Overcoming obstacles to effective treatment: use of clinical practice improvement methodology

Clinical practice improvement (CPI) is a method for examining the steps of a care process to determine how to achieve the best medical outcomes at the least necessary cost over the continuum of a patient's care. This methodology includes tracking of medical care process factors (management strategies, interventions, medications), patient factors (physiologic severity of illness and psychosocial deviations at each visit), and outcomes and furnishes information that presents distinct advantages over information furnished by outcomes research or clinical trials in the designing of management protocols. The Managed Care Outcomes Project, a large-scale CPI study, examined the effects of health maintenance organization (HMO) cost-containment strategies on patient outcome and utilization of care. Approximately 13,000 patients with otitis media, arthritis, hypertension, asthma, or ulcer disease were analyzed; since all patient diagnoses and medication use were captured in the CPI model, my colleagues and I were able to assess factors in psychiatric illness diagnosis, treatment, and outcome. Among the findings were the following: (1) the majority of patients receiving psychiatric drugs do not have a specific psychiatric diagnosis; (2) a significant proportion of patients with a specific diagnosis of major depression do not receive antidepressant medication; (3) cost-containment strategies appeared to markedly limit psychiatric referral and frequency of visits and use of serotonin selective reuptake inhibitor treatment; and (4) severity of the primary illness in the study population was markedly increased in patients with a psychiatric diagnosis. Further analysis of data from this study may help to determine which processes of care for depression were associated with better outcomes.