1. Resolving outcome disparities in depression for minority primary care patients with collaborative care management
Kurt B. Angstman, MS MD
Associate Professor of Family Medicine
Vice Chair of Education
Mayo Clinic- Rochester
Family Medicine Midwest
October 11, 2015
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2. Disclosure
Faculty Disclosure Statement The Illinois Academy of Family Physicians adheres to the conflict of interest policy of the ACCME and the AMA. It is the policy of Illinois AFP to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. All individuals in a position to control the content in our programs are expected to disclose any relationships they may have with commercial companies whose products or Services may be mentioned so that participants may evaluate the objectivity of the presentations. In addition, any discussion of off-label, experimental, or investigational use of drugs or devices will be disclosed by the faculty. Only those participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in the CME activity. Speaker & Faculty Disclosures Kurt B. Angstman has disclosed no relevant financial relationship or interest with a proprietary entity producing health care goods or services. This program does not include any discussion or demonstration of any pharmaceuticals or medical devices that are not approved by the Food and Drug Administration (FDA) or that are considered “off-label.”

3. Background
A broad range of social factors can impact health care utilization and outcomes for depression and other psychiatric problems.
Race, ethnicity, lower socioeconomic status, poverty, insurance coverage, education, language barriers and length of time in the United States.
The U.S. Surgeon General issued a report in highlighting issues of racial disparity and the impact of race on clinical outcomes and utilization for depression.

4. Background
Contributing factors to disparities include reluctance or inability among minority group to:
Access mental health treatment
Systematic differences in provider behavior or decision-making and
Possible difference in treatment response.
When it comes to seeking treatment for major depression:
41% of African Americans, 36% of Hispanics and 31% of Asian Americans sought treatment compared to 60% of non-Latino Whites.

5. Hypotheses
Use of a CCM in treating depressed primary care patients would:
(1) improve minority race patient retention in depression care and
(2) decrease racial disparity in 6-month clinical outcomes (PHQ-9 score),

6. Methods
Adult primary care patients from a Midwestern United States multi-site clinical practice (100,000 adult patients)
Eligible for CCM (i.e., diagnosed with major depressive disorder or dysthymia and a PHQ-9 score of ≥10 from March 1, through December 31, 2011)
As of December 31, 2011, 7,412 individual patients were identified as eligible.
For the purpose of this study, patients who chose not to self-identify their racial or ethnic status and who declined to participate in research were excluded.

7. Methods
The study cohort included the remaining 7,010 patients (94.6% of depression registry) in this retrospective chart review analysis.
Patients diagnosed with depression were treated with usual primary care by their provider or were enrolled in CCM.
Data were obtained from the depression care registry.

8. Methods
Variables:
The primary independent variable for this study was self-reported race/ethnicity, which was categorized into Non-Hispanic White or Minority race/ethnicity.
Demographic covariates were age at enrollment, gender, and marital status.
Clinical covariates were diagnosis and baseline PHQ-9 and six month PHQ-9 score (if obtained).

9. Results: Depressed primary care patients treated with usual care, comparing minority race to white patients by variable.
No difference between the groups for:
Gender
Depression diagnosis
Marital Status
Minority patients more likely:
Younger (39.3 vs yrs)
Initial depression severity
PHQ vs. 15.0
Usual Care=3,588
Minority status
(N=340)
White, non-Hispanic
(N=3,248) P=
Compliance with six month follow up:
% (N)
14.4% (49)
16.0% (519)
0.500
Remission at six months (PHQ-9 <5)
Intention to treat model
1.5% (5/340)
5.5% (180/3,248)
0.002
Remission at six months: Re-measured patients. % (N)
10.2% (5/49)
34.7% (180/519)
<0.001
Persistent depressive symptoms (PHQ-9≥10) at six months: % (N)
63.3% (31/49)
35.8% (186/519)

10. Results: Depressed primary care patients treated with collaborative care management, comparing minority race to white patients by variable.
No difference between the groups for:
Gender
Depression diagnosis
Minority patients more likely:
Younger (37.9 vs yrs)
Not married (41.1% vs 53.5%)
Initial depression severity
PHQ vs. 15.5
CCM= 3,422
Minority status
(N=231)
White, non-Hispanic
(N=3,191) P=
Compliance with six month follow up:
% (N)
61.8% (143)
66.5% (2,186)
0.045
Remission at six months (PHQ-9 <5)
Intention to treat model
34.0% (72)
37.0% (1,187)
0.078
Remission at six months: Re-measured patients. % (N)
50.3% (72/143)
54.1% (1,187/2,186)
0.406
Persistent depressive symptoms (PHQ-9≥10) at six months: % (N)
26.6% (38/143)
21.5% (471/2,186)
0.192

11. Initial depression severity
Results: Depressed minority primary care patients treated with collaborative care management or usual care by variable at intake and with six month follow up.
No differences in:
Age
Gender
Marital Status
Initial depression severity
No differences in self- identified minority group
Black, Hispanic, Asian/Pacific or Other
N=671
UC (340)
CCM
(231) P=
6 month compliance
14.4%
61.9%
<0.001
6 month remission
10.2%
50.3%
6 month PDS
63.3%
26.6%

12. Forest plot of odds ratio using logistic regression analysis for remission of depression (PHQ-9< 5) or persistent depressive symptoms (PHQ-9≥10) six months after diagnosis, in primary care patients treated with usual primary care (N=568).

13. Forest plot of odds ratio using logistic regression analysis for remission of depression (PHQ-9< 5) or persistent depressive symptoms (PHQ-9≥10) six months after diagnosis, in primary care patients treated with collaborative care management (N=2,329).

14. Strengths
A significant disparity in outcomes persisted between minority and non-Hispanic White patients who received usual care.
But, this disparity was eliminated in patients who received CCM.
This supports the use of a primary care CCM model in diverse populations. Indeed, our current study showed that for patients in CCM, race was not independently associated with changes in outcomes at six months, reduced the disparity in retention, and appeared to eliminate the disparity gap in depression management

15. Limitations
The number of minority patients diagnosed with depression and treated under CCM is small; hence, results may not be generalizable to larger urban population centers with higher and more diverse minority groups.
Future studies could consider nativity in addition to ethnicity and race.
Was a retrospective chart review analysis.
There was the potential that the two groups of minority patients could have been dramatically different.

16. Conclusions:
In a large primary care practice, utilization of CCM for depression was associated with resolution of the disparity for minority patients with depression for outcomes of:
Compliance
Remission at six months or
Persistence of depressive symptoms

17. Conclusions:
Since CCM reduced evidence of racial disparity, this study would suggest for the continued use and extension of collaborative care models.
Angstman KB, Phelan S, Myszkowski MR, Schak KM, DeJesus RS, Lineberry TW, van Ryn M. Minority Primary Care Patients With Depression: Outcome Disparities Improve With Collaborative Care Management. Med Care Jan; 53(1):32-7. PMID:

18. Questions & Discussion angstman.kurt@mayo.edu