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Team-Based Approach Benefits Patients with Depression and Diabetes, Heart Disease

Posted: Wednesday, January 19, 2011

Many people have multiple common chronic diseases such as diabetes and cardiovascular disease, complicating healthcare needs.

In a randomized controlled trial, testing a primary care intervention called TEAMcare, nurses worked with patients and health teams to manage care for depression and physical disease together, using evidence-based guidelines. The result for patients: less depression, and better control of glucose, blood pressure and cholesterol as well as improved quality of life.

Wayne J. Katon, MD, University of Washington and Group Health Research Institute, Seattle, Washington, stated that, "Depressed patients with multiple uncontrolled chronic diseases are at high risk of heart attack, stroke and other complications." "We are excited about finding a new way to help patients control these chronic diseases, including depression."

Depression is common in patients with diabetes and heart disease, and it has been linked to worse self-management and more complications and deaths. Depression can make people feel helpless and hopeless about managing other chronic diseases. In turn, coping with chronic disease can worsen depression.

To explore possible solutions, the trial focused on 214 Group Health Cooperative patients who were randomly assigned to either standard care or the TEAMcare intervention. In the TEAMcare intervention, a nurse care manager coached each patient, monitored disease control and depression, and worked with the patient's primary care doctors to make changes in medications and lifestyle when treatment goals were not reached. Working together, the nurse and patient set realistic step-by-step goals: reductions in depression and blood glucose, blood pressure and cholesterol levels. Patients assigned to the standard care arm of the study did not receive the nurses' coaching and monitoring services.

To reach these goals, the nurse regularly monitored the patient's mental and physical health. Based on guidelines that promoted incremental improvements, the care team offered recommendations to the patient's primary care doctor to consider changes to the dose or type of medication used for managing blood pressure, blood glucose, lipids or depression.

Dr. Katon said that this "treating to target" approach helped boost patients' confidence as goals were accomplished. "It reverses what happens when they set overly ambitious goals they don't reach, which discourages them, their families, and healthcare providers."

At 1 year, patients with the TEAMcare intervention were significantly less depressed and also had improved levels of blood glucose, low-density lipoprotein (LDL) cholesterol, and systolic blood pressure, compared with the standard care control group. These differences are clinically significant, particularly if achieved in large numbers of patients, Dr. Katon said.

"Each of these 4 disease control measures has been linked to higher risks of complications and deaths from diabetes and heart disease," he added.

The researchers have not yet completed their analysis of possible cost savings from the intervention, but they estimated that the 2-year TEAMcare intervention cost $1,224 per patient, on average. This is for patients whose medical care costs health care systems approximately $10,000 per year, said Dr. Katon.

TEAMcare intervention patients reported enhanced quality of life and satisfaction with care for depression and either diabetes, heart disease or both. Patients were more likely to have timely adjustment of glucose levels, high blood pressure, cholesterol and antidepressant medications.

Elizabeth H.B. Lin, MD, MPH, Group Health family physician and an affiliate investigator at Group Health Research Institute noted that, "TEAMcare is a truly patient-centered approach that enhances a primary care team to deliver optimal care for both physical and mental health in a seamless manner."

Source: http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=10372&catid=53&Itemid=8, New England Journal of Medicine, Dec. 30 2010