ObjectivesThis study describes an emergency department (ED)-based intervention for individuals with opioid use disorder (OUD) in an urban health system. The intervention utilized electronic health records to screen for OUD and implemented warm hand-offs using certified recovery specialists (CRS). The intervention also encouraged physicians to become certified to prescribe buprenorphine.MethodsWe surveyed individuals using the Center for Substance Use Treatment Government Performance and Results Act (GPRA) survey. 302 individuals were surveyed at baseline on self-reported drug use, quality of life, and health care utilization, and 53 completed a reassessment at three or six-month intervals. Differences in outcomes were assessed using pairwise t-tests at the 95% level of significance.ResultsParticipation in the intervention was associated with a reduction in self-reported drug use and reductions in inpatient care. While we found an increase in quality of life, there were also increases in reports of "any depression."ConclusionBetter screening, warm hand-offs, and buprenorphine prescriptions in the ED can improve outcomes for individuals with OUD. Lessons learned include challenges reassessing individuals with OUD, the importance of supporting ED staff with buprenorphine training and CRS, and the possibility that depressive symptoms may emerge and worsen as individuals with OUD seek treatment.

Most depressed patients are seen and treated exclusively by primary care clinicians. However, primary care patients with depression are often not adequately treated. The aims of this pilot study were to measure the impact of a telephone disease management program on patient outcome and clinician adherence to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes. Thirty-five primary care practices in the University of Pennsylvania Health System were randomized to telephone disease management (TDM) or "usual care" (UC). All patients received a baseline and a 16-week follow-up clinical evaluation performed over the telephone. Those from TDM practices also received follow-up contact at least every 3 weeks, with formal evaluations at weeks 6 and 12. These interval contacts were designed to facilitate patient and clinician adherence to a treatment algorithm based on the Agency for Health Research and Quality (AHRQ) practice guidelines. Depressive symptoms evaluated with the Community Epidemiologic Survey of Depression (CES-D) scale as well as guideline adherence were the primary outcome measures. Sixty-one patients were enrolled in this pilot project. The overall effect for CES-D scores over time was significant, (P <.001), indicating that those participating in the trial (both TDM and UC groups) showed significant improvement. The interaction between intervention condition and time was also significant (P <.05), indicating that TDM patients improved significantly more over time than did UC patients. A greater proportion of TDM patients had CES-D scores <16 by Week 16 (66.7 versus 33.3%; chi(2), P <.05). The improvement in depression outcome for the TDM group was related to its impact on improving clinician adherence to depression treatment algorithms. The TDM pilot did not show a statistically significant effect on improving patient adherence to clinician recommendations, however. This preliminary data suggests that TDM for depression improves both clinician guideline adherence and patient outcomes in the acute phase of depression. The effect on patient outcome is at least partially explained by the effect of TDM on clinician adherence to depression treatment algorithms.

Disease management (DM) programs have been designed to overcome barriers to provider and patient adherence to treatment guidelines with the goal of improving treatment outcomes. In this article, the authors report on the acute treatment phase of a depression DM program and examine the impact of patient and provider adherence on outcomes. 154 patients from 11 practices were referred by their primary care clinicians to a DM program. The program’s main intervention was a trained nurse who visited the practices and met with patients. Patient demographics, psychiatric history, current mental health treatment, and medical comorbidity were recorded, and depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression scale (CES-D). Data on adherence were gathered retrospectively from interview notes made by the DM nurse. Patients enrolled had a mean ± SD baseline CES-D score of 30.8 ± 11.0 and mean ± SD age of 49.1 ± 15.5; 78.6% were female, and 96.1% were diagnosed with unipolar depression. 109 (70.8%) completed the 6-week evaluation, and 76 (49.4%) completed the 12-week evaluation. 27.5% showed significant reduction of symptoms (at least a 50% reduction in CES-D scores) at 6 weeks, and 42.1% showed improvement by 12 weeks. Active clinician adherence at 6 and 12 weeks was 63.4% and 32.4%, respectively. Guideline adherence by physicians at 6 weeks significantly predicted 12-week outcome (F = 4.49; P = 0.04). Patient adherence to clinician recommendations within 6 weeks also strongly predicted outcome (F = 6.47; P < 0.05). In conclusion, monitoring adherence as an early “outcome” in a DM program and modifying intervention and recruitment strategies as needed may be necessary to optimize rates of clinical response. Depressive disorders are common in primary care, with a prevalence rate of approximately 22% in this setting [1]. Most patients with depression are seen by primary care clinicians rather than by specialty mental health providers [2]. However, rates of detection of depression in primary care are low, with as many as half of depressed patients in primary care not detected as depressed by their clinicians [3]. Furthermore, even when depression is detected, patients often are not adequately treated [4,5] and treatment guidelines are seldom followed [4]. Thus, primary care patients identified by clinicians as depressed seldom experience better outcomes than placebo controls in clinical trials [6,7]. A well-implemented disease management (DM) program could address some of the barriers to effective care for patients with depression. Research shows that components of DM programs such as clinician and patient education, clinician feedback, and more frequent patient monitoring can improve depression care outcomes [5,8–11]. These studies suggest that DM may improve outcomes for depression through its impact on clinician adherence to treatment guidelines. In this paper, we report the results of the acute treatment phase of a depression DM program and examine the impact of provider adherence and patient adherence to clinician treatment recommendations on outcomes.