Team care of chronic diseases seems cost-effective

The collaborative TEAMcare program for people with depression and either diabetes, heart disease, or both appears at least to pay for itself, according to a UW Medicine and Group Health Research Institute report in the May 7 Archives of General Psychiatry. Over two years, after accounting for the $1,224 per patient that the program cost, it may save as much as $594 per patient in outpatient costs.

"Also, over the course of two years, people who received the TEAMcare intervention had a mean of 114 more days free from depression than did the people who received usual care," said the leader of this randomized controlled trial, Wayne J. Katon, MD. Dr. Katon is a University of Washington (UW) professor of psychiatry and behavioral sciences and an affiliate investigator at Group Health Research Institute. Because of individual variability, the trial was not large enough to assess the program's effect on inpatient costs.

"TEAMcare is a 'high-value intervention,' because the odds are 99.7 percent that it would cost less than $20,000 per quality-adjusted life year," Dr. Katon said. People who received the TEAMcare intervention were estimated to have a third of an additional quality-adjusted life year (QALY). The QALY measure estimates how much time an intervention would add to a person's quality of life. One QALY is an extra year of life in good health that the intervention would add. The standard is that if an intervention costs less than $20,000 per QALY, it is "high value" and should be spread quickly into health care systems.

"This is important because more and more people have multiple physical and mental chronic conditions, and caring for them is difficult—and costly," Dr. Katon said. The one in four U.S. adults with two or more chronic illnesses now account for two-thirds of health care spending, he added.

At Group Health, health care and coverage are integrated, with clinicians paid a salary. Most Americans get care from fee-for-service practices, and the researchers estimate that in such settings TEAMcare may have a higher return on investment: If diabetes nurses bill for their services at $54 per visit for up to 10 visits, the 24-month mean outpatient cost savings would be $1,116, with a cost savings per QALY of $3,297.

Earlier, Dr. Katon and his colleagues published the clinical results of the same randomized controlled trial in the New England Journal of Medicine. They reported that TEAMcare resulted in less depression and better-controlled blood pressure, sugar, and cholesterol levels for 214 Group Health Cooperative patients with depression and diabetes and/or heart disease.

With Michael Von Korff, ScD, a senior investigator at Group Health Research Institute, the same research group also published in the British Medical Journal that patients receiving the intervention had better quality of life and less disability than did patients with usual care.

With Elizabeth H.B. Lin, MD, MPH, the group published in the Annals of Family Medicine that the TEAMcare program works through primary-care doctors starting and adjusting medications sooner and more often to reach goals ("treating to target"); and motivating patients to participate in their own care and monitor their illnesses. Dr. Lin is a Group Health family physician and an affiliate investigator at Group Health Research Institute.

TEAMcare is a patient-centered program that is based on the Chronic Care Model. Nurses work with patients and health teams to manage care for depression and physical diseases together, using evidence-based guidelines. Together, the nurse and patient set realistic step-by-step goals: improving function and quality of life and reducing depression and blood sugar, pressure, and cholesterol levels. To reach these goals, the nurse regularly monitored the patient's mental and physical health. Based on guidelines that promoted incremental improvements, the multidisciplinary care team offered recommendations to the patient's primary care doctor to consider treatment changes to manage blood pressure, blood sugar, lipids, or depression.

Interest is high in spreading integrated, coordinated, team-based care for patients with depression and poorly controlled physical diseases. Dr. Lin is leading a project to implement TEAMcare as part of usual primary care at Group Health, and there is also interest in spreading the program to other organizations.