Advertisement

Medical Assistant Protocol Improves Disparities in Depression Screening Rates

      Introduction

      Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting.

      Methods

      Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations.

      Results

      A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40–64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18–39 years.

      Conclusions

      Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • WHO
        Depression and other common mental disorders: global health estimates.
        WHO, Geneva, SwitzerlandPublished 2017
        • Brody DJ
        • Pratt LA
        • Hughes JP
        Prevalence of depression among adults aged 20 and over: United States, 2013–2016.
        NCHS Data Brief. 2018; : 1-8
        • Laursen TM
        • Musliner KL
        • Benros ME
        • Vestergaard M
        • Munk-Olsen T
        Mortality and life expectancy in persons with severe unipolar depression.
        J Affect Disord. 2016; 193: 203-207https://doi.org/10.1016/j.jad.2015.12.067
        • Lett HS
        • Blumenthal JA
        • Babyak MA
        • et al.
        Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment.
        Psychosom Med. 2004; 66: 305-315https://doi.org/10.1097/01.psy.0000126207.43307.c0
        • Knol MJ
        • Twisk JW
        • Beekman AT
        • Heine RJ
        • Snoek FJ
        • Pouwer F
        Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis.
        Diabetologia. 2006; 49: 837-845https://doi.org/10.1007/s00125-006-0159-x
        • DiMatteo MR
        • Lepper HS
        • Croghan TW
        Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence.
        Arch Intern Med. 2000; 160: 2101-2107https://doi.org/10.1001/archinte.160.14.2101
        • Siu AL
        U.S. Preventive Services Task Force (USPSTF), Bibbins-Domingo K et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement.
        JAMA. 2016; 315: 380-387https://doi.org/10.1001/jama.2015.18392
        • Akincigil A
        • Matthews EB
        National rates and patterns of depression screening in primary care: results from 2012 and 2013.
        Psychiatr Serv. 2017; 68: 660-666https://doi.org/10.1176/appi.ps.201600096
        • Kato E
        • Borsky AE
        • Zuvekas SH
        • Soni A
        • Ngo-Metzger Q
        Missed opportunities for depression screening and treatment in the United States.
        J Am Board Fam Med. 2018; 31: 389-397https://doi.org/10.3122/jabfm.2018.03.170406
        • Hahm HC
        • Cook BL
        • Ault-Brutus A
        • Alegría M
        Intersection of race-ethnicity and gender in depression care: screening, access, and minimally adequate treatment.
        Psychiatr Serv. 2015; 66: 258-264https://doi.org/10.1176/appi.ps.201400116
        • Brown AF
        • Vassar SD
        • Connor KI
        • Vickrey BG
        Collaborative care management reduces disparities in dementia care quality for caregivers with less education.
        J Am Geriatr Soc. 2013; 61: 243-251https://doi.org/10.1111/jgs.12079
        • Chin MH
        • Cook S
        • Drum ML
        • et al.
        Improving diabetes care in Midwest community health centers with the health disparities collaborative [published correction appears in Diabetes Care. 2004;27(8):2099].
        Diabetes Care. 2004; 27: 2-8https://doi.org/10.2337/diacare.27.1.2
        • Thompson H
        • Faig W
        • Gupta N
        • et al.
        Collaborative care for depression of adults and adolescents: measuring the effectiveness of screening and treatment uptake.
        Psychiatr Serv. 2019; 70: 604-607https://doi.org/10.1176/appi.ps.201800257
        • Reiter JT
        • Dobmeyer AC
        • Hunter CL
        The primary care behavioral health (PCBH) model: an overview and operational definition.
        J Clin Psychol Med Settings. 2018; 25: 109-126https://doi.org/10.1007/s10880-017-9531-x
        • Yin I
        • Wan W
        • Staab EM
        • Vinci L
        • Laiteerapong N
        Use of report cards to increase primary care physician depression screening.
        J Gen Intern Med. Online July 23, 2020; (In press)https://doi.org/10.1007/s11606-020-06065-w
        • Kroenke K
        • Spitzer RL
        • Williams JB
        The Patient Health Questionnaire-2: validity of a two-item depression screener.
        Med Care. 2003; 41: 1284-1292https://doi.org/10.1097/01.MLR.0000093487.78664.3C
        • Ell K
        • Unützer J
        • Aranda M
        • Sanchez K
        • Lee PJ
        Routine PHQ-9 depression screening in home health care: depression, prevalence, clinical and treatment characteristics and screening implementation.
        Home Health Care Serv Q. 2005; 24: 1-19https://doi.org/10.1300/J027v24n04_01
        • Kontopantelis E
        • Doran T
        • Springate DA
        • Buchan I
        • Reeves D
        Regression based quasi-experimental approach when randomisation is not an option: interrupted time series analysis.
        BMJ. 2015; 350: h2750https://doi.org/10.1136/bmj.h2750
        • Willard-Grace R
        • Chen EH
        • Hessler D
        • et al.
        Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial.
        Ann Fam Med. 2015; 13: 130-138https://doi.org/10.1370/afm.1768
        • Nelson K
        • Pitaro M
        • Tzellas A
        • Lum A
        Practice profile. Transforming the role of medical assistants in chronic disease management.
        Health Aff (Millwood). 2010; 29: 963-965https://doi.org/10.1377/hlthaff.2010.0129
        • Stockdale SE
        • Lagomasino IT
        • Siddique J
        • McGuire T
        • Miranda J
        Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995–2005.
        Med Care. 2008; 46: 668-677https://doi.org/10.1097/MLR.0b013e3181789496
        • Williams DR
        • González HM
        • Neighbors H
        • et al.
        Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life.
        Arch Gen Psychiatry. 2007; 64: 305-315https://doi.org/10.1001/archpsyc.64.3.305
        • Bailey RK
        • Mokonogho J
        • Kumar A
        Racial and ethnic differences in depression: current perspectives.
        Neuropsychiatr Dis Treat. 2019; 15: 603-609https://doi.org/10.2147/NDT.S128584
        • Whaley AL
        Ethnicity/race, paranoia, and psychiatric diagnoses: clinician bias versus sociocultural differences.
        J Psychopathol Behav Assess. 1997; 19: 1-20https://doi.org/10.1007/BF02263226
        • Baker FM
        Diagnosing depression in African Americans.
        Community Ment Health J. 2001; 37: 31-38https://doi.org/10.1023/a:1026540321366
        • Jones LE
        • Doebbeling CC
        Depression screening disparities among veterans with diabetes compared with the general veteran population.
        Diabetes Care. 2007; 30: 2216-2221https://doi.org/10.2337/dc07-0350
        • Kessler RC
        • McGonagle KA
        • Swartz M
        • Blazer DG
        • Nelson CB
        Sex and depression in the National Comorbidity Survey. I: lifetime prevalence, chronicity and recurrence.
        J Affect Disord. 1993; 29: 85-96https://doi.org/10.1016/0165-0327(93)90026-g
        • Hopman WM
        • Harrison MB
        • Coo H
        • Friedberg E
        • Buchanan M
        • VanDenKerkhof EG
        Associations between chronic disease, age and physical and mental health status.
        Chronic Dis Can. 2009; 29: 108-116https://doi.org/10.24095/hpcdp.29.3.03
        • Salisbury C
        • Johnson L
        • Purdy S
        • Valderas JM
        • Montgomery AA
        Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study.
        Br J Gen Pract. 2011; 61: e12-e21https://doi.org/10.3399/bjgp11X548929
        • Chapel JM
        • Ritchey MD
        • Zhang D
        • Wang G
        Prevalence and medical costs of chronic diseases among adult Medicaid beneficiaries.
        Am J Prev Med. 2017; 53: S143-S154https://doi.org/10.1016/j.amepre.2017.07.019
        • Rodda J
        • Walker Z
        • Carter J
        Depression in older adults.
        BMJ. 2011; 343: d5219https://doi.org/10.1136/bmj.d5219
        • Kok RM
        • Reynolds 3rd, CF
        Management of depression in older adults: a review.
        JAMA. 2017; 317: 2114-2122https://doi.org/10.1001/jama.2017.5706
        • Hart S
        • Morris R
        Screening for depression after stroke: an exploration of professionals’ compliance with guidelines.
        Clin Rehabil. 2008; 22: 60-70https://doi.org/10.1177/0269215507079841
        • Hammond MF
        Doctors’ and nurses’ observations on the Geriatric Depression Rating Scale.
        Age Ageing. 2004; 33: 189-192https://doi.org/10.1093/ageing/afh037