Project IMPACT: Depression

Depression is widely recognized as one of the most common and disabling chronic conditions affecting industrialized nations.5 About one in six U.S. adults will experience an acute episode of major depressive disorder during their lifetime, and more than 10% will suffer from a depressive illness during the next 12 months.6 Depression has strong economic consequences in addition to social consequences such as emotional withdrawal and isolation. Mood disorders impact nearly every aspect of a person’s life, including their ability to do their job. Reports indicate that employees with depression will have an average of 9.9 sick days annually, and their productivity when they do go to work can decrease anywhere from 10% to 20%.7 In America, many cases of depression go undetected or if treatments are prescribed, evidence suggests that fewer than 50% of patients adhere to the therapeutic course.

Read the white paper or the full manuscript published in JAPhA

The Background

The APhA Foundation’s Project IMPACT Depression employed enhanced employee outreach, patient education, and systematic follow-up by pharmacists to improve the outcomes of depressed patients. Partnering employer groups changed the way they paid for health care by aligning incentives for patients and providers. Covered beneficiaries received waived copayments, as they participated in the depression

management program that empowered them to live healthier lives. Following consultations with a pharmacist, patients increased their medication adherence and took steps to make lifestyle changes resulted in quantifiable benefits apparent in clinical and economic outcomes.

Key Objective

To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression using a prospective, nonrandomized, proof-of-concept investigation design.

The Participants

Employers

This demonstration project was conducted in a community setting in Asheville, NC with two self-insured employers participating: the City of Asheville and Mission Hospitals. Both agreed to offer a care management program for covered health plan members with depression.

Patients

All eligible participants were older than 18 years and employees or covered beneficiaries of Mission Hospitals or the City of Asheville. Participants had an existing diagnosis of depression and had been prescribed antidepressant treatment by their primary care provider. Patients with baseline and year 1 medical and pharmacy claims and two or more documented visits with pharmacists were included in both the clinical and economic subgroup analyses. A total of 159 patients met the inclusion criteria and 130 participated for the duration of the project.

Pharmacists

A community pharmacist and an outpatient hospital pharmacist provided care to the participants. Both pharmacists had previously obtained a doctor of pharmacy degree, had been in practice for a minimum of 3 years, and completed a postdoctoral residency program. One of the pharmacists had completed a 12-month psychiatric residency, and the other had completed a 12-month ambulatory care residency. Immediately before the investigation, the pharmacists received approximately 16 hours of depression management training (8 hours self-study and 8 hours live) provided by the APhA Foundation based on national treatment guidelines. The live training delivered by a multidisciplinary team that included a primary care provider, psychiatrist, behavioral health counselor, and psychiatric pharmacist, consisted of didactic presentations, patient cases, and role playing among participants.

The Methods

Study Period

Patient enrollment began in July 2006 and continued at each site dependent on employer-specific enrollment timetables. Data was collected for this evaluation up until December 31, 2007.

Enrollment

Upon enrollment into the program, participants:

Scheduled an intake interview with participating pharmacists to assess their current mental status, ongoing stressors, past psychiatric history, social and family histories, and medical history (including allergies and comorbid conditions).
Completed a validated, self-rated depression scale (the nine-item Patient Health Questionnaire [PHQ-9] instrument) at baseline.
Worked closely with pharmacists to achieve consensus on treatment goals and subsequently formulated a treatment plan primarily consisting of medication recommendations, patient education, and lifestyle changes.

Innovation

All participating patients met with a pharmacist on a regular, long-term basis - as frequently as once a month - with the option to withdraw at any time. Pharmacist–patient encounters were face to face, scheduled, and conducted in a private area, with access to the Internet for documenting and tracking of patient care interventions.
Pharmacists partnered with the patient and members of the health care team to identify the best ways to empower that patient to become more adherent to prescribed medications and to make lifestyle modifications that would improve control of depressive symptoms. At each visit:

Treatment goals were revisited;
Medication therapy management was performed;
Treatment adherence was evaluated by patient self-report;
Participants completed a follow-up PHQ-9 assessment; and
Pharmacists delivered tailored education to meet specific patient needs and placed strong emphasis on anticipated benefits and risks of treatment, as well as lifestyle changes needed to reduce stress and improve overall health (e.g., exercise, yoga, dietary modifications).

Following these visits, pharmacists communicated with physicians via faxes that summarized the patient–pharmacist encounter. These included patient comments, PHQ-9 scores, and suggestions for therapy changes when indicated, with the prescriber having ultimate decision-making authority in the process. If urgent needs were identified, the pharmacist would call the office to collaborate on an action plan.

The Results

Aggregated, de-identified data was collected for general demographics, economic outcomes, and clinical outcomes from 130 of the 159 patients enrolled.

Clinical Outcomes

Evaluation

The clinical outcomes analysis compared initial and follow-up results that were collected during the course of patient care primarily using PHQ-9, a validated depression assessment tool. PHQ-9 is a survey that addresses the presence and severity of each of the nine symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, diagnostic criteria for major depression.

Interpretation of PHQ-9 Total Scores

Less than 5: suggests the patient probably does not require treatment
5 to 14: implies that the provider should use clinical judgment in considering the necessity of treatment.
Greater than 14: strongly suggests that some form of evidence-based treatment is warranted

Interpretation of PHQ-9 Clinical Outcomes

Treatment response is defined as a decrease of 50% or more from the baseline score.
Treatment remission is defined as a PHQ-9 score of less than 5.

Results

80% of patients exhibited a decrease in PHQ-9 scores between the baseline visit and the most recent follow-up; 8% had no change in depression severity; and 12% of patients worsened in depression severity.
In general, clinical improvements and outcomes were superior for patients with severe depression (PHQ-9 score > 14): 83% with severe depression achieved remission; 20% with mild or moderate symptoms achieved remission.
Overall, 56% of the 130 patients achieved remission.

Economic Outcomes

Evaluation
Before the program was implemented, the self-insured employers provided the actual 1-year cost of care for the participants during the year prior. They also provided the projected total cost of care for the study year for those same patients based on trend data. The economic outcomes analysis compared the actual cost of care during the 1-year project to the projected costs of care if the program had not been implemented.

Results

Baseline mean total health care costs to the employer per patient per year was $7,935, and employers projected the 48 evaluable patients would have an average total cost of care of $9,023, if no program was implemented.
At the end of the 1-year evaluation, the actual mean total health care costs per patient were $8,040, a savings of $983 per patient per year.

Savings Breakdown

The majority of costs savings were due to a decline in medical costs, which were projected to amount to $5,353 per patient annually, but actual mean values were $3,600 (33% lower than projected).
Annual employer costs for prescription medications increased by 21% compared with the projected costs ($3,670 vs. $4,440/patient).
Individual out-of-pocket costs for prescriptions decreased by 41% ($323/patient) compared with projected estimates, due to waived copayment incentives. However, enrollee out-of-pocket medical costs increased by 24% ($434/patient) above projected values.
Payment for pharmacists’ services and waived copayments were included as an increased cost to the employer while calculating the net savings.