Depression screening may improve care after breast cancer diagnosis
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Tailored strategies for implementation of routine depression screening increased the proportion of patients with breast cancer referred to behavioral care, according to study results.
The findings, published in JAMA, highlighted a need for additional research to fully comprehend the clinical benefit and cost-effectiveness of a routine depression-screening program.
Rationale
“Evidence-based guidelines from multiple oncology societies recommend screening for depression in patients with cancer. However, implementing a successful and sustainable screening program can be difficult, and very often the results generated from clinical trials are difficult to replicate in real-world clinical practice,” Erin E. Hahn, PhD, MPH, researcher at Kaiser Permanente Southern California, told Healio.
“In the field of implementation science, we have been studying what strategies may help to get evidence into practice more easily. Also, the importance of addressing the local context of the setting is becoming evident,” Hahn said. “For example, what kinds of resources might be available to help support the program in one clinic compared with another, and how can we adapt the program to fit? This study is an example of this type of approach, where we could adapt and tailor the program to local context and select feasible, replicable strategies to support the program.”
Methodology
Hahn and colleagues evaluated the effectiveness of an implementation-strategy guided depression screening program among 1,436 patients (mean age, 61.5 years; 99% women; 37% white) with a primary breast cancer who underwent a medical oncology consultation between Oct. 1, 2017, and Sept. 30, 2018, across six community medical centers within the Kaiser Permanente California network.
Researchers assigned patients 1:1 to either a tailored implementation strategy (n = 744) or education-only (n = 692) group.
The tailored implementation strategy included education about depression screening for physicians and nurses, as well as regular feedback on their performance and support to help determine the best ways to add depression screening into the current workflow. They used the 9-item Patient Health Questionnaire (PHQ-9) for screening.
For the education-only group, physicians and nurses received general education on the screening program at the start of the study.
Percentage of eligible patients screened and referred, based on PHQ-9 score, at intervention compared with education-only groups measured at the patient level served as the primary outcome. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care and ED.
Key findings
More patients in the intervention group vs. the education-only group received referral for depression screening (7.9% vs. 0.1%; percentage-point difference, 7.8%; 95% CI, 5.8-9.8).
Moreover, 75% of patients who received treatment at an intervention site completed referrals to a behavioral health clinician compared with only one patient in the education-only group.
Results of adjusted models showed patients who received treatment at intervention sites experienced significantly fewer outpatient visits in medical oncology (rate ratio = 0.86; 95% CI, 0.86-0.89) and researchers observed no significant difference in utilization of primary care, urgent care and ED visits between the groups.
“Overall, tailored implementation strategies resulted in a much greater proportion of [patients with breast cancer] screened for depression and, if needed, appropriately referred for behavioral health care,” Hahn said. “At our tailored strategy sites, 80% of eligible patients were offered screening and of those who needed additional care, 94% received an appropriate referral.”
Implications
Depression screening in medical oncology is critically important, Hahn said, as patients with cancer may experience high levels of distress during and after treatment.
“Our results show that implementing guideline-recommended depression-screening programs is feasible with pre-implementation planning to select strategies to support the program and ensuring that the program suits local resources,” Hahn said.
“With funding from our Kaiser Permanente Care Improvement Research Team, we are rolling out the depression screening initiatives across all of our Kaiser Permanente medical oncology departments in Southern California, and we are evaluating the program over time,” Hahn added. “Importantly, we are incorporating the lessons learned from the original trial and are encouraging our clinical teams to adapt the clinical workflow to meet their local context.”
For more information:
Erin E. Hahn, PhD, MPH, can be reached at Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91101; email: erin.e.hahn@kp.org.
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