The influence of primary care clinic characteristics on the quality of care for depression in patients with different comorbidity profiles

In primary care settings, most patients presenting with major depression also suffer from comorbid chronic mental and/or physical conditions.  Delivering high quality depression care to these patients represents an important challenge for primary care providers and for health care systems.  There are reasons to believe that the organizational contexts in which providers practice have an important influence on the care they provide to patients with depression and comorbid chronic conditions.  However, few studies have directly examined how primary care organizational characteristics facilitate or impede care for these patients.  The main objective of this thesis was to better understand how different primary care organizational characteristics influence the quality of depression care provided to patients with different profiles of comorbid chronic conditions.    The thesis has two components.  First, we conducted a systematic review examining relationships between chronic physical comorbidity and the quality of depression recognition and treatment in primary care in order to clarify the nature of these relationships and identify factors associated with observed differences in these relationships across studies.  Next, we carried out a mixed-methods study conducted in two sequential phases: (a) a quantitative phase examining relationships between depression care quality, patients’ comorbidity profiles, and primary care clinic characteristics using multilevel regression analyses of data collected from two inter-related surveys, and (b) a qualitative phase relying on a case study approach that examines primary care professionals’ perceptions of the organizational factors that influence the quality of care they provide to patients living with depression and other comorbid chronic diseases.  Results of these studies revealed that while the quality of depression care in primary care is suboptimal, some patient subgroups are more at risk of receiving low quality of care than others.  Specifically, depressed patients with chronic physical comorbidity only were more at risk of receiving suboptimal care than patients presenting only with psychiatric comorbidity.  However, several characteristics of primary care organizations facilitated the delivery of high quality care to patients with depression and comorbid chronic conditions.  These included norms and values related to teamwork and mutual support, access to supports from professionals with expertise in mental health, use of decision support tools for depression treatment, and a lack of barriers due to inadequate payment models.  One of the ways these characteristics support quality is by facilitating the flow of knowledge in primary care organizations.   Our findings suggest that targeted organizational interventions are needed to improve the quality of depression care delivered to patients with depression and comorbid chronic conditions. Interventions could target multiple organizational domains (e.g. structural/strategic, social, informational and epistemic characteristics) and should consider how elements in each domain interact and how they might impact patients with different comorbidity profiles.

Keyphrases: Depression, Mental health, Comorbidity, Multimorbidity, Quality of health care, Primary care, Organizational factors, Knowledge management, Systematic review, Mixed methods