TeamCare PCN: Collaborative Care for Diabetes and Depression (TeamCare-PCN)

July 9, 2013 updated by: Dr. Jeffrey Johnson, The Alliance for Canadian Health Outcomes Research in Diabetes

TeamCare PCN: Collaborative Care for Patients With Diabetes and Depression in Primary Care Networks

Background & Objective: Type 2 diabetes is a complex disease characterized by multiple comorbidities. Depression is one of the most common comorbidities in individuals with diabetes with prevalence rates reaching 30%. Depression complicates diabetes treatment, portends worse outcomes and increases health care costs. One novel approach to managing diabetes with co-morbid depression is a collaborative primary care model involving a multidisciplinary health care team guiding patient-centered care. This model has been tested in the US and showed a significant reduction of depressive symptoms, improved diabetes care and patient-reported outcomes, and saved money. Our aim is to evaluate the implementation of this collaborative care model for type 2 diabetes and comorbid depression within the non-metro Primary Care Network (PCN) setting in Canada.

Intervention: The intervention involves three phases: (1) improving depressive symptoms, (2) improving blood sugar, blood pressure and cholesterol, and (3) improving lifestyle behaviours. The intervention is administered by a CM in collaboration with family physicians, psychiatrists, and internists.

Hypotheses: The TeamCare-PCN intervention will reduce depressive symptoms, achieve targets for cardio-metabolic measures and improve lifestyle behaviours. Furthermore, the investigators anticipate this intervention will be acceptable and implemented in a cost-effective manner in the PCN environment.

Methods: The investigators will employ a mixed-methods approach to our evaluation, using a controlled "on-off" trial design. Our primary analysis will be based on a multivariable scaled marginal model for the combined outcome of depressive symptoms and medical care. Secondary analyses will assess changes in lifestyle behaviours and patient-reported outcomes.

Significance: Our work will serve as a platform upon which an emerging model of primary care can incorporate an effective and cost-effective depression intervention into the management of individuals with type 2 diabetes, and as a framework for implementing and evaluating similar interventions in individuals with other chronic conditions.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

I. Brief Overview The over-arching objectives of this study are to implement and evaluate an evidence-based intervention called TeamCare-PCN for individuals with type-2 diabetes and comorbid depression within primary care networks (PCNs). TeamCare-PCN is based on a proven efficacious and cost-saving collaborative primary care model (Katon et al., 2010) which involves a Care Manager (CM) providing active patient management under the supervision of a family physician and consulting psychiatrists and internists. The goal of the intervention is to achieve remission of depression, reach targets for cardio-metabolic measures, and improve lifestyle behaviours.

II. Hypothesis The investigators hypothesize that the TeamCare-PCN intervention will reduce depressive symptoms, achieve targets for cardio-metabolic measures and improve lifestyle behaviours.

III. Setting, Participants, and Sample Size TeamCare-PCN will be conducted in collaboration with 4 PCNs in non-metro Alberta: St. Albert Sturgeon PCN, Leduc/Beaumont/ Devon PCN, Camrose PCN, and Heartland PCN.

We estimate that a minimum total sample size of 120, with 60 in each arm, would provide power of 0.80 to detest a mean difference of 5 points in the PHQ-9, assuming a repeated measures correlation of 0.6, and 2-tailed alpha of 0.05. This sample size also provides more than 80% power (two sided alpha = 0.05) to detect any between-group absolute difference in proportions of 15% or more (e.g., 45% of usual care patients achieve depression remission vs 60% of intervention patients) (Katon et al., 2010). Anticipating a 40% attrition rate, we planned to recruit 168 patients in total across our 4 PCN sites.

IV. Participant Recruitment and Allocation Recruiting participants into TeamCare-PCN involves four steps. i) A screening survey accompanied with an endorsement letter from the PCN and a general information letter. Included in the screen is the PHQ-9.

ii) After potential participants have completed the screening survey and mailed it back to the PCN, staff at the PCN will identify the respondents who are eligible to participate TeamCare-PCN through the responses on the screening survey and by scoring the PHQ-9.

iii) PCN staff will contact eligible participants through a brief phone interview to confirm all eligibility criteria and schedule an initial assessment visit with the CM at the PCN.

iv) CM will meet with the participant, and during the initial assessment, the CM will explain the intervention, provide an intervention-specific information letter and obtain a signed written informed consent from the patient to participate in the study.

Participants will be allocated to study groups using an 'on-off' allocation method. Eligible and consenting respondents who book for an initial assessment with the CM during month 1 will be allocated to the intervention arm (On-group). Those who book the initial assessment in month 2 will be allocated to the usual care arm (Off-group). This allocation process will continue until the target sample size is recruited.

V. Team Care Depression Intervention for Diabetes

A. Patient Management:

Patients entering the intervention will have an initial one-hour appointment with the CM. This first visit will include a bio-psychosocial semi-structured assessment (reviewing medical history, previous treatments for depression and diabetes), patient education, potential treatment options (anti-depressant medications and/or psychotherapy) and developing an overall individualized care plan. The intervention will consist of 3 phases; the first focusing on depression management, the second on cardio-metabolic diabetes management, and the third on general lifestyle modifications. The CM will also have weekly meetings with the consulting specialists to review new cases and patient progress, and then make treatment recommendations to the primary care physician.

B. Training of Care Managers and Specialists:

The CMs and consulting specialists have already received a 2-day training course on the TeamCare-PCN intervention, including the pharmacotherapy of depression and an introduction to psychotherapeutic techniques (i.e. problem solving, behavioural activation, and motivational interviewing), as well as team interactions, roles and responsibilities. An overview of cardio-metabolic diabetes management, including, glucose control, insulin management, blood pressure management and treatment of high lipid levels based on the developed algorithms, was also provided at the training session. TeamCare-PCN training manuals were developed and used in the training sessions, and retained by the CM.

VI. Usual Care All participants in TeamCare-PCN will be actively screened for depression and those allotted to usual care will be identified as such to their family physician. For depression management, patients will receive care from their family physician, without additional active support from the Care Manager.

VII. Data Analysis As the initial focus of the intervention is on the management of depressive symptoms, we have considered the PHQ-9 as a main primary outcome, and will assess changes in PHQ-9 scores over 12-months between groups, adjusting for baseline PHQ-9 score, using a mixed effects multivariate model. For our second primary outcome of improvements in global disease control, we will employ a multivariate model that jointly tests the changes in multiple clinical outcomes, namely A1c, LDL cholesterol and systolic blood pressure. Using the same analytic approach as in the recently published RCT of this intervention, we will apply a scaled marginal model (Katon et al., 2010) to simultaneously compare the change in these continuous outcomes at 12 months, adjusting for the baseline status for each variable. In either primary outcome analyses, the models will be estimated iteratively and the potential correlations among and between outcomes within individuals will be handled using generalized-estimating equation (GEE) models for each outcome.

For all analyses the investigators will employ an intention-to-treat framework for our primary analysis, using a last-observation-carried-forward method of imputation for subjects who do not have complete follow-up data for primary or secondary outcomes.

Study Type

Interventional

Enrollment (Actual)

157

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Canada
    • Alberta
      • Edmonton, Alberta, Canada
        • Camrose PCN
      • Edmonton, Alberta, Canada
        • Leduc/Beaumont/ Devon PCN
      • Edmonton, Alberta, Canada
        • St. Albert & Sturgeon PCN
      • Fort Saskatchewan, Alberta, Canada
        • Heartland PCN

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Have family physician-identified type 2 diabetes
  • 18 years of age or older
  • Score >=10 on the PHQ-9
  • Speak English and have adequate hearing to complete phone interviews
  • Be willing and able to provide written informed consent to participate

Exclusion Criteria:

  • Severe and/or terminal physical illness
  • Serious and/or severe mental or psychiatric illness
  • Pregnant or breastfeeding
  • Live in long term care facility
  • Already participating in other clinical trials

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Usual Care
Participants in this arm will be actively screened for depression and will receive the usual standard care for diabetes from their family physicians based on available clinical practice guidelines.
Other: Usual diabetes and depression care
Usual care of diabetes and depression involves providing care by the family physician based on usual standards of care and available clinical practice guidelines. Usual care does not involve additional active support from the Care Manager.
Experimental: TeamCare Depression Intervention
Participants in this arm will be actively screened for depression, and will receive care for depression and diabetes based on the collaborative teamcare model for the management of diabetes and co-morbid depression.
Other: TeamCare Depression Intervention
The TeamCare-PCN intervention involves a registered nurse Care Manager (CM), who coordinates collaborative team management for patients with diabetes and depression. The goal of the intervention is to reduce depressive symptoms, achieve targets for cardio-metabolic measures and improve lifestyle behaviours. The intervention includes three phases: (1) managing depression and improving depressive symptoms, (2) managing diabetes and controlling blood glucose, blood pressure and cholesterol, and (3) improving lifestyle behaviours such as healthy eating, physical activity and smoking cessation.
Other Names:
  • TEAMcare

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Patient Health Questionnaire-9 items (PHQ-9) score
Time Frame: Baseline, 3-month, 6-month, 9-month, 12-month
A remission of depression symptoms is indicated with a PHQ-9 score <10 for a period of three consecutive months.
Baseline, 3-month, 6-month, 9-month, 12-month

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in HbA1c level
Time Frame: baseline, 6-month, 12-month
Improvement is defined as 10% improvement over baseline
baseline, 6-month, 12-month
Change in total cholesterol level
Time Frame: baseline, 6-month, 12-month
Improvement is defined as 10% improvement over baseline
baseline, 6-month, 12-month
Change in Systolic blood pressure measurement
Time Frame: baseline, 6-month, 12-month
Improvement is defined as 10% improvement over baseline
baseline, 6-month, 12-month
Change in self-reported Health Related Quality of Life
Time Frame: Baseline, 6-month, 12-month
Measured by SF-12-V2 and EQ-5D-5L
Baseline, 6-month, 12-month
Change in Diabetes-specific stress
Time Frame: Baseline, 6-month, 12-month
Measured by Problem Areas In Diabetes 5-level questionnaire (PAID-5)
Baseline, 6-month, 12-month
Change in Health behaviours
Time Frame: Baseline, 6-month, 12-month
Includes assessment of smoking behaviours, alcohol consumption, substance use, and physical activity
Baseline, 6-month, 12-month
Change in Self-care management activities
Time Frame: Baseline, 6-month, 12-month
Measured using the Summary of Diabetes Self Care Activities questionnaire (SDSCA)
Baseline, 6-month, 12-month
Change in Satisfaction with care
Time Frame: Baseline, 12-month
Measured using the Consumer Assessment of Healthcare Providers and Systems questionnaire (CAHPS), Adult Primary Care 1.0, and the Patient Assessment of Chronic Illness Care questionnaire (PACIC)
Baseline, 12-month

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

The Alliance for Canadian Health Outcomes Research in Diabetes

Collaborators

Canadian Institutes of Health Research (CIHR)
Alberta Health & Wellness

Investigators

  • Principal Investigator: Jeffrey A Johnson, PhD, University of Alberta
  • Principal Investigator: Sumit Majumdar, MD, University of Alberta

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

November 1, 2010

Primary Completion (Actual)

January 1, 2013

Study Completion (Actual)

January 1, 2013

Study Registration Dates

First Submitted

March 30, 2011

First Submitted That Met QC Criteria

April 4, 2011

First Posted (Estimate)

April 5, 2011

Study Record Updates

Last Update Posted (Estimate)

July 11, 2013

Last Update Submitted That Met QC Criteria

July 9, 2013

Last Verified

July 1, 2013

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • Achord 1101-10

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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