Increasing Recognition and Diagnosis of Adolescent Depression: Project RedDE: A Cluster Randomized Trial

Abstract

Adolescent depression causes appreciable morbidity and is underdiagnosed in primary care. This study investigated whether a quality improvement collaborative (QIC) increases the frequency of adolescent depression diagnoses, thus reducing missed diagnoses.

Methods: During a cluster-randomized clinical trial, a national cohort of primary care pediatric practices worked in different orders based on randomization to improve performance on each of three different diagnoses; one was increasing adolescent depression diagnoses. While improving their first diagnosis during an 8-month action period, practices collected control data for a different diagnosis. In two subsequent 8-month periods, practices worked to improve two additional diagnoses and continued to provide data on the ability to sustain and maintain improvements. The QIC intervention included day-long video conferences, transparent data sharing, analysis of failures, QI coaching, and tools to help improve diagnostic performance, including the Patient Health Questionnaire-9 Modified. The primary outcome was the measured frequency of depression diagnoses in adolescent health supervision visits compared via generalized mixed-effects regression models.

Results: Forty-three practices were randomized with 31 in the final analysis. We included 3,394 patient visits in the control and 4,114 in the intervention phases. The adjusted percentage of patients with depression diagnoses increased from 6.6% in the control to 10.5% in intervention phase (Risk Difference (RD) 3.9%; 95% CI 2.4%, 5.3%). Practices sustained these increases while working on different diagnoses during the second (RD -0.4%; 95% CI -2.3, 1.4%), and third action periods (RD -0.1%; 95% CI -2.7%, 2.4%).

Conclusions: A QIC intervention can sustainably increase adolescent depression diagnoses.

Fig. 1.

Modified consort flow diagram for cluster randomized stepped-wedge trial. *One practice in group 1 withdrew after the first phase of the project. Their data were included in the primary analysis.

Fig. 2.

Project RedDE timeline for adolescent depression. ^aPractices were involved in Project RedDE during this time but working exclusively on the 2 nondepression errors. Practices in groups 2 and 3 had already worked to reduce 1 or 2 other DEs before beginning to work on depression errors. ^bDuring the sustain and maintenance phases, practices began working to reduce a second and third DE, respectively. ^cWave 2 practices integrated alongside wave 1 practices, intervening first on wave 1’s second DE. These practices never intervened on a third DE. DEs indicates diagnostic errors.

Fig. 3.

p charts of primary and secondary outcomes UCL, upper control limit; LCL, lower control limit.