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2006 HSR&D National Meeting Abstract

1004 — Telemedicine-Based Collaborative Care To Reduce Rural Disparities

Author List:
Fortney JC (HSR&D CeMHOR)
Edlund MJ (HSR&D CeMHOR)
Williams DK (Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences)
Robinson DE (Shreveport VAMC)
Mittal D (HSR&D CeMHOR)
Henderson KL (South Central Veterans Health Care Network, Mental Health Product Line)

Implementing collaborative care for depression in small rural Primary Care (PC) practices without on-site mental health specialists presents unique challenges. To reduce disparities for rural veterans with depression treated in CBOCs, we adapted the collaborative care model using telemedicine technologies (e.g., telephone, interactive video, electronic medical records, internet). The Telemedicine Enhanced Antidepressant Management (TEAM) intervention was implemented by off-site personnel including nurse managers, clinical pharmacists, and tele-psychiatrists. Telemedicine facilitated the communication between the off-site depression care team and on-site PC providers.

Seven small rural CBOCs lacking on-site psychiatrists/psychologists were randomized to receive the TEAM intervention or usual care. Of the 24,882 clinic patients, 73.6% (n=18,306) were successfully screened for depression and 6.9% screened positive (PHQ9 =12). Of those eligible, 91.3% agreed to participate, and 91.9% of those attended their appointment and consented. Over an 18-month period, 395 patients were enrolled. Follow-up rates at six and twelve months were 91.1% and 84.8%. Multivariate analyses were used to examine the impact of telemedicine-based collaborative care on adherence (taking antidepressants >80% of time), response (>50% decrease in SCL20 depression severity score), remission (SCL20<0.5), health status (PCS and MCS), health related quality of life (QWB), and satisfaction (CAPHS).

Compared to patients at usual care sites, intervention patients reported better medication adherence at both six (OR=1.9, p=0.04) and twelve months (OR=2.2, p=0.01). Intervention patients were more likely to experience a response to treatment at six months (OR=2.0, p=0.02), and were more likely to experience remission at twelve months (OR=2.4, p=0.02). Intervention patients reported larger increases in MCS scores at both six (p=0.04) and twelve months (p<0.01). Intervention patients also reported larger increases in quality of life at six months (p<0.01). Intervention patients reported higher satisfaction at both six (p=0.01) and twelve months (p=0.03). Intervention patients had fewer PC depression-related encounters over the twelve month period (p<0.01).

Telemedicine-based collaborative care improves process and outcomes of depression care and may help reduce rural/urban disparities.

Collaborative care can be successfully adapted for small rural CBOCs using telemedicine technologies. For national rollout of collaborative care, telemedicine-based models should be considered an evidence-based alternative to practice-based models.

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