Asynchronous versus synchronous screening for depression and suicidality: A quality improvement study in a primary care health system (Preprint)

Abstract

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Pre-visit Patient Health Questionnaire–9s (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of pre-visit web-based PHQ-9s on patient care and safety.

Investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.

This quality improvement study was conducted at 33 clinic sites across two health systems in Northern California from November 1, 2020 to May 31, 2021 and evaluated 1,683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (Q#9) following implementation of a depression screening program that included automated electronic pre-visit PHQ-9 distribution. Patient demographics and providers’ clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.

Of the 1,683 patients (63.7% female, 80.5% non-Hispanic, and 51.6% White), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (OR=0.6; 95% CI: 0.45-0.8; p<0.001). Patients with Medicare insurance were 36% (OR=0.64; 95% CI: 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI: 1.21-2.15; p=0.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR=2.41; 95% CI: 1.89-3.06; p<0.001) and 77% less likely to receive a referral to psychiatry (OR=0.23; 95% CI: 0.16-0.34; p<0.001). Those who endorsed Q#9 “more than half the days” (OR=1.62; 95% CI: 1.06-2.48) and “nearly every day” (OR=2.38; 95% CI: 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed Q#9 “several days” (p=0.002).

Shifting depression screening from in-clinic to pre-visit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9s can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.