SummaryIn a program known as "Bypassing the Blues," nurse care managers routinely screen patients after cardiac bypass surgery for symptoms of depression in seven Pittsburgh-area hospitals and provide those who exhibit meaningful symptoms with ongoing, telephone-based support over an 8-month period. Using the collaborative care model, these nurses educate patients about depression, work with them to practice self-management skills, and explore and encourage adherence to recommended treatment options. Nurses meet weekly to review cases with a psychiatrist, psychologist, and internist, and routinely communicate with the primary care physician to ensure the provision of coordinated, consistent care. The program improved mental and physical health status in both men and women; men experienced a greater degree of benefit, along with a decline in hospital readmissions.Strong: The evidence stems from a randomized controlled trial (RCT) that included 150 depressed post-CABG patients who participated in the program, 152 similar patients assigned to usual care, and a comparison group of 151 post-CABG patients without depression.
Developing OrganizationsUniversity of Pittsburgh School of Medicine
Date First Implemented2004
Problem AddressedMany patients report depressive symptoms after coronary artery bypass graft (CABG) surgery; such symptoms can have a negative effect on quality of life and functional status and lead to increased risk of chest pain, rehospitalizations, and death. Hospitals and physicians seldom conduct systematic screening to identify depressed patients after CABG surgery or provide ongoing treatment and support to help them manage depression. Available support often does not align with patient preferences. Although nurse-led, collaborative care programs have been effective with depressed patients in primary care settings and in patients with other chronic conditions, they have generally not been used in post-CABG patients suffering from depression.
- A common problem, leading to poor outcomes: Up to half of patients report depressive systems after CABG surgery.1 Those who do face increased risk of a decline in health-related quality of life and functional status,2 continued chest pains,3,4 readmission to the hospital, and death.5-9
- Systematic failure to identify and support depressed patients: Very few hospitals systematically screen patients after CABG surgery to identify those with depressive symptoms. Those who happen to be identified seldom receive significant support in managing their depression.
- Available support not aligned with patient preferences: Any support offered to depressed patients tends to emphasize face-to-face encounters, which many patients (particularly those who live in rural areas) find impractical or unacceptable,10 especially during the recovery period after surgery. Support also tends to focus on prescribing pharmacotherapy, which may not be acceptable to many patients. Finally, programs often rely heavily on referrals to mental health specialists, even though many patients prefer receiving care from their primary care physician (PCP).11 Although collaborative patient-centered approaches have been effective with depressed primary care patients and in patients with other chronic conditions, they generally have not been used with depressed patients after bypass surgery.12
Description of the Innovative ActivityNurse care managers routinely screen post-CABG patients for symptoms of depression in seven Pittsburgh-area hospitals, and provide those who exhibit meaningful symptoms with ongoing telephone-based support over an 8-month period. Using the collaborative care model,13 these nurses educate patients about depression, work with them to practice self-management skills, and explore and encourage adherence to recommended treatment options. Nurses meet weekly to review cases with a psychiatrist, psychologist, and internist, and routinely communicate with the PCP to ensure the provision of coordinated, consistent care. Key elements of the program are described below:
- In-hospital and followup screening to identify eligible patients: A nurse performs a quick screen of all post-CABG patients just before discharge, using the two-question Patient Health Questionnaire (PHQ)-2 that screens for depressive symptoms. For any patient affirmatively answering either question (56 percent did during the initial study14), the nurse also administers the Folstein Mini-Mental Status Exam to ensure that the patient is mentally competent to provide informed consent and reliable responses to assessment instruments. The nurse telephones those passing this screen 2 weeks after discharge to administer a second screen, the more extensive PHQ-9. Those scoring at or above 10 on that survey (indicating at least a moderate level of depressive symptoms) qualify for additional telephone-based support (see below), provided they are not already actively seeing a mental health specialist. (During the study, 31 percent of those given the PHQ-9 screen qualified for the program, with half of those who agreed to participate being randomized to a control group receiving usual care.14) A committee of the American Heart Association has recommended a similar type of depression screening process for those with coronary heart disease.15
- Ongoing telephone support based on collaborative care, shared decisionmaking: Nurses use a collaborative, shared decisionmaking approach, letting patient preferences dictate the nature of the intervention, including their willingness to learn and practice self-management skills, use pharmacotherapy, or see a mental health specialist. Key components of this ongoing support are described below:
- Initial contact: Nurses contact eligible patients to explain the program; review their psychiatric history; discuss medical history (particular cardiac-related factors, such as smoking and diabetes); provide basic education about depression, including describing its impact on cardiac disease and reviewing self-management strategies (e.g., getting sufficient rest; engaging in exercise and appropriate pleasurable activities; avoiding tobacco, alcohol, and unhealthy foods); and assess the patient's initial treatment preferences related to depression. Nurses present patients with a variety of treatment options, including not only self-management, but also initiation or adjustment of medication therapy under the PCP's direction and/or referral to a community mental health specialist. Patients with no history of depression and mild symptoms may be offered the option of "watchful waiting" to see if symptoms abate over time.
- Weekly case reviews with clinical management team: After the initial contact, the nurse meets with a clinical management team made up of a psychiatrist, psychologist, and internist to review the patient's case. The nurse presents the patient's clinical information, with relevant patient-specific data from a computerized patient registry (see below for more details) projected on a wall for all to see. After discussing the case, the nurse and physicians jointly develop a set of treatment recommendations (usually one to three), which the nurse conveys to the PCP via fax, telephone, or mail (depending on the urgency) and to the patient (during the next call). As needed, the nurse provides periodic updates on patients at future case review sessions, which typically last 1 hour, and then uses key findings from these sessions to inform subsequent calls with the patient (see below for more details).
- Self-management workbook: Nurse care managers mail all patients a copy of The Depression Helpbook,16 which has been shown to be effective when used under the supervision of a trained care manager.17 The workbook covers therapeutic and pharmacologic approach to managing depression in a flexible manner that helps patients learn to handle depression, formulate treatment-related decisions, acquire the skills and confidence to self-manage depressive episodes, and develop maintenance strategies.
- Regular (usually biweekly) calls to support self-management, treatment: The nurse care managers telephone patients roughly every other week. During these 15- to 45-minute calls, the nurse and patient review lesson plans and practice the skills outlined in the workbook. Nurses also give patients "homework" assignments from the book, and administer follow up PHQ-9 surveys to gauge progress and further inform treatment recommendations. Calls typically continue for a period of 2 to 4 months, with the frequency depending on the patient's motivation to complete assignments and whether the patient has accepted pharmacotherapy. During the study period, participants received an average (mean) of 10 nurse contacts, with most patients (83 percent) having three or more contacts in the first 4 months.14 Although the nurses let patient preferences dictate the course of treatment (and hence do not push pharmacotherapy), they use various motivational interviewing approaches and other educational materials to encourage those who remain symptomatic to consider medications if appropriate. The nurses also help to facilitate access to a mental health specialist as appropriate, typically by identifying a provider within the patient's insurance network, scheduling an appointment, and following up to ensure the appointment is kept. (During the study, 4 percent of participants received care from a mental health specialist.14)
- Less frequent maintenance calls after "recovery" achieved: Once patients achieve a "complete recovery" (as defined by two more consecutive PHQ-9 assessment scores below 5), the nurse reduces the frequency of calls to a monthly or bimonthly basis, with calls continuing until the patient has been in the program for 8 months. During this maintenance period, the nurse begins to prepare the patient for the time when the program will end.
- Final call: At the end of the 8-month period, the nurse conducts one final call with all participants. Those who no longer exhibit symptoms are reminded to continue adhering to the current treatment approach. Those still exhibiting symptoms (with a PHQ-9 score above 10) are encouraged to initiate pharmacotherapy, make a change to existing pharmacotherapy, or to see a mental health specialist if they have not previously done so.
- Electronic support, including for responding to suicidal ideation: Each nurse uses a tablet personal computer (PC) at every patient contact (beginning with initial screening in the hospital) to enter relevant information into formatted data entry questionnaires linked to an electronic data management system/patient registry. This registry helps to inform the weekly case reviews and provides a way to track a patient's progress over time. The system has been programmed so that if a care manager uncovers suicidal ideation during the routine administration of a rating scale, an online suicide protocol form automatically launches to guide the nurse through a step-by-step approach to determining the appropriate support for the patient. (During the trial, several patients expressed suicidal thoughts, and this approach helped ensure an effective response, with no harm coming to any patient.)
- Regular contact with PCP: Throughout the process, the nurse calls the PCP as necessary, and regularly sends faxes and letters on the patient's status and progress (including the PHQ-9 report). As needed, the nurse secures verbal authority from the physician to prescribe medications, with a follow up fax to obtain written authorization. (Nurses have this authority in Pennsylvania, but may not in other states.)
References/Related ArticlesRollman BL, Belnap BH, LeMenager MS, et al. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. JAMA. 2009;302(19):2095-2103. [PubMed]
Rollman BL, Belnap BH, LeMenager MS, et al. The Bypassing the Blues treatment protocol: stepped collaborative care for treating post-CABG depression. Psychosom Med. 2009;71(2):217-30. [PubMed]
Contact the InnovatorBruce L. Rollman, M.D., M.P.H.
Professor of Medicine, Psychiatry, Biomedical Informatics and Clinical and Translational Science
Center for Research on Health Care
Division of General Internal Medicine
University of Pittsburgh School of Medicine
Suite 600 McKee Place
230 McKee Place
Pittsburgh, PA 15213
Phone: (412) 692-2659
Innovator DisclosuresDr. Rollman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThe program improved mental and physical health status in both men and women; men experienced a greater degree of benefit, along with a decline in hospital readmissions.
Strong: The evidence stems from a randomized controlled trial (RCT) that included 150 depressed post-CABG patients who participated in the program, 152 similar patients assigned to usual care, and a comparison group of 151 post-CABG patients without depression.
- Improved mental health status: Participants exhibited greater improvements in mental health status than did usual care patients. During the 8-month intervention, program participants increased their Short-Form 36 (SF-36) Mental Health Component Scale score by an average of 6.8 points, compared with a 3.6-point average increase for usual-care patients, a small to moderate effect size. Men achieved greater improvements than did women, although average scores in program participants remained below those in a separate comparison group of nondepressed post-CABG patients. Participants also achieved greater reductions in mood symptoms, as measured by the Hamilton Rating Scale for Depression, with half of participants reporting a 50 percent or larger reduction in symptoms, compared with just 29.6 percent of usual care patients.14
- Improved physical health status: Participants exhibited greater improvements in physical health and functional status than did usual care patients. Scores on the SF-36 Physical Health Component Scale increased by an average of 12.8 points among program participants, above the 11.1-point average increase in those receiving usual care; the magnitude of this difference suggests a moderate effect from the program. Similarly, participants achieved an average 18.1-point increase on the Duke Activity Status Index, above the 13.5-point increase in those receiving usual care. Physical health improvements tended to lag mental health improvements, suggesting that once patients began exhibiting improvements in mood, they then started to engage in more physical activity as well. As with the mental health component, the physical functional status scores achieved by participants did not reach the levels of the comparison group of nondepressed post-CABG patients.14
- Fewer readmissions among men: Overall rates of hospital readmission were similar for both program participants and usual-care patients. Among men, however, only 13 percent of program participants were readmitted during the 8-month study period, compared with 23 percent of usual-care patients.14 (Due to small sample size, this finding was not statistically significant.)
- Cost-effectiveness and cost savings to be determined: Program leaders are currently conducting a study to determine the cost-effectiveness and cost savings potential of the program.
Context of the InnovationSeven hospitals in the Pittsburgh area implemented this program, including two university-affiliated teaching hospitals and five community hospitals; all participating hospitals perform a significant number of CABG surgeries each year. The impetus for the program came from Bruce L. Rollman, MD, and his colleagues at the University of Pittsburgh School of Medicine, who realized that many patients become depressed after bypass surgery and that such depression can have a negative impact on their recovery and health status. Seeing little support for such patients in managing depressive symptoms, Dr. Rollman thought that a systematic program to identify and proactively reach out to such patients was needed. In his work, Dr. Rollman had become familiar with the successful use of nurse-led, telephone-based interventions based on the collaborative care model for the management of depression and other chronic diseases in a variety of populations. Seeing this success, he felt that this approach could also work well for post-CABG patients suffering from depression.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Securing grant funding: Dr. Rollman and colleagues engaged in a 4-year process to secure significant grant funding from the National Heart, Lung, and Blood Institute (NHLBI).
- Recruiting hospital participants and principal investigators: Dr. Rollman networked with surgeons and administrators at local hospitals that perform a large number of CABG surgeries. During these conversations, he explained the current challenges facing post-CABG patients suffering from depression, and described the proposed program and its potential benefits. As noted, seven hospitals agreed to participate in the initial study. As part of this effort, he secured agreement from a thoracic surgeon or cardiologist at each hospital to serve as the site's principal investigator, responsible for encouraging patients to participate.
- Hiring and orienting nurse care managers: The University of Pittsburgh hired four general nurses to serve as care managers. Each nurse received a brief orientation on the program and job responsibilities, although most training occurred on the job, particularly during the weekly case review sessions described earlier.
- Educating hospital staff: Dr. Rollman and the nurses visited each of the participating hospitals, meeting with thoracic surgeons, cardiologists, nurses, cardiac rehabilitation specialists, and others who come into daily contact with patients after bypass surgery. During these meetings, the nurses introduced themselves to the hospital staff and explained how they would be screening post-CABG patients for depression, including what HIPAA (Health Insurance Portability and Accountability Act)–compliant procedures needed to be followed to secure consent. In addition, Dr. Rollman periodically visited each hospital to deliver educational inservice and grand rounds presentations on the link between depression and cardiovascular morbidity and on the potential of this program to reduce such morbidity.
- Developing marketing and educational materials: Program leaders developed press releases, newspaper articles, wall posters, and brochures designed to inform physicians, hospital staff, and patients about the program and the impact of depression on cardiovascular disease. As needed, materials were approved by the Institutional Review Board at the University of Pittsburgh School of Medicine. Program leaders also chose to use The Depression Helpbook to guide nurse–patient interactions, as it was written at an appropriate reading level and included a chapter on depression comorbid with medical illness.
- Developing patient registry: Information technology staff at the University of Pittsburgh developed an electronic registry for the program that could be accessed through a tablet PC provided to the nurses.
Resources Used and Skills Needed
- Staffing: The University of Pittsburgh hired four full-time general nurses to perform the screening and provide ongoing, telephone-based support to study participants. (Hospitals adopting the program could use existing nurses or care managers if available.) During the pilot, these nurses screened more than 3,000 post-CABG patients at seven hospitals and provided ongoing telephone-based support to 150 patients over an 8-month period. The nurses do not have specific expertise in cardiac care. Although lower-level staff likely could perform these tasks, program leaders wanted to be sure that those conducting the work had the medical knowledge necessary to respond appropriately to any health issues that might arise, such as a patient experiencing chest pains. In addition to the nurses, the psychiatrist, psychologist, and internist who make up the clinical management team participate in the weekly hour-long case review sessions.
- Costs: Although hard data are not available, program leaders estimate (based on similar approaches used with other patient populations) that costs average roughly $450 to $500 per participant. The biggest upfront expense involves developing the patient registry/data management system (although would-be adopters with an existing electronic medical record may be able to use the registry function within that system) and buying the tablet PCs. Operating expenses consist primarily of the salary and benefits for the nurses, along with the time spent by the clinical management team on case review. During the RCT, participants also received modest compensation (four $20 payments) for participating in periodic assessments of their physical and mental health status, conducted by researchers.
Funding SourcesNational Heart, Lung, and Blood Institute (U.S.)
NHLBI provided a $5.4-million grant to cover all aspects of the program, including the RCT with three patient cohorts, as described earlier; insurers typically do not provide reimbursement for program services.
Tools and Other ResourcesFor more information on this program, visit http://www.bypassingtheblues.pitt.edu. This site contains links to assessment tools used in the program and to a commercial site where the workbook can be purchased. The site also contains a wide array of related background information on cardiac disease and depression for both health professionals and the general public. In addition, it has study materials and links to their latest study-related publications.
Getting Started with This Innovation
- Evaluate potential financial impact: Compare program-related costs to potential benefits, including reductions in emergency department (ED) visits and readmissions. The program may be most beneficial for integrated health systems that have their own health plan or that otherwise take on full capitated risk, as reductions in ED visits or readmissions will not have a negative impact on revenues but will yield meaningful cost savings. For these organizations, averting just a handful of inpatient admissions (which can cost $30,000 or more) may more than justify the expense. By contrast, standalone hospitals implementing the program might see a reduction in revenues that would exceed any cost savings, while standalone outpatient clinics would absorb program costs without realizing any savings from the reductions in ED or hospital use. However, capacity-constrained hospitals could also benefit financially from the program, as utilization reductions will allow the hospital to ease such constraints without building new facilities.
- Secure buy-in from administrators and clinician leaders: Educate hospital administrators and physician leaders (e.g., cardiac surgeons, cardiologists, thoracic surgeons) on the prevalence of depression in cardiac patients, the negative impact it can have on recovery, and the potential benefits to be gained from implementing the relatively simple components of the telephone-based collaborative approach.
- Educate relevant hospital staff: Explain the program and its potential benefits to all hospital staff involved in the care of CABG surgery patients to ensure they understand why the program is being implemented and how it works.
- Use existing resources to extent possible: Consider layering the program onto existing care management programs if available (e.g., disease management programs), thus reducing or eliminating the need for additional staffing. Take advantage of the many available public resources that can assist with assessments and ongoing collaborative care management. All assessments used in this program are available free of charge, and, as noted, the workbook can be purchased commercially.
Sustaining This Innovation
- Continually communicate with PCPs: The program's sustainability depends on maintaining the support of the PCPs responsible for managing the overall health of patients after bypass surgery. To that end, communicate regularly with the PCPs, making every effort to keep them informed of any changes in their patient's status or treatment recommendations.
- Consider lobbying insurers for reimbursement: Adopting institutions that do not realize the cost savings from reduced ED and inpatient utilization or who suffer revenue losses as a result of the program may wish to minimize the negative financial impact by lobbying insurers for reimbursement for program services. Successfully securing reimbursement will require the sharing of data on the program's potential to reduce ED and hospital utilization and overall costs.
Additional Considerations and Lessons
- Consider expansion to other patient populations: This approach can also be used for other cardiac patient populations at risk of depression, including those suffering from congestive heart failure, and for patients with other chronic conditions often accompanied by depression, such as chronic pain and diabetes.
Use By Other Organizations
- Several organizations have begun testing similar collaborative care programs for heart disease patients with depression, including Veterans Administration hospitals in Seattle and Iowa City.
Pignay-Demaria V, Lesperance F, Demaria RG, et al. Depression and anxiety and outcomes of coronary artery bypass surgery. Ann Thorac Surg. 2003;75(1):314-21. [PubMed]
Goyal TM, Idler EL, Krause TJ, et al. Quality of life following cardiac surgery: impact of the severity and course of depressive symptoms. Psychosom Med. 2005;67(5):759-65. [PubMed]
Malik S, Krumholz HM, Lin ZQ, et al. Patients with depressive symptoms have lower health status benefits after coronary artery bypass surgery. Circulation. 2005;111(3):271-7. [PubMed]
Doering LV, Moser DK, Lemankiewicz W, et al. Depression, healing, and recovery from coronary artery bypass surgery. Am J Crit Care. 2005;14(4):316-24. [PubMed]
Rumsfeld JS, Ho PM, Magid DJ, et al. Predictors of health-related quality of life after coronary artery bypass surgery. Ann Thorac Surg. 2004;77(5):1508-13. [PubMed]
Blumenthal JA, Lett HS, Babyak MA, et al. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet. 2003;362(9384):604-9. [PubMed]
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Oxlad M, Stubberfield J, Stuklis R, et al. Psychological risk factors for cardiac-related hospital readmission within 6 months of coronary artery bypass graft surgery. J Psychosom Res. 2006;61(6):775-81. [PubMed]
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Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA. 2003;289:3106-16. [PubMed]
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Rollman BL, Belnap BH, LeMenager MS, et al. The Bypassing the Blues treatment protocol: stepped collaborative care for treating post-CABG depression. Psychosom Med. 2009;71:217-30. [PubMed]
Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27(2):63-80. [PubMed]
Lichtman JH, Bigger JT, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008;118(17):1768-75. [PubMed]
16 Katon W, Ludman E, Simon G. The Depression Helpbook. Boulder, CO: Bull Publishing; 2002.
Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56(12):1109-15. [PubMed]
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Service Delivery Innovation Profile
Original publication: February 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 08, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 14, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.