Disparities in the Treatment Engagement Cascade of Collaborative Care for Depression in a Pragmatic Implementation...

The aim of this study was to examine disparities in treatment engagement in a pragmatic implementation trial of the collaborative care model (CoCM) for depression and anxiety.

This was a pragmatic, type 2 effectiveness-implementation, randomized rollout study of CoCM. Eleven primary care clinics were randomly assigned an intervention start date and engaged in a 1-year implementation and 1-year sustainment period. Data were extracted from electronic health records of primary care patients attending an associated clinic during the study period (October 1, 2018-January 31, 2023). Treatment engagement cascade steps were screened, referred, assessed, engaged, and completed. Logistic regression models identified demographic predictors (gender, race-ethnicity, age, and insurance status) at each step.

A total of 117,949 primary care patients were included (59.3% were female, 78.9% were age <65, and 65.5% were White), and 59,000 patients (50.0%) were screened for CoCM. Screened patients were more likely to be Asian than White (adjusted odds ratio [AOR]=1.11) and less likely to be male (AOR=0.97), Black/African American than White (AOR=0.84), and Medicaid insured (AOR=0.80). Of 1,999 patients referred to CoCM, 469 (20% of 2,329 patients eligible for referral) were CoCM eligible; referred patients were more likely to be Black/African American than White (AOR=1.60) and less likely to be male (AOR=0.72). A total of 986 patients (49% of referred) were assessed, 882 (90% of assessed) were engaged, and 307 (35% of engaged) completed treatment; no demographic differences were observed.

Implementation strategies are needed to increase overall and equitable reach in CoCM treatment engagement for the most vulnerable patients.