Transforming primary care for anxiety disorders (PDF)

Tilburg University Transforming primary care for anxiety disorders Muntingh, A.D.T. Publication date: 2013 Document Version Publisher's PDF, also known as Version of record Link to publication in Tilburg University Research Portal Citation for published version (APA): Muntingh, A. D. T. (2013). Transforming primary care for anxiety disorders: The collaborative stepped care model. Ipskamp Drukkers. 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Download date: 27. jun.. 2022   Transforming primary care for anxiety disorders The collaborative stepped care model Anna Muntingh  Printing of this thesis was financially supported by Tilburg University Rivierduinen ISBN: 978-94-6191-560-3 Author: A.D.T. Muntingh Cover design: Studio Lakmoes, Arnhem Lay-out: proefschrift-opmaken.nl Printed by: Ipskamp Drukkers, Enschede, The Netherlands © 2012 A.D.T. Muntingh All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, without permission of the author.  Transforming primary care for anxiety disorders The collaborative stepped care model Proefschrift ter verkrijging van de graad van doctor aan Tilburg University, op gezag van de rector magnificus, prof. dr. Ph. Eijlander, in het openbaar te verdedigen ten overstaan van een door het college voor promoties aangewezen commissie in de aula van de Universiteit op vrijdag 11 januari 2013 om 14.15 uur door Anna Dirksje Trijntje Muntingh geboren op 10 november 1983 te Berkel en Rodenrijs.  Promotores: Prof. dr. C.M. van der Feltz-Cornelis Prof. dr. A.J.L.M. van Balkom Prof. dr. Ph. Spinhoven Copromotor: Dr. H.W.J. van Marwijk Beoordelingscommissie: Prof. dr. H.F.L. Garretsen Prof. dr. E. Hoencamp Dr. A. van Straten Prof. dr. P.F.M. Verhaak Prof. dr. H.J.M. Vrijhoef  Contents Chapter 1 11 General introduction Chapter 2 31 Collaborative care interventions for anxiety disorders in primary care: a systematic review and meta-analysis Chapter 3a 63 Collaborative stepped care for anxiety disorders in primary care: aims and design of a randomised controlled trial Chapter 3b 93 Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial Chapter 4 121 Cost-utility analysis of a Collaborative Stepped Care intervention for panic - and generalised anxiety disorder in primary care Chapter 5a 145 Screening high risk patients and assisting in diagnosing anxiety in primary care: The Patient Health Questionnaire evaluated Chapter 5b 165 Is the Beck Anxiety Inventory a good tool to assess the severity of anxiety? A primary care study in The Netherlands Study of Depression and Anxiety (NESDA) Chapter 6 181 General discussion Addendum 211 Summary 212 Samenvatting 217 Dankwoord 232 Curriculum vitae 237 Publications 238   Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning. Albert Einstein (1879 – 1955)   Chapter 1 General introduction 1  Chapter 1 12 Chronic illness: the largest problem in modern health care Major advances in health care have led to the minimisation of infectious diseases in the 20th century. People tend to live longer and healthier lives, especially in the more developed countries. In the 21st century we have a new problem: worldwide around 50% of the disease burden is caused by non-communicable diseases which frequently run a chronic or recurrent course (WHO 2008). In high income countries, this type of diseases accounts for even 85% of the burden of disease (WHO 2008). In the Netherlands, there are around 4.5 million adults with such a chronic illness and expectations are that these numbers will accumulate in the near future (Gommer et al. 2010). Prevalent chronic illnesses are cardiovascular disease, diabetes and various mental disorders. Chronic illnesses are conditions that need "continuous adjustments by the affected person and interactions with the health care systems" (Improving chronic illness care & Group Health Research Institute 2012). The quality of care for chronic illnesses is often below the optimal standard. A review concluded that in the United States, adults with a chronic condition receive just over 50% of recommended care according to quality indicators (McGlynn et al. 2003). Care for chronic illnesses is complex and differs from care for acute diseases. While a reactive approach and one or more health care providers working independently is appropriate for acute diseases, chronic conditions need continuous and more proactive attention from both patients and providers. Common problems in care for patients with chronic conditions are the fragmented communication between health care providers involved, the absence of planned interactions and insufficient involvement of the patient in the care process (Wagner et al. 2001). Improving care for chronic illnesses: the chronic care model As a reaction to problems identified in chronic care, multifaceted strategies were developed to improve and integrate care. Those strategies were directed at improving knowledge of the provider or the patient about the chronic illness, or did address organisational changes such as adding a nurse specialist to a primary care practice team. A review about diabetes care (Renders et al. 2001) shed some light on the effectiveness of different strategies by indicating that strategies focussing on both the professional and the organisational system may improve diabetes management, while  Introduction 13 adding patient education or a nurse care manager improve patient outcomes. This evidence led researchers to conclude that a model was needed that included various forms of interventions that could be used as a theoretical framework: the chronic care model (Wagner et al. 2001). The chronic care model has six elements that should foster quality improvement: self- management support, decision support, delivery system design, clinical information systems, health care organisation, and community resources (see Table 1) (Bodenheimer et al. 2002).Effort directed at improvements on all of these levels, should result in enhanced self-management, efficient and high quality encounters between health care professionals and patients and improved patient outcomes (Bodenheimer et al. 2002). The chronic care model was widely adopted, particularly in managed care settings, to improve the quality of care for different chronic illnesses and numerous studies have been performed evaluating its effectiveness. A recent review suggests that the model leads to quality improvements in most types of chronic care (Coleman et al. 2009). Due to the variation in the elaboration of the chronic care model, it is difficult to summarise results of the studies. There is no consensus yet about which elements are crucial for the effectiveness of the chronic care model (Vrijhoef 2010). The use of the chronic care model in mental health care At the same time of the development of the chronic care model, researchers in the field of depression made similar movements towards a different organisation of primary care. They found that interventions consisting of providing feedback about depression scores of patients did not lead to better outcomes for patients with depression (Katon & Gonzales 1994). A collaborative care model was developed which had many similarities with the chronic care model of Wagner and colleagues (Katon et al. 2001; Katon et al. 2010). The collaborative care model as evaluated in the early trials encompassed patient education materials, the use of allied health professionals (care managers) who provided monitoring and follow-up and sometimes provided evidence based psychotherapy, the use of a monitoring tool (PHQ-9), a liaised psychiatrist who provided consultations about antidepressant medication and 1  Chapter 1 14 Table 1. Elements of the chronic care model 1. Self management support • Emphasise the patient's central role. • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow- up. • Organise resources to provide support. 2. Decision support • Embed evidence-based guidelines into daily clinical practice. • Integrate specialist expertise and primary care. • Use proven provider education methods. • Share guidelines and information with patients. 3. Delivery system design • Define roles and distribute tasks among team members. • Use planned interactions to support evidence-based care. • Provide clinical case management services for high risk patients. • Ensure regular follow-up. • Give care that patients understand and that fits their culture. 4. Clinical information systems • Provide reminders for providers and patients. • Identify relevant patient subpopulations for proactive care. • Facilitate individual patient care planning. • Share information with providers and patients. • Monitor performance of team and system. 5. Health care organisations • Visibly support improvement at all levels, starting with senior leaders. • Promote effective improvement strategies aimed at comprehensive system change. • Encourage open and systematic handling of problems. • Provide incentives based on quality of care. • Develop agreements for care coordination. 6. Community resources and policies • Encourage patients to participate in effective programs. • Form partnerships with community organisations to support or develop programs. • Advocate for policies to improve care. (Group Health's MacColl Insitute 2007)  Introduction 15 supervised the caseload of care managers and the use of IT support to facilitate outcome monitoring and caseload supervision (Katon et al. 2010). The rationale behind these collaborative care programs was that patient outcomes could be improved by 1) organising primary and secondary care practice differently (i.e. adding a care manager and consultant psychiatrist to the primary care team), 2) making treatment more systematic and pro-active and 3) enhancing patient self- management. Many randomised controlled trials were conducted and evidence accumulated rapidly that collaborative care was more effective than care as usual for primary care patients with depression in the United States (Gilbody et al. 2003). At present, over 60 trials considering collaborative care management for depression have been conducted, also in specific groups such as patients with depression and diabetes (Van der Feltz-Cornelis et al. 2010), teenagers or low-income patients (Gilbody et al. 2006; Thota et al. 2012). Two meta-analyses considering publications until 2004 (Gilbody et al. 2006) and from 2004 until 2009 (Thota et al. 2012) concluded that collaborative care leads to a significant improvement compared to care as usual for patients with depression, with a small to moderate clinical effect. Expanding the evidence of collaborative care for mental disorders Most research on collaborative care for mental disorders stems from managed health care settings in the United States. However, there are some important differences between primary care in the United States and in European countries which may influence the implementation and comparative effectiveness of collaborative care (de Jong et al. 2009). When we look at the primary care system in the Netherlands, for example, general practitioners receive a more extensive training in mental health care than general practitioners in the United States. Furthermore, accessibility of mental health services is generally lower for American citizens compared to Dutch citizens due to financial barriers (Russell 2010; Westert et al. 2010). Lastly, in the United States primary care practices usually employ a larger number of professionals than in the Netherlands (de Jong et al. 2009). For those reasons, it is important to test if collaborative care may also improve care in a system such as seen in the Netherlands. Furthermore, as research has focussed mainly on collaborative care for depression, additional evidence of its effectiveness for other mental disorders is needed. 1