	14	9	160/98	150/85	6.4	6.8	108	67
	EVM	10/30/2007	13	2	209/119	126/76	7.3	7.7	119	103
	LYN	8/23/2007	14	3	149/71	111/58	8.1	7.7	85	82

Slide 13

Improving Adherence

• Patient self-care materials: book and video on depression, patient manual (Tools for Managing Your Chronic Disease)
• Nurse support/education/motivational interviewing
• Medisets
• Simplifying medication regimen
• $4 generics to avoid $10 co-pays

Slide 14

Self-Care Enhancements

• Glucometers: Group Health provides
• Home blood pressure monitors
• Pedometers to increase exercise
• Medisets to improve adherence

Slide 15

Phases of Treatment

• Intervene on depression initially
  • Behavioral activation
  • Antidepressant medication

Slide 16

Medical Disease Control

• Is patient adhering to medication regimen?
• If adhering and in poor control, is patient on optimal dosage?
• If maximum dosage has been reached should a new medication be tried instead or augmentation of initial medication?
• Team recommendations of medication changes are reviewed with primary care physician for approval.

Slide 17

Treat-to-Target Guidelines

• Nurses ask for physician approval for gradually increasing insulin or blood pressure medications based on these guidelines.

Slide 18

Behavioral Goals

• Behavioral activation/exercise
• Dietary changes
• Checking blood glucose/altering insulin
• Cessation of smoking

Slide 19

Mean of SCL Score

Image: Line graph shows mean SCL score dropping over 12 months. The table below provides details.

Mean	Baseline	6 months	12 months
Intervention mean (N)	1.7 (105)	0.8 (97)	0.8 (94)
Control mean (N)	1.7 (106)	1.3 (96)	1.1 (92)

Slide 20

Mean of HbA1c

Image: Line graph shows mean of HbA1c dropping over 12 months. The table below provides details.

Mean	Baseline	6 months	12 months
Intervention mean (N)	8.1 (105)	7.4 (99)	7.3 (101)
Control mean (N)	8.0 (105)	7.9 (95)	7.8 (97)

Slide 21

Mean of Systolic BP

Image: Line graph shows mean of systolic blood pressure (BP) changing over 12 months. The table below provides details.

Mean	Baseline	6 months	12 months
Intervention mean (N)	135.7 (105)	131.9 (102)	131.0 (101)
Control mean (N)	131.9 (106)	133.5 (101)	132.3 (101)

Slide 22

Mean of LDL

Image: Line graph shows mean of LDL dropping over 12 months. The table below provides details.

Mean	Baseline	6 months	12 months
Intervention mean (N)	106.8 (105)	N/A	91.9 (98)
Control mean (N)	109.4 (103)	N/A	101.4 (90)

Slide 23

Any Adjustment

Image: Bar graph compares I (Intervention) and UC (Control) for various factors. The table below provides details.

	UC	I
OH	26%	38%
IH	33%**	53%**
AH	49%***	77%***
LL	40%*	56%*
AD	30%***	88%***

*p-value <0.05; ** p-value <0.01 ; ***p-value <0.001.

Slide 24

Satisfaction with Care of Depression

Image: Bar graph shows satisfaction with depression care over time. The table below provides details.

Time	Intervention	Control
Baseline	51%	47%
6 months (p <.001)	87%	62%
12 months (p <.001)	90%	55%

Slide 25

Satisfaction with Care of Diabetes and/or CHD

Image: Bar graph shows satisfaction with diabetes or coronary heart disease (CHD) care over time. The table below provides details.

Time	Intervention	Control
Baseline	70%	68%
6 months (p <.001)	90%	68%
12 months (p <.001)	86%	70%

Slide 26

Conclusions

• Economies of scale: New health services interventions are needed for patients with multiple comorbidities (one of which is a psychiatric disorder).
• The TEAMcare model is a promising approach to improving depression and medical disease control.