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 determinehow to achieve the best medical outcomes at the least necessary cost over the continuum of apatient’s care. This methodology includes tracking of medical care process factors (managementstrategies, interventions, medications), patient factors (physiologic severity of illness and psychosocialdeviations at each visit), and outcomes and furnishes information that presents distinct advantagesover information furnished by outcomes research or clinical trials in the designing of managementprotocols. The Managed Care Outcomes Project, a large-scale CPI study, examined the effectsof health maintenance organization (HMO) cost-containment strategies on patient outcome and utilizationof care. Approximately 13,000 patients with otitis media, arthritis, hypertension, asthma, orulcer disease were analyzed; since all patient diagnoses and medication use were captured in the CPImodel, my colleagues and I were able to assess factors in psychiatric illness diagnosis, treatment, andoutcome. Among the findings were the following: (1) the majority of patients receiving psychiatricdrugs do not have a specific psychiatric diagnosis; (2) a significant proportion of patients with a specificdiagnosis of major depression do not receive antidepressant medication; (3) cost-containmentstrategies appeared to markedly limit psychiatric referral and frequency of visits and use of serotoninselective reuptake inhibitor treatment; and (4) severity of the primary illness in the study populationwas markedly increased in patients with a psychiatric diagnosis. Further analysis of data from thisstudy may help to determine which processes of care for depression were associated with better outcomes.