Barriers to improving primary care of depression: perspectives of medical group leaders.

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.

Relationship between the presence of practice systems and the quality of care for depression.

A valid measure of practice systems for improving chronic disease care is needed as a guide for both improvement and public accountability. We tested whether a new survey measure of the presence of practice systems (the PPC-R) is associated with performance measure rates for depression among 40 medical groups in Minnesota. These PPC-R scores were compared with standardized medical group measures of antidepressant persistence. Only 54% of potentially important systems were present, and there was high variability. However, there was a positive correlation between systems and quality on the 90-day measure of antidepressant persistence, both overall (r = .33, P = .04) and for the Chronic Care Model domains of decision support (r = .38, P = .02) and delivery system redesign (r = .31, P = .05). Thus, practice systems overall and several domains of the Chronic Care Model appear to be associated with higher quality care for depression. This questionnaire may help practices identify particular systems to improve.

Screening for colorectal cancer. Guidelines for choosing the appropriate test for each patient.

The importance of screening for colorectal cancer has been established, but the decision about which test to use for each patient may seem less clear. In this article, Dr Wineman discusses assessment of colorectal cancer risk and the advantages and disadvantages of the fecal occult blood test, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Potential screening methods that could make regular colon examination more acceptable to patients also are presented.

Follow-up and follow-through of depressed patients in primary care: the critical missing components of quality care.

Certainly we could improve our identification, diagnosis, and initial treatment approaches to the large numbers of depressed patients we see in primary care. However, until we have established the kind of systematic follow-up and follow-through that the US Preventive Services Task Force said is a prerequisite for its recommendation to routinely screen for depression, none of these earlier actions will make much difference. Recently, a number of controlled trials of innovative approaches to care management have demonstrated clearly how much patient outcomes are improved when systematic follow-up is in place. The problem is that there are few examples of such systems in real clinical practices. This article describes the main components of such a systematic approach.