Community-Based Medical Oncology Depression Screening Program Delivers More Referrals for Behavioral Care in Breast Cancer

Community-based oncology practices that routinely screened patients with breast cancer for depression gave more referrals for behavioral care compared with an education-only control group, according to a study (NCT02941614) published in JAMA Original Investigation.

In terms of primary outcomes, 59 of 744 patients from tailored sites were referred for behavioral care compared with 1 patient of 692 at the education-only sites, with a difference of 7.8% (95% CI, 5.8%-9.8%). At the intervention sites, referrals to behavioral health clinicians were completed by 44 of 59 patients compared with 1 patient at the education-only site.

“Among patients with breast cancer treated in community-based medical oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program,” investigators of the study wrote.

A total of 1436 patients were enrolled on the study. Patients had a mean age of 61.5 years, and 99% were women. Investigators reported a mean Charlson Comorbidity Index of 2.2. Additionally, 87% of patients spoke English as a primary language and 9% spoke Spanish. A total of 18% of patients self-reported as being Asian or a Pacific Islander, 17% were Black, 26% Hispanic, and 37% White. Additionally, 82% of patients had stage 0 to stage II disease.

During the trial, 28 patients died, including 19 patients in the intervention arm and 9 in the control arm with a difference of 1.3% (95% CI, 95% CI, -0.2% to 2.7%). An additional 51 patients in the intervention group and 42 in the control group disenrolled from the health plan with a difference of 0.8% (95% CI, -1.8% to 3.3%). Investigators attributed the deaths to metastatic cancer, or other comorbid conditions.

In terms of secondary outcomes, 80% patients at tailored sites were offered a PHQ-9 screening during their consultation appointment compared with less than 1% of patients at the control site. In total, 11% patients at the tailored sites were scored in the moderate or high range, prompting the need for immediate referral. Additionally, 94% received an appropriate referral and 6% either declined or were not offered one. Of those patients who were referred to a behavioral health clinician, 75% completed a visit, and 25% declined to schedule a visit, cancelled, or did not show up. For the 3 patients who were screened at the education site, 2 scored low and 1 was moderate.

The mean follow-up for the 730 patients in the utilization cohort in the tailored group was 1.15 years vs 1.14 years for the 683 patients in the education group.

Investigators used an unadjusted comparison to find the difference in per person-year of outpatients oncology visits at tailored interventions sites vs education-only sites, and reported a difference of -1.81 (95% CI, -2.11 to -1.51), 0.04 for outpatient primary care (95% CI, -0.17 to 0.24), -0.18 for urgent care (95% CI, -0.27 to -0.09), and 0.04 for emergency department visits (95% CI, -0.04 to 0.12).

These models were adjusted for age, race, ethnicity, cancer stage, partner status, and Charlson comorbidity index. Patients who were treated at tailored intervention sites were significantly less likely to have medical oncology outpatient visits (adjusted rate ratio [RR], 0.86; 95% CI, 0.86-0.89; P = .001). Additionally, no statistically significant differences were observed in primary care (adjusted RR, 1.07; 95% CI 0.93-1.24), urgent care (adjusted RR, 0.84; 95% CI, 0.51-1.38, or emergency department visits (adjusted RR, 1.16; 95% CI, 0.84-1.62).

In a post-hoc analysis of the PHQ-9 screening, more patients in the tailored group (n = 135) had a referral than the education only (n = 74) with a difference of 7.5% (95% CI, 3.7%-11.2%). Patients received multiple types of referrals with the exception of external referrals, which were given to no patients in the tailored group and 13 in the education group. The number of patients who were referred to a behavioral health specialist by the oncology department was greater in the intervention clinics cohort vs the control cohort (97 vs 23;).

Reference

Hahn EE, Munoz-Plaza CE, Pounds D, et al. Effect of a community-based medical oncology depression screening program on behavioral health referrals among patients with breast cancer: a randomized clinical trial. JAMA. 2022;327(1):41-49. doi:10.1001/jama.2021.22596