Purpose: Determine the comparative effectiveness of an automated telephonic depression symptom monitoring tool combined with automated provider notifications for depression care follow-up among low-income, primary care, minority patients with diabetes.
Method: In a quasi-experimental clinical trial, 1440 patients with diabetes were recruited from 8 primary care safety net clinics in the Los Angeles County Department of Health Services from April 2011 to May 2012. The study compares three arms – usual primary care, high burden of illness diabetes care management (CM), and CM plus the enhanced depression intervention technology. Depression care is guided by a clinical protocol in both CM arms. The technological intervention is designed to assist time-pressured healthcare providers to routinely screen and monitor patients’ depression symptoms, track treatment adherence, and reduce recurrence. It includes an automated speech-recognition or touchtone response to administer assessment questions in the patient’s choice of language (English or Spanish). The calls are dynamically scheduled based upon a combination of calendar dates, clinical history and events, call history, and patient preference. The telephonic system includes an automated alert system with escalation to prompt a clinician if a patient reports self-harm or suicidal intent. Patient responses are integrated into an existing patient disease registry in near real-time for clinician information. The specific issues such as patient callback requests, depressive symptoms and antidepressant medication issues that need medical attention will trigger follow-up tasks for providers. A radio-button structured documentation system, with the option of free text, is incorporated within the task system to facilitate easy documentation and to track task completion. The study assesses the call completion and compares patient depression and anxiety outcomes 6 months post baseline.
Result: In the first six months of implementation, the automated telephonic system completed assessment on 55% of patients (62% English-speaking; 53% Spanish-speaking). Incomplete calls included no-answer, disconnected number, or patient inability to participate at the time of the call. Of 713 respondents at 6 months, patients in the technology arm have significantly lower PHQ-9 depression scores (Differences-in-differences ANOVA test, p<0.05) and are less likely to have major depression (Pearson Chi-square test, p<0.01).
Conclusion: Using automated periodic and customizable telephonic assessment system to facilitate collaborative team care is likely to improve depression outcomes among low-income populations.
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