overview of phase i data: approach and findings gary bess associates april 15, 2009
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Overview of Phase I Data:Overview of Phase I Data: Approach and FindingsApproach and Findings
Gary Bess AssociatesGary Bess Associates
April 15, 2009April 15, 2009
Background
Demonstration Sites
Evaluation & Assessment
Launched
in March 2006
with support
from. . .
BackgroundBackground Extensive assessment process
Reviewed literature Identified evaluative elements Treatment approaches
Meetings with key stakeholders Primary Care Providers Behavioral Health Professionals
BackgroundBackground
Goals
Increase patient access
Reduce stigma
Improve outcomes
Demonstration Demonstration SitesSites
Golden Valley Health Center, Merced
Family Healthcare Network, Visalia
Mendocino Community Health Clinic, Ukiah
Family Health Centers of San Diego
Sierra Family Medical Clinic, Nevada City
SACHS-Norton Clinic, San Bernardino
Open Door Community Health Centers, Arcata
Primary Care Primary Care ClinicsClinics
Selection CriteriaSelection Criteria Experience providing integrated
services
Currently operating integrated program with specific components
Ability to implement quantifiable model
Demonstration Demonstration SitesSites
Data CollectionData CollectionMeasurementRationaleIBHP ElementsLocal ElementsFrequencySource
The DUKE The DUKE Health ProfileHealth Profile
The Duke Health Profile (DUKE) is a 17-item generic self-report instrument containing six health measures (physical, mental, social, general, perceived health, and self-esteem), and four dysfunction measures (anxiety, depression, pain, and disability).
Scales Measurement and Sample Items
Physical Health
Physical capacity for ambulation (walking and running) and physical symptoms (sleeping, fatigue, and pain).
Mental Health
Psychological symptoms (depressed feelings, nervousness), cognition (concentrating), and personal self-esteem (I like who I am, I give up too easily).
Social Health
Participation in social activities (socializing with friends or relatives, participation in group activities and social self-esteem (getting along with others, family relationships).
General Health
Combination of physical, mental, and social health.
Perceived Health
Self-assessment of overall health (I am basically a healthy person).
Self-Esteem
Personal self-esteem (I like who I am) and social self-esteem (getting along with others, comfortable levels around other people, family relationships).
AnxietyAnxiety with social self-esteem (getting along with others, comfortable levels around other people, family relationships) and psychological symptoms (nervousness).
Depression
Depression with personal self-esteem (I like who I am, I give up too easily), psychological symptoms (nervousness), and cognition (concentrating).
Anxiety/ Depression
Psychological symptoms (nervousness), personal self-esteem (I like who I am), and somatic symptoms (sleeping and fatigue).
Pain Hurting or aching in any part of the body.
Disability
Confinement to home, nursing home, or hospital because of sickness, injury, or other health problems in the preceding week.
Overview of DUKE Overview of DUKE AnalysisAnalysis
Comparing the DUKE scores at baseline (first administration of the DUKE after commencement of grant) and most recent follow-up (most recent administration of the DUKE near the end of the grant period).
The mean number of days between baseline administration and most recent administration of the DUKE was 144.26 days (4.5 months), with the minimum, three (3) days, and the maximum, 284 days.
Ns range between 250 and 290 based on item analyzed.
Summation of Summation of FindingsFindings
Mean health scores increased (the desired clinical outcome) in each of the six health measures from baseline to most recent follow-up, changes were statistically significant for the measures of physical health, mental health, and general health. Though attaining improvement, each of the health scores at the time of the most recent assessment, however, were lower than the normative sample for the Duke.
Summation of Summation of FindingsFindings
Subgroups showing the greatest increase in health scores (those subgroups with sizeable or statistically significant increases in the majority of health scores from baseline to most recent follow-up) included female patients, patients 50 to 59 years old, White patients, patients whose entry in to a behavioral health program was after the start of the study, patients with more than10 visits during the study period, and patients with at least one missed visit.
Physical Health Physical Health ScoresScores
39.5
4
31.82 40.14
33.19
40.0
0
38.9
8
45.2
6
33.4
0
40.3
4
42.3
4
28.8
6 42.3
4
41.49
37.7
3
43.11
46.4
2
38.9
0
41.84
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Aggregate(N=282)
Diabetes(n=44)
White(n=214)
Non-White(n=47)
Old BHClient(n=55)
New BHClient(n=196)
Up to 5Visits(n=95)
6 to 10Visits
(n=100)
Greaterthan 10Visits(n=87)
Old/New Patients
p < .05
Race/EthnicityD
iab
ete
sAll
p < .05
Number of Visits
p < .01
62.8Average
Belo
wA
bove
Summation of Summation of FindingsFindings
Mean dysfunction scores decreased (the desired clinical outcome) in each of the four health measures from baseline to most recent follow-up, and were statistically significant for the measures of anxiety and depression. Like health scores, each of the dysfunction scores at the time of the most recent health scores, however, were greater than the normative sample at statistically significant levels.
Summation of Summation of FindingsFindings
Subgroups showing the greatest decrease in dysfunction scores (those subgroups with sizeable or statistically significant increases in the majority of dysfunction scores from baseline to most recent follow-up) included female patients, patients less than 40 years old, non-White patients, patients whose entry into a behavioral health program was after the start of the study, patients with more than10 visits during the study period, and patients with at least one missed visit.
Anxiety ScoresAnxiety Scores49.7
8
45.4
2
53.10
49.9
2
49.8
0
46.2
8
50.3
4
53.0
5
45.6
3
43.18
47.7
0
44.9
7
45.6
6
44.0
2
46.7
5
46.10
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Aggregate(N=272)
Male (n=102) Female(n=164)
White(n=209)
Non-White(n=43)
Up to 5 Visits(n=92)
6 to 10 visits(n=98)
Greater than10 visits(n=82)
All
25.4Average
Belo
wA
bove
p < .005
Gender
p < .005
Race/Ethnicity Number of Visits
p < .005 p < .005
PHQ-9PHQ-9
The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 is a tool for assisting for diagnosing depression, as well as selecting and monitoring treatment. The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV).
Interpretation of Scores on Interpretation of Scores on PHQ-9PHQ-9Score Action
≤ 4Suggests the patient may not need depression treatment.
5 to 14
Use clinical judgment about patient; based on patient’s duration of symptoms and functional impairment.
≥15 Warrants treatment for depression.
Overview of PHQ-9 Overview of PHQ-9 AnalysisAnalysis
Comparing PHQ-9 scores at baseline (first administration of the PHQ-9 after commencement of grant) and most recent follow-up (most recent administration of the PHQ-9 near the end of the grant period).
The mean number of days between baseline administration and most recent administration of the PHQ-9 was 127.14 days, with the minimum, one (1) day, and the maximum, 284 days.
N=422
Summation of Summation of FindingsFindings
The mean PHQ-9 depression score for patients decreased from baseline to most recent follow-up assessment at statistically significant levels. At baseline, approximately one-third of patients had a PHQ-9 depression score that warranted treatment for depression (≥15). At the time of the most recent follow-up assessment, less than one-quarter of patients had a score that warranted treatment.
Baseline and Most Recent Baseline and Most Recent
Follow-up (N=422)Follow-up (N=422)
18.2
%
48.1%
33.6
%
29.6
% 47.2
%
23.2
%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Less than orequal to 4
5 to 14 15 and greater
Baseline Most Recent Follow-up
Baseline and Most Recent Baseline and Most Recent
Follow-up – Change Follow-up – Change (N=422)(N=422)
67.1%
32.9
%
9.5%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Decrease Increase No Change
Summation of Summation of FindingsFindings
Statistically significant decreases in the PHQ-9 depression score from baseline to most recent follow-up assessment occurred for male and female patients; patients 50 years old or greater; white and non-white patients; patients whose entry into a behavioral health program was prior to study and patients whose entry into a behavioral health program was after study commencement; patients with diabetes; patients with more than one visit during the study period; patients without a missed visit during the study period; and patients with at least one missed visit during the study period.
Change in PHQ-9 ScoresChange in PHQ-9 Scores10
.50 11.7
4
10.5
2 11.7
1
11.3
9
11.6
7
11.9
2
8.56
8.77 9.
84
9.20
9.14 9.
95 10.5
6
9.59
6.82
0.00
4.00
8.00
12.00
16.00
20.00
Male (n=128) Female(n=281)
White (n=239) Non-White(n=102)
Less than 40(n=93)
40 to 49(n=84)
50 to 59(n=133)
60 and greater(n=55)
p < .005
Gender
p < .001
Race/Ethnicity Age
p < .005 p < .001 p < .001 p < .05
Patient Patient Satisfaction Satisfaction
Patient Patient Satisfaction Satisfaction
Patients were asked to respond to a nine (9) item general satisfaction survey assessing their satisfaction with services and the model and comfort levels with treatment and treatment setting utilizing the following scale: 1 = Strongly Disagree; 2 = Disagree; 3 = Neither Disagree Nor Agree; 4 = Agree; and 5 = Strongly Agree.
Overview of Patient Overview of Patient Satisfaction AnalysesSatisfaction Analyses
Mean satisfaction scores generated by patients with at least two completed Patient Satisfaction Surveys, i.e., at baseline (first administration of the Patient Satisfaction Survey after commencement of grant) and most recent follow-up (most recent administration of the Patient Satisfaction Survey near the end of the grant period).
Ns were at least 250 for each inquiry.
Summation of Summation of FindingsFindings
Aggregate mean scores and subgroup mean scores (e.g., mean scores by gender, age, or ethnicity) for the majority of the items were above 4.50 on the five-level scale, suggesting high levels of satisfaction with services, model, treatment, and treatment setting…
Summation of Summation of FindingsFindings
…However, there was an exception concerning the item, “I would follow through if I were referred outside this clinic for mental health services.” An association was found between length of engagement in counseling and the likelihood that patients would be more likely to follow through with an outside referral for mental health services.
Change in Mean Scores From Change in Mean Scores From Baseline to Most Recent Baseline to Most Recent
Follow-upFollow-up“I would follow through if I were referred outside this
clinic for mental health services”
3.52
4.02
3.19
4.12
3.19
3.82
1.00
2.00
3.00
4.00
5.00
Up to 5Visits
Baseline
Up to 5VisitsMost
RecentFollow-
up
6 to 10Visits
Baseline
6 to 10VisitsMost
RecentFollow-
up
Morethan 10Visits
Baseline
Morethan 10VisitsMost
RecentFollow-
up
n=64
Number of Visits
n=89 n=79
p < .005p < .001
p < .001
S
om
ew
hat
Agre
e
A
gre
e
A
gre
e
N
eari
ng A
gre
e
Un
decid
ed
Un
decid
ed
Summation of Summation of FindingsFindings
There were statistically significant variances in mean scores between some subgroups; however, mean scores for all subgroups suggest high levels of satisfaction.
Concerns Regarding Mental Concerns Regarding Mental Health Treatment Plan Were Health Treatment Plan Were
Quickly AddressedQuickly Addressed
*Average of mean scores from baseline administration of the Patient Satisfaction Survey to most recent follow-up administration.
4.53 4.574.36
4.534.40
4.534.69
4.424.58
1.00
2.00
3.00
4.00
5.00
Aggregate White All Others Less than40
40 to 49 50 to 59 60 andGreater
Male Female
N=
26
2
Race/Ethnicity Age Gender
n=
90
n=
55
n=
54
n=
92
n=
61
n=
19
7
n=
43
n=
16
6
p < .05p < .05
