Do Patients of Racial/Ethnic Minority and
Lower SES Use Depression Care
Management Differently?
Yuhua Bao, Ph.D.
Division of Health Policy, Department of Public Health
Weill Cornell Medical College
2009 AcademyHealth Annual Research Meeting
Chicago, IL
June 30, 2009
Acknowledgement
The following people provided helpful discussion and guidance (in
alphabetical order)
Martha L. Bruce, Ph.D.
Julie M. Donohue, Ph.D.
Edward P. Post, M.D., Ph.D.
Thomas R. Ten Have, Ph.D.
I thank the PROSPECT team for granting me access to the PROSPECT
data, and participants at the Weill Cornell Health Policy/Outcomes
and Geriatric Psychiatry research-in-progress seminars, for helpful
comments.
Funding from the Pfizer Scholars Grant in Health Policy supported my
time in managing the PROSPECT intervention data.
2
Collaborative Depression Care Management
(DCM) Model
• A team of clinicians
– Depression care manager
– Primary care physician (PCP)
– Consulting psychiatrist
• Care manager
– Works with PCP and patient to establish a treatment plan
– Follows up with patient to
• Assess depression symptoms
• Monitor medication effectiveness and side effects
• Promote medication adherence
– Revise treatment plan and/or consult with psychiatrist
• Over 30 RCTs provided strong evidence for efficacy
of the model
• Offers potential to compensate for poor selfmanagement and ineffective physician-patient
communication
3
Racial/Ethnic and Socioeconomic Disparities
in Depression Care
• Previous studies found persistent disparities in
– Access to depression care
– Level of guideline-concordant, appropriate care
• Underlying mechanisms are likely multi-fold
– Health care systems level
– Patient population level
– Care encounter level
• Health literacy / understanding of treatment strategies
• Self-management and treatment compliance
• Physician bias/stereotype
4
Racial/Ethnic and Socioeconomic Disparities
in Depression Care
• Previous studies found persistent disparities in
– Access to depression care in specialty and non-specialty
settings
– Level of guideline-concordant, appropriate care
• Underlying mechanisms are likely multi-fold
– Health care systems level
– Patient population level
– Care encounter level
• Health literacy / understanding of treatment strategies
• Self-management and treatment compliance
• Physician bias/stereotype
Can collaborative DCM help?
5
Research Questions of Interest
Research Question 1
Do patients of racial/ethnic minority and lower SES use
collaborative DCM differently?
Research Question 2
Does DCM help these patients more in improving
treatment processes such as antidepressant
medication?
Research Question 3
Does DCM help patients of racial/ethnic minority and
lower SES more in improving their depression treatment
outcomes?
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Research Questions of Interest
Research Question 1
Do patients of racial/ethnic minority and lower SES use
collaborative DCM differently?
Research Question 2
Does DCM help patients of racial/ethnic minority and
lower SES more in improving antidepressant
medication?
Research Question 3
Does DCM help patients of racial/ethnic minority and
lower SES more in improving their depression treatment
outcomes?
7
The PROSPECT Study
• A multi-site, clinic randomized controlled trial
of DCM
– Older depressed primary care patients (60+)
– 20 primary care practices at 3 different sites
– No special accommodations for minority patients
• All patients need be able to communicate in English
• Research funding supported DCM for up to 2
years
– Thus taking out the “access to care” factor
• N=599 with major or clinically significant
minor depression at baseline
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Racial/Ethnic and Education Breakdown of
Prospect Sample
Race/
Ethnicity
Education
N
%
White
419
70%
African American
163
Other
67%
27%
NonHispanic
white
16
3%
Minority
33%
Hispanic
26
4%
Less than high school
155
26%
High school
204
34%
Some college
238
40%
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Data and Measures
• The Intervention Checklist (ITCK) Data
– ITCK forms filled out periodically by care managers for each
patient
– Documented
• # of care manager contacts with patient, PCP, and family members
• Care manager time spent one each type of activities
–
–
–
–
–
Patient assessment
Medication management (effectiveness and side effects)
Care coordination
Administrative tasks
Other (including patient and family education)
– All measures aggregated to 3-month intervals
• PROSPECT baseline research interview
– Baseline depression diagnosis and severity
– Social and demographic data
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Analytical Approaches
• Descriptive analysis of DCM use by patient race/ethnicity
and education
– Ever used DCM
– Care manager contacts and time
• Negative binomial regressions of care manager contacts
and time during each quarter of the first year
– As a function of:
• minority, education, quarter of the year
• Minority x quarter, education x quarter
– Control for patient demographics, baseline depressive symptoms, Charlson comorbidity
score, and study site indicators
– Robust standard errors
– Adjusted Incident Rate Ratios (IRRs) between groups
e.g. IRR(minority/white)=2: minority patients use twice as much DCM as whites during a
given time interval
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Baseline Depression by Patient
Race/Ethnicity and Education
Minority
NonHispanic
White
Less
Than
High
School
High
School
Some
College
17.9
18.0
19.1
18.0
17.1
% Major
depression
68.7%
65.2%
68.4%
70.1%
61.3%
% With
suicidal
ideation
22.6%
26.4%
27.1%
24.5%
24.4%
HDRS score
HDRS: Hamilton Depression Rating Scale
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Ever Used DCM
100
90
88.6
88.5
< high school
high school
91.6
80
%
70
60
50
40
30
20
some college
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Care Manager Contacts and Time
An example
Number of Contacts w/ Patient
By Education
Num ber of Contacts w / Patient
By Race/Ethnicity
12.0
12.0
< High school
Minority
10.0
10.0
8.0
8.0
NonHispanic
w hite
6.0
4.0
High school
6.0
4.0
Som e college
2.0
2.0
0
3
6
Months
9
12
0
3
6
9
12
Months
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Adjusted Minority/White Differences in DCM Use
Adjusted Incident Rate Ratios
(IRRs)
0-3 mo.
3-6 mo.
6-9 mo.
9-12 mo.
Patient
1.2
[1.0, 1.4]
1.2
[0.9, 1.6]
0.9
[0.6, 1.2]
0.7
[0.5, 1.0]
PCP
1.0
[0.8, 1.2]
0.9
[0.6, 1.4]
0.8
[0.5, 1.2]
0.6
[0.4, 1.1]
Family
Members
1.5
[0.8, 3.0]
1.0
[0.5, 2.2]
1.0
[0.5, 2.0]
1.0
[0.4, 2.3]
Patient
Assessment
1.0
[0.8, 1.2]
0.9
[0.7, 1.3]
0.7
[0.5, 0.9]
0.6
[0.4, 0.9]
Medication
Management
1.3
[1.0, 1.7]
1.3
[0.9, 2.0]
0.8
[0.5, 1.1]
0.6
[0.4, 1.0]
Care
Coordination
0.7
[0.5, 1.1]
0.8
[0.5, 1.5]
0.3
[0.2, 0.7]
0.7
[0.4, 1.4]
Contacts
Time
Results based on negative binomial models with robust standard errors with clusters specified at the patient level.
Ninety-five percent confidence intervals of IRRs are shown in square brackets.
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Adjusted Less Than High School/Some College
Differences in DCM Use
Adjusted Incident Rate Ratios
(IRRs)
0-3 mo.
3-6 mo.
6-9 mo.
9-12 mo.
Patient
1.1
[0.9, 1.3]
1.1
[0.8, 1.5]
1.0
[0.7, 1.5]
1.0
[0.7, 1.4]
PCP
1.0
[0.8, 1.3]
1.2
[0.7, 1.8]
1.3
[0.8, 2.2]
1.4
[0.7, 2.6]
Family
Members
1.8
[0.8, 3.9]
4.7
[2.0, 11.4]
2.4
[1.0, 5.5]
5.1
[1.8, 14.4]
Patient
Assessment
1.0
[0.8, 1.2]
1.2
[0.9, 1.6]
1.0
[0.8, 1.4]
1.1
[0.8, 1.7]
Medication
Management
0.9
[0.7, 1.1]
1.1
[0.8, 1.7]
1.1
[0.7, 1.6]
1.1
[0.7, 1.7]
Care
Coordination
1.1
[0.7, 1.6]
1.5
[0.8, 2.8]
1.7
[0.8, 3.7]
1.0
[0.5, 2.2]
Contacts
Time
Results based on negative binomial models with robust standard errors with clusters specified at the patient level.16
Ninety-five percent confidence intervals of IRRs are shown in square brackets.
Adjusted High School/Some College
Differences in DCM Use
Adjusted Incident Rate Ratios
(IRRs)
0-3 mo.
3-6 mo.
6-9 mo.
9-12 mo.
Patient
1.0
[0.9, 1.2]
1.0
[0.7, 1.3]
1.1
[0.8, 1.5]
1.3
[0.8, 2.0]
PCP
0.9
[0.7, 1.2]
1.0
[0.6, 1.5]
1.2
[0.7, 2.0]
2.1
[1.1, 4.3]
Family
Members
1.3
[0.6, 2.5]
1.3
[0.5, 3.4]
1.0
[0.4, 2.9]
2.1
[0.7, 6.5]
Patient
Assessment
1.0
[0.8, 1.2]
1.0
[0.7, 1.3]
1.1
[0.8, 1.5]
1.1
[0.7, 1.6]
Medication
Management
1.0
[0.7, 1.3]
1.2
[0.8, 1.7]
1.2
[0.9, 1.7]
1.4
[0.9, 2.2]
Care
Coordination
0.8
[0.5, 1.1]
1.3
[0.7, 2.4]
1.4
[0.7, 2.7]
2.0
[0.9, 4.3]
Contacts
Time
Results based on negative binomial models with robust standard errors with clusters specified at the patient level.17
Ninety-five percent confidence intervals of IRRs are shown in square brackets.
Study Limitations
• DCM contact and time not recorded for each
care manager contact, calling into question
– Accuracy of recorded DCM use
– Consistency between study sites
• Strategies to mitigate data limitation
– Grouping DCM use by time intervals
– Controlling for study site fixed effects
• Group differences reflect relative use as long as recording
pattern is consistent within sites
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Summary of Findings &
Implications
• Racial/ethnic differences:
– Minority patients had comparable or slightly higher use of DCM in the
first 6 months
– Over time, DCM use declined much more rapidly among minorities
• Educational differences:
– DCM use comparable between educational groups throughout the first
year, with one exception
• Much more intensive care manager contacts with family members of
patients with the lowest education
• Implications
– Collaborative DCM effective in engaging all patient groups in treatment
– Cultural differences associated with race/ethnicity remain a barrier to
engaging minority patients in longer-term depression treatment
– Engaging family members seemed necessary and important for the less
educated
19