Implementing Patient Health Questionnaire Depression Screening in Inflammatory Arthritis Clinic: Insights From a Quality Improvement Project at a Tertiary Rheumatology Center

Abstract

Objective

This quality improvement project evaluates the feasibility and sustainability of adopting the Patient Health Questionnaire (PHQ) depression screening tool into routine clinical care at a rheumatology fellows’ inflammatory arthritis (IA) clinic at a large tertiary center. The aim was to achieve 50% compliance in documentation of PHQ after five months.

Methods

Providers received a 30‐minute education on the importance of depression screening in patients with IA. A week after the education, two‐step depression screening with the PHQ‐2 followed by the PHQ‐9 was implemented. Nurses performed PHQ‐2 at each IA clinic visit verbally and documented the results while rooming patients using an electronic health record (EHR) dotphrase. Patients completed paper forms of the PHQ‐9 only if the PHQ‐2 score was positive for depression. Fellows then reviewed the PHQ‐9 during the clinic visit and documented it using a separate EHR dotphrase. We tracked both PHQ‐2 and PHQ‐9 documentation rates as the key outcome measures.

Results

Before to the intervention, depression documentation rate was only 2%. After initial poor participation, nurses achieved the aim after repeated reminders and ongoing education by the senior nurse. Fellows failed to achieve the aim despite repeated reminders and education. Lack of time during clinic visit was found to be the biggest challenge.

Conclusion

Sustained adoption of the PHQ was difficult to achieve. Additional support at the health systems level that prioritizes depression screening may need to take place. Additional research demonstrating improved IA outcomes in screened patients may also be helpful to gain more buy‐in from providers.

INTRODUCTION

Depression is a common comorbidity among patients with inflammatory arthritis (IA). The prevalence of major depressive disorder in patients with rheumatoid arthritis (RA) is estimated to be 38.8%, measured by the Patient Health Questionnaire‐9 (PHQ‐9). ¹ A large German health insurance database showed that depression was more frequent in patients with psoriatic arthritis (PsA) compared with controls (28% vs 16%). ² Recent studies in RA have shown that depression is also associated with decreased medication adherence, ³ increased disease activity, ⁴ reduced odds of reaching clinical remission, ⁴ , ⁵ and increased risk of all‐cause death. ⁶ Similarly, in PsA, depression and anxiety in PsA are associated with decreased treatment adherence, ⁷ negative health behaviors, ⁸ and negative perceived health. ⁹ , ¹⁰ Therefore, there is a growing body of literature that supports rheumatologists screening for comorbid depression in their patients with IA. ¹ , ⁴ , ⁵ , ⁶ , ⁷ , ⁹

Currently, American College of Rheumatology (ACR) clinical practice guidelines do not specifically recommend depression screening in patients with IA. However, screening for depression (in all patient encounters, not just limited to patients with IA) is one of the Qualified Clinical Data Registry 2024 quality measures (Quality ID no. 134) in the ACR's Rheumatology Informatics System for Effectiveness (RISE) registry, ¹¹ the largest electronic health record (EHR) enabled rheumatology registry in the United States, with participation of more than 1,000 rheumatology clinicians, ¹² leading to the adoption of universal depression screening at some academic rheumatology medical centers. ¹³

RISE's registry quality measure on depression screening does not specify which age‐appropriate standardized depression screening tool should be used. PHQ is a validated depression screening survey with short (PHQ‐2) and long (PHQ‐9) forms that are widely adopted in various clinical settings. PHQ‐2 has the advantage over PHQ‐9 of being brief (only two of the nine questions on the PHQ‐9) and easy to administer verbally. ¹⁴ It is often used as a preliminary screening tool, and, if positive, followed‐up with the more detailed screening of PHQ‐9. The advantage of this two‐step strategy is efficiency. A recent systematic review and meta‐analysis showed that the combination was estimated to reduce the number of participants needing to complete the full PHQ‐9 by ¹⁵ 57%. The combination of PHQ‐2 (with a cutoff score of ≥2) followed by PHQ‐9 (with a cutoff score of ≥10) had similar sensitivity but higher specificity compared with PHQ‐9 cutoff scores of 10 or greater alone. ¹⁵ The PHQ‐9 is a useful tool to screen or diagnose depression and assess depression severity, and it has validity evidence in RA. ¹⁶ It grades depression severity based on the total score from minimal depression to severe depression and can be administered at regular intervals. ¹⁶

The Hospital for Special Surgery (HSS) is a large tertiary academic medical center in New York City (NYC) with a large Division of Rheumatology. Currently, there is no formal division‐level protocol on depression screening in routine care of patients with IA. Rheumatologists and rheumatology fellows may be screening for depression individually in their patients, but it is unknown how often this occurs. There is a hospital‐wide protocol in which nurses perform mandatory suicide screening in all patients every six months. However, this is likely only capturing a small subset of patients with severe depression.

Here, we report our quality improvement (QI) efforts implementing the PHQ‐2 and PHQ‐9 into routine clinical care of patients with IA at our center. This project was a smaller‐scale feasibility study scaled for the adult rheumatology fellows’ IA clinic at the HSS. Because the IA clinic operates only once a week for a half day, we believed it would be easier to monitor progress with fewer providers and patient encounters. This study was also fellow driven (JMY), making the fellow's clinic a readily accessible target. This clinic serves established patients with IA and all visits are follow‐up visits. We aimed to achieve 50% compliance in the documentation of PHQ‐2 and PHQ‐9 at each clinic visit by the fellows and clinic staff members over a five‐month period.

PATIENTS AND METHODS

Setting, context, and ethical considerations

HSS is a large tertiary medical center in NYC. This project was undertaken as part of Weill Cornell Medicine‐Quality Improvement Academy and was approved by the Chief of the Division of Rheumatology at HSS in recognition of the value of the project. The HSS Institutional Review Board conducted a review of our QI initiative and determined that the activities described do not constitute human study participants research because the activities were not considered a systematic investigation designed to contribute to generalizable medical knowledge.

Interventions

We recruited a multidisciplinary team to champion the project at the IA clinic, which included rheumatologists (one rheumatology fellow and one supervisory attending rheumatologist), nurses (one senior nurse and one Assistant Vice President of nurse administration), three social workers, and QI experts (one physician adviser and one program manager). We presented our QI intervention and the importance behind the initiative to the rheumatology fellows, IA clinic supervisory rheumatology attending physicians, and the clinic staff members who work in IA clinic to engage their participation and subject matter expertise for the intervention. Fellows, nurses, and patient care assistants (PCAs) received a 30‐minute education on the importance of depression screening, PHQ tools, and usage of the EHR dotphrases to document the results. The EHR dotphrases are shortcut tools that are commonly used in her, in which small pieces of text that start with a period expand into larger body of preset texts that are easily searchable. ¹⁷ One dotphrase for the PHQ‐2 and one for the PHQ‐9 were created before the start of the intervention (JY). A week after the education, two‐step depression screening with the PHQ‐2 followed by the PHQ‐9 if the PHQ‐2 was positive was implemented at the fellows’ IA clinic to explore feasibility of the intervention and its long‐term sustainability.

Nurses and PCAs administered the PHQ‐2 verbally and documented the results while rooming patients using the standardized EHR dotphrase. Patients were given paper forms of the PHQ‐9 only if the PHQ‐2 was positive for depression (cutoff score of ≥2). Afterwards, fellows started the clinic visit and reviewed PHQ‐9 when indicated and documented the result in clinic note using the corresponding EHR dotphrase (Figure 1). The study was not limited to English‐speaking patients. Spanish versions of the PHQ‐2 and PHQ‐9 were used for native Spanish speakers, and for other languages, in‐person or telephone interpreters were used. We tracked both PHQ‐2 and PHQ‐9 documentation rates as the key outcome measures, using a run chart to assess nonrandom signals of change.

Figure 1.

Process Map. The diagram highlights the major workflow. The blue represents workflow before the intervention, and the red indicates the quality improvement intervention. PHQ, Patient Health Questionnaire; SI, suicidal ideation.

The study officially launched on July 24, 2023, and the aim was to achieve 50% compliance in documentation of the PHQ‐2 and PHQ‐9 by the clinic staff members and by the rheumatology fellows by December 18th, 2023. We designed a key driver diagram to design interventions that could improve compliance with the intervention (Supplementary Figure 1). A manual retrospective analysis of patient charts from three randomly chosen IA clinic days using an online app was undertaken from February 2023 to July 2023, before the intervention to get a baseline depression documentation rate.

Studies of the intervention

Because of patient volumes at the IA clinic per week, Plan‐Do‐Study‐Act (PDSA) cycles, which is a QI method to test a change that is implemented, ¹⁸ were conducted monthly to review performances, share current practices, discuss successes and challenges, and adapt changes. The project steps and interventions are annotated in Figure 2. Initial PDSA cycles revealed that the most significant barrier to administering either survey was the time required to ask questions and tally the score to evaluate whether the PHQ‐9 is needed (in the case of PHQ‐2) or whether depression is present (in the case of PHQ‐9). To streamline the process, the first intervention to directly impact compliance occurred in July 2023 when the senior nurse ensured that all IA clinic rooms were adequately stocked with paper copies of PHQ‐9. In addition, IA nurses formed a Unit Practice Council to improve PHQ‐2 documentation as one of their goals.

Figure 2.

Plan‐Do‐Study‐Act cycles performed between July 2023 and December 2023. PHQ, Patient Health Questionnaire.

Measures

Our outcome measure was the percent of patient encounters with PHQ (both PHQ‐2 and PHQ‐9) documented in a given IA clinic day. For the PHQ‐2, our numerator was the number of patient encounters in an IA clinic day with the PHQ‐2 documented; the denominator was the number of patient encounters total in the same IA clinic day. For the PHQ‐9, our numerator was the number of patient encounters in an IA clinic day with the PHQ‐9 documented; the denominator was the number of patient encounters with a positive PHQ‐2 score in the same IA clinic day.

Our process measures were time to room patients and time spent reviewing the PHQ‐9 during the clinic visit. As a balancing measure, we obtained provider feedback with the depression screening process using the PHQ QI Provider Experience Survey.

Analysis

We gathered PHQ documentation rates from an automated EHR report generated from the EHR dotphrases. We created a run chart for our outcome measure to monitor documentation rates over time. Data were analyzed weekly starting from July 2023.

RESULTS

Before the intervention, depression documentation rate as a free text was 2% during the six‐month run‐in period. Nine fellows, five nurses, and two PCAs participated in the intervention. When we surveyed rheumatology fellows before the start of the intervention to understand barriers to depression screening, we found insufficient time and uncertainty about whose responsibility it is to screen for depression to be the most significant barriers.

The outcome measure of the documentation rate was tracked weekly. We used the standard run chart rules to analyze for nonrandom signals of change. ¹⁹ After initial poor participation due to vacations, nurses and PCAs met the project aim of achieving 50% compliance in documentation of the PHQ‐2 in patient charts (Figure 3). Fellows did not achieve 50% compliance in documenting PHQ‐9 results in patient charts despite repeated reminders and education (Supplementary Figure 2). Our survey of providers revealed lack of time during the clinic visit as the biggest barrier and challenge to compliance (Supplementary Figure 3). However, none of the five fellows and five clinic staff who responded to the PHQ QI Provider Experience Survey felt that there was a significant increase in the length of rooming patient and patient encounter.

Figure 3.

Shewhart chart showing percentage of patient encounters with PHQ‐2 documentation each clinic day in inflammatory arthritis clinic. The blue points and lines represent the weekly data, and the black line is the mean. PDSA, Plan‐Do‐Study‐Act; PHQ, Patient Health Questionnaire; RN, registered nurse.

DISCUSSION

This was a multidisciplinary effort at an IA rheumatology fellows’ clinic in a large tertiary rheumatology center in NYC to align resources and efforts to implement standardized screening of a patient population at a high risk of depression. Our project core was to understand the feasibility of the intervention before wider division‐level adoption of the PHQ screening, which was essential to create a sustainable process. By standardizing depression screening using the PHQ tool, standardizing documentation, engaging stakeholders, creating an automated EHR report, and developing workflow process, we significantly increased the documentation rate of depression in patient encounters compared to the baseline, demonstrating feasibility of the intervention. The run chart supports a nonrandom signal of change in documentation efforts by the nurses and PCAs supporting the value of a systematic screening process. Some rheumatology fellows expressed lack of time as one of the main barriers to screening depression. In some cases, language barriers contributed to longer encounter times, which likely added to the time constraints. This suggests that education and reminders alone are not enough to result in sustainable changes in practice and providers may need more support for depression screening or other creative solutions and system level changes that prioritize depression screening.

The baseline depression screening and documentation in patient encounters were only 2% before the start of the intervention. Root causes identified in our driver diagram included awareness about its importance related to IA, priority for depression screening during visits, assessment deferral to the primary care physicians, and knowledge on how to properly assess for depression. Our provider education addressed all of these potential barriers. Adopting PHQ eliminated the discomfort with screening for depression by providing an objective and validated tool for assessment. Our QI intervention created a standardized process through the involvement of a multidisciplinary team so that the burden of screening does not fall on individual providers.

The most striking increase we had in our project was seen among IA clinic staff members consisting of nurses and the PCAs; we suspect that is due to having a dedicated team that included a senior nurse champion. In addition, clinic staff met weekly and formed a Unit Practice Council to help improve screening and documentation. Although the fellows did not meet the aim of 50%, the mean documentation rate was 47.7%, which was an improvement from the baseline 2%. There were peaks in documentation after PDSA cycles, but they were not sustained. It is possible that adopting a similar method for the rheumatology fellows, such as doing a weekly team huddle before the start of the clinic to discuss depression screening, could have led to a more successful result. Some fellows have also suggested adding PHQ‐9 prompts directly in the EHR, instead of using paper forms.

Our QI project has limitations related to the automated EHR report. Although the report captures the dotphrases in patient encounters, the lack of natural language processing tools failed to capture the free‐text documentation within encounters. However, this limitation is unlikely to have affected our numbers greatly because of continued education and reminders about using the standardized dotphrases for this study.

Using QI methodology, we successfully adopted depression screening using the PHQ‐2 tool by nursing staff while rooming patients in the rheumatology fellows’ IA clinic. However, the same result was not replicated using the PHQ‐9 by rheumatology fellows. One of the next steps moving forward would focus on understanding ways to incorporate PHQ‐9 more reliably so that it could lead to a durable change in practice. Results have been shared with leadership to recommend additional resources and prioritization of depression screening that will allow for expansion to other rheumatology practices, leveraging the hospital's participation in RISE, which includes a quality measure in screening for depression that will get tracked for quality performance. Partnership with mental health and primary care practices would also benefit patients with positive PHQ‐9 screens to facilitate ongoing treatment for depression. Additional research demonstrating improved outcomes in screened patients may also be helpful to gain more buy‐in from rheumatology providers, which could help sustain the adoption of the intervention.

AUTHOR CONTRIBUTIONS

All authors contributed to at least one of the following manuscript preparation roles: conceptualization AND/OR methodology, software, investigation, formal analysis, data curation, visualization, and validation AND drafting or reviewing/editing the final draft. As corresponding author, Dr Yu confirms that all authors have provided the final approval of the version to be published, and takes responsibility for the affirmations regarding article submission (eg, not under consideration by another journal), the integrity of the data presented, and the statements regarding compliance with institutional review board/Helsinki Declaration requirements.

Supporting information

Disclosure form

Supplementary Figure 1: Key driver diagram. We show identified interventions and key drivers that lead to compliance with PHQ documentation in IA clinic.

Supplementary Figure 2: Shewhart Chart showing percentage of patient encounters with positive PHQ‐2 that had PHQ‐9 documented each clinic day in IA clinic. The blue points and lines represent the weekly data, and the black line is the mean.

Supplementary Figure 3: Pareto Chart showing barriers to PHQ screening and documentation based on the Provider Experience Survey administered post‐intervention.