Effect of Improved Primary Care Access on Quality of Depression Care

Abstract

PURPOSE We wanted to determine whether a major improvement in access to primary care during 2000 was associated with changes in the quality of care for patients with depression.METHODS Health plan administrative data were analyzed by multilevel regression to compare the quality of care received by patients with depression between 1999 and 2001, a time without major changes in depression care guidelines. Approximately 6,000 patients with depression who received all care in a large multispecialty medical group during any single year were subjects for this study. Thirteen different quality measures assessed process quality under the dimensions of effectiveness, timeliness, safety, and patient-centeredness. RESULTSThe largest change was a reduction in the proportion of depressed patients with no follow-up visit in primary care after starting a new antidepressant medication: from 33.0% before a change in access to care to 15.4% afterward, P =.001. During the same period, continuity of care in primary care improved (>50% of primary care visits to 1 doctor increased from 67.3% to 74.0%, P = <.001), as did persistence of 6-month antidepressant medication (from 46.2% to 50.8%, P = <.001). Further analyses found that the latter change was primarily associated with the change in continuity of care. Measures of subspecialty mental health care worsened during this time.CONCLUSION Marked improvement in access to primary care for 1 year was associated with some improvement in primary care for patients with depression, but the mechanism appeared to be improved continuity. Those planning to implement advanced access to care need to do so in such a way that continuity of care is enhanced rather than harmed by the change. 1 This report identifi ed 6 domains or aims of quality: safety, timeliness, effectiveness, effi ciency, equity, and patient-centeredness, each of which had large gaps between "the care we have and the care we could have." Although the report identifi ed a whole series of recommendations to improve quality, it did not address the relationship between the different domains, and it is unclear whether improvements in any particular domain will improve others as well.Although the IOM reports dramatically raised the national awareness about quality, it is not clear that much has happened to change care since then, with the possible exception of what the IOM called "timeliness" ("reducing waits and sometimes harmful delays"). Recent articles suggest that many medical groups are making substantial improvements in access to primary care through using an advanced access model of patient scheduling or Second Generation Open Access. 2,3 In this approach, the goal is to offer patients an offi ce visit with the patient' s personal physician the same day the 70IMPROVED ACCESS AND DEPRESSION CARE patient requests one (if that physician is in the offi ce that day and if the patient wants an appointment that day).Although most reports about successful implementation of advanced access are either anecdotal or case studies,...

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“…16,[18][19][20][21][22] Fortunately, that study was supplemented by studying the approach to change by a small and exemplary family practice group. 21 Some of my previous experiences that are especially worth highlighting follow.…”