February 2, 2006
Team care for older adults with diabetes and depression improves health and saves money
Older diabetic patients with depression who received a new type of team care had more depression-free days, better physical functioning, and lower medical costs than patients treated with a standard model of care. The findings are the result of a University of Washington-led study, published in the Feb. 6 issue of the journal Diabetes Care.
Depression affects an estimated 3 million older adults in the United States, including 15 percent of patients with Diabetes. In a new team care approach, called IMPACT (Improving Mood — Promoting Access to Collaborative Treatment for Late Life Depression), a depression care manager (usually a nurse, social worker or psychologist) works closely with the patient’s primary care physician and a consulting psychiatrist to treat depression in the patient’s regular primary care clinic. Previous studies have shown the IMPACT program provides powerful health benefits, including decreased depression and pain, improved physical functioning and better quality of life for up to two years (www.impact.ucla.edu).
This study examined the cost-effectiveness of the IMPACT program in 418 depressed older adults with diabetes who participated in the IMPACT trial. Depression in diabetic patients is associated with increased symptoms of diabetes, impaired functioning, higher medical costs, and increased mortality. In addition, patients with depression often have poor self-care, a behavior that can lead to diabetes complications and even death.
The researchers found that the IMPACT model of depression care helped patients have an average of 115 more depression-free days than patients receiving standard care for depression. Patients in the IMPACT program also had improved functioning and quality of life and lower overall medical costs over 2 years, more than offsetting the cost of providing IMPACT care.
“These older adults with diabetes were able to enjoy nearly four more months free of depression under the IMPACT model,” said Dr. Wayne Katon, professor and vice-chair of psychiatry and lead author of the study. “In addition, the cost of implementing this model was offset by the savings we saw due to patients having lower overall medical costs.”
Diabetes treatment requires a complex regimen of self-care, including increased exercise, altered diet, checking blood sugar, and altering medication based on blood sugar readings. This study indicates that reducing the effects of depression in diabetic patients — not only improves quality of life but helps to cut medical costs associated with diabetes care.
“Patients with depression struggle with self-care, and that can present a big problem for diabetics who have to follow a complex program of self care that includes changes in diet, exercise, and frequent blood sugar adjustments,” said Dr. Jürgen Unützer, professor and vice chair of psychiatry at the UW and director of the IMPACT Coordinating Center. “The IMPACT team care model not only reduced depression symptoms; it also gave patients the hope and energy they needed to participate in their self-care. Over two years, this resulted not only in better quality of life but also in a reduction in patient’s overall health service utilization.”
Based on its cost-effectiveness, several major health organizations have already implemented the IMPACT model for depression care, including Kaiser Permanente of Southern California, which serves more than 3 million members in its 12 regional medical centers. The John A. Hartford Foundation is supporting the efforts of Katon and Unützer to help other health systems take up the IMPACT model.
The cost of using the IMPACT model of depression care treatment is only about $580 per year for each patient — a modest investment compared to the total medical costs of about $9,000 per year for an older adult with depression and diabetes. When the cost of the IMPACT model is spread out over an entire population of older adults, the cost amounts to less than $1 per month for each member.
A more effective method of treating clinical depression in late life has become more important in recent years, as physicians have learned that the condition affects many older adults and helps drive up health care costs. Studies estimate that 5 to 10 percent of older adults seen in primary care suffer from clinical depression. The condition is associated with a variety of other medical problems, including more suffering and physical pain, decreases in physical ability and self-care of chronic illnesses, and a high potential for suicide. It also can significantly increase medical costs.
The IMPACT study, which began in 1999, randomly assigned 1,801 depressed older adults from 18 primary care clinics affiliated with eight diverse health care organizations in five states to usual depression care or to the IMPACT program. In IMPACT care, a depression care manager (a nurse or psychologist) with consultation from a psychiatrist and an expert primary care physician helped patients and their primary care doctors treat depression in the primary care setting. The care managers helped educate patients about depression, closely tracked depressive symptoms and side effects, helped make changes in treatment when necessary, supported patients on anti-depressant medications, and offered a brief course of psychotherapy to help patients make changes in their lives. The IMPACT program did not replace the patient’s regular primary care physician, but instead supported these physicians to help them provide higher quality depression care. An independent evaluation of the study outcome was done at baseline 3, 6, 12, and 24 months to compare IMPACT to usual care.
The 18 study sites that were part of the IMPACT Project are located at Duke University, South Texas Veterans Health Care System, Central Texas Veterans Health Care System, San Antonio Preventive and Diagnostic Medicine Clinic, Indiana University School of Medicine, Health and Hospital Corporation of Marion County in Indiana, Group Health Cooperative of Puget Sound in cooperation with the University of Washington, Kaiser Permanente of Northern California, Kaiser Permanente of Southern California, and Desert Medical Group in Palm Springs, California.
The IMPACT study was supported primarily by a grant from the John. A. Hartford Foundation with additional support from the California Healthcare Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation. The John A. Hartford Foundation (http://www.jhartfound.org) is dedicated to improving health care for older Americans.
The IMPACT Coordinating Center, where physicians and health care professionals can learn more about implementing the IMPACT model in their organizations, can be found at http://www.impact.ucla.edu