Sunday, March 12, 2017

Does ACT mean we don't need IBH-PC?

A recent article by IBH-PC consultants Deborah CohenFrank DeGruy and others reports a study of integration with many of the same goals as ours. It is based on a sub-analysis of the ACT study from Colorado. The key findings were improvement in depression (measured by interviews and by PHQ-9 depression score). These results are more good news for the idea of Integrating Behavioral Health and Primary Care.

Does this study (and other results of ACT) mean that the IBH-PC study is not needed? No - important as ACT is, there are a lot of limitations and unanswered questions that we will address in IBH-PC.

This analysis did not have a control group. IBH-PC has randomized concurrent controls.

Because it studied only patients with high scores on the PHQ-9 at baseline, it is subject to regression to the mean. IBH-PC will not select for high scores at baseline.

It had 475 patients from five practices, all in one state. IBH-PC will enroll 3,000 patients from 40 practices all over the country.

It addressed only depression.  IBH-PC will study a broad range of overlapping medical and behavioral conditions.

All of these issues weaken the conclusions that can be drawn and limit the ability of policy- and decision-makers to get fully behind integration. So, we soldier on!


- Ben Littenberg

Outcomes of Integrated Behavioral Health with Primary Care
Bijal A. Balasubramanian, Deborah J. Cohen, Katelyn K. Jetelina, L. Miriam Dickinson, Melinda Davis, Rose Gunn, Kris Gowen, Frank V. deGruy III, Benjamin F. Miller, and Larry A. Green
J Am Board Fam Med March-April 2017; 30:130-139; doi:10.3122/jabfm.2017.02.160234

Background: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care.
Methods: This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices.
Results: Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.
Conclusions: Integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care. Integration is a worthwhile investment; clinical leaders, policymakers, and payers should support integration in their communities.

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