OCTOBER 2007 HOT TOPICS

Patients Treated for Depression in Primary Care Often Do Not Receive High-Quality Care

Most patients with depression are identified and initially treated by primary care physicians rather than mental health specialists. A recent RAND Health study led by Drs. Kimberly Hepner and Lisa Rubenstein assessed the quality of care that such patients receive. The analysis examined the experiences of more than 1,100 patients with depression who had been treated in 45 primary care practices across 13 states. Study sites ranged from small, private practices to large managed care organizations.

The study found that primary care physicians accurately identified patients as depressed but did not deliver care for depression that met basic quality standards. Primary care physicians followed guidelines for identifying depression more than 70 percent of the time. However, they did not perform as well in assessing patients carefully or in delivering follow-up treatment over time. For example, only 26 percent of patients were assessed to see if they were suicidal, and fewer than half completed the minimal course of treatment with either antidepressant drugs or psychotherapy. The rate of treatment completion among elderly patients was only 26 percent.

The study also found that depressed patients who received better-quality care subsequently reported fewer symptoms of depression for up to two years. The findings are among the first that link quality guidelines for depression treatment with improved patient outcomes in community settings. The findings suggest that, while primary care clinicians are alert to depression, these clinicians need help implementing measures to ensure that detected patients receive appropriate care.

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The Health Care Needs of Immigrants

Immigrants to the United States are often identified as a vulnerable population—that is, at elevated risk of poor health and inadequate medical care. A RAND team, led by Kathryn Pitkin Derose, recently published an article on immigrants' health care access and quality which shows that the picture is more complex. Overall, immigrants and their U.S.-born children have lower rates of health insurance, use less health care, and receive a lower quality of care than do U.S.-born populations and the children of U.S. citizens; however, there are differences among subgroups. The immigrants most likely to face barriers to access are those with lower incomes and less education, those who lack legal status, and those with limited English proficiency. These characteristics are more likely to describe immigrants from Mexico and Central America than those from Asia or Africa.

Although most immigrants are relatively healthy and often experience better outcomes, including lower mortality, than their U.S.-born counterparts, their health often deteriorates over time in the United States. Poor health care access and quality likely play a role. Given that immigrants are a large and growing segment of the population—12 percent in 2007—this has serious implications for the health of the nation. The factors that make immigrants vulnerable to poor health care can be remedied, in part, through policies that apply to disadvantaged populations more generally: living wages, access to education, decent housing, and safe jobs. However, health policies targeted specifically to immigrants will also likely be needed to expand access to care and improve quality. These include expanded health insurance coverage through public- and private-sector initiatives, broader implementation of cultural and linguistic standards for health care providers, and policies to support the medical safety net in communities that experience high influxes of immigrants.

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Can the Outcomes of Malpractice Litigation Help Identify Physicians Who Make the Most Medical Errors?

Injuries caused by medical errors are a serious problem in the United States. To reduce medical errors and injuries, some states are, and others are considering, using the outcomes of medical malpractice litigation—specifically, compensation payments made by physicians for injuries caused by negligent medical care—to identify physicians who may have unusually high rates of error and intervene to protect patients. Uses of this information include targeting physicians for investigation and possible sanctions by state medical boards and publicizing individual physicians' medical malpractice histories so that consumers may use this information in choosing a physician. However, a study conducted by RAND's Institute for Civil Justice suggests that these policies should not be expected to affect rates of medical negligence to any substantial degree. Using data from earlier empirical studies, researchers created a simulation model to examine the relationship between malpractice compensation payments and rates of negligent injuries caused by doctors. They estimated that almost three-quarters of negligent injuries were caused by doctors who made no damage payments over a four-year period. At best, targeting physicians who make payments for investigation by medical boards would reduce the incidence of medical malpractice by less than one-quarter of one percent. Providing consumers with information about physicians' medical malpractice payments would have a trivial effect on reducing negligent injuries.

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