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The Partners in Care Approach to Ethics Outcomes in Quality Improvement Programs for Depression

OBJECTIVE: Patient centeredness and equity are major quality goals, but little is known about how these goals are affected by efforts to improve the quality of care. The authors describe an approach to addressing these goals in a randomized trial of quality improvement for depressed primary care patients. METHODS: For four ethics goals (autonomy, distributive justice, beneficence, and avoiding harm), the authors identify intervention features, study measures, and hypotheses implemented in Partners in Care, a randomized trial of two quality improvement interventions, relative to usual care and summarize published findings pertinent to these outcomes. RESULTS: To implement an ethics framework, modifications were required in study design and in measures and analysis plans, particularly to address the autonomy and justice goals. Extra resources were needed for sample recruitment, for intervention and survey materials, and to fund an ethics coinvestigator. The interventions were associated with improvements in all four ethics areas. Patients who received the interventions were significantly more likely to receive the treatment they had indicated at baseline as their preferred treatment (autonomy goal). Intervention-associated benefits occurred more rapidly among sicker patients and extended to patients from ethnic minority groups, resulting in a reduction in ethnic-group disparities in health outcomes relative to usual care (distributive justice goal). The interventions were associated with improved quality of care and health outcomes (beneficence goal) and with reduced use of long-term minor tranquilizers (goal of avoiding harm). CONCLUSIONS: It is feasible to explicitly address ethics outcomes in quality improvement programs for depression, but substantial marginal resources may be required. Nevertheless, interventions so modified can increase a practice's ability to realize ethics goals.

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