Pos1468-HPR Implementing Patient Health Questionnaire Depression Screening in Inflammatory Arthritis Clinic: Insights From a Quality Improvement Project at a Tertiary Rheumatology Center

Background: Depression is a common comorbidity in inflammatory arthritis (IA). Prevalence is estimated to be 38.8% in rheumatoid arthritis (RA) and is more common in patients with psoriatic arthritis (PsA) compared to controls or patients with psoriasis only. Depression in RA is associated with decreased medication adherence, increased disease activity, reduced odds of reaching clinical remission, and increased risk of all-cause mortality. Similarly, depression and anxiety in PsA are associated with decreased treatment adherence, negative health behaviors, and negative perceived health. Therefore, there is a growing body of literature that supports rheumatologists screening for comorbid depression in their IA patients to improve IA outcomes. Patient Health Questionnaire (PHQ) is a validated depression screening survey with a short (PHQ-2) and long (PHQ-9) forms that are widely adopted in various clinical settings. Objectives: This quality improvement project aimed to assess the feasibility of implementing PHQ-2 and PHQ-9 into routine clinical care of IA patients at a large tertiary rheumatology center in New York City. The study launched on July 24th, 2023, and the aim was to achieve 50% compliance in documentation of PHQ-2 and PHQ-9 by the staff members by December 18th, 2023. Methods: A retrospective analysis of patient charts of three randomly chosen IA clinic days using an online app was undertaken from February 2023 to June 2023 to get a baseline depression documentation rate. Here, documentation was assumed to have taken place if verbal depression screening occurred during clinic visit. Then, fellows, nurses, and patient care assistants (PCAs) received 30-minute education on the importance of depression screening in IA clinic. A week after the education, two-step depression screening with PHQ-2 followed by PHQ-9 if PHQ-2 is positive was implemented at the fellows' IA clinic to explore feasibility of the intervention and its long-term sustainability. Nurses and PCAs performed PHQ-2 verbally and documented the results while rooming patients using a standardized EPIC dotphrase. Patients were given paper form of the PHQ-9 only if PHQ-2 was positive for depression. Afterwards, fellows started the clinic visit and reviewed PHQ-9 if the patient had it and documented the result in clinic note using a separate standardized EPIC dotphrase. We tracked both PHQ-2 and PHQ-9 documentation rates as the key outcome measures, using a run chart to assess special cause variation. Results: Prior to the intervention, depression documentation rate was only 2%. Nine fellows, five nurses, and two PCAs participated in the intervention. After initial poor participation due to vacation schedules, nurses and PCAs met the project aim of achieving at least 50% compliance in documentation of PHQ-2 in patient charts with repeated reminders and ongoing education by the lead nurse, as illustrated on a run chart (Figure 1). Fellows failed to achieve 50% compliance in documenting PHQ-9 results in patient charts (Figure 2) despite repeated reminders and education. Survey to elicit barriers with the intervention revealed lack of time during clinic visit as the biggest challenge to compliance. Conclusion: The run chart supports a positive signal of change in documentation efforts by the nurses and PCAs in the IA clinic with repeated reminders. However, this feasibility study demonstrates that it is difficult for all providers to consistently and sustainably screen for depression using PHQ and document results in patient charts in IA clinics despite education on its clinical importance. One of the main barriers to screening identified was lack of time in clinic suggesting that education and reminders alone are not enough to result in sustainable changes in practice. Providers either need more support for depression screening or systematic changes from a division or hospital-wide level may need to take place. Additional research demonstrating improved outcomes in screened patients may also be helpful to gain buy-in from more providers resulting in more sustainable adoption of the intervention. REFERENCES: [1] Pezzato et al. Adv Rheumatol 2021. [2] Husni et al. Semin Arthritis Rheum 2017. Acknowledgements: Jeong Min Yu. Disclosure of Interests: Jeong Min Yu: None declared, Susan Goodman Novartis and UCB, Novartis and UCB, Juliet Aizer Pfizer, Nancy Pan: None declared, Tricia Dougherty: None declared, Ann Rakowicz: None declared, Mary Carey: None declared, Mavis Seehaus: None declared, Nadia Murphy: None declared, Brandon Blau: None declared, Genna Braverman: None declared, Romy Kallas: None declared, Sandhya Shri Kannayiram: None declared, Julia Levy: None declared, Cara Murphy: None declared, Robert Spandorfer: None declared, Jonathan Thaler: None declared, Ericka Fong: None declared, Jennifer Inhae Lee: None declared.