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The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial

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Morgan, Mark A J, Coates, Michael J, Dunbar, James A, Reddy, Prasuna, Schlicht, Kate, Fuller, Jeff·2013·BMJ Open
DOI 10.1136/bmjopen-2012-002171PMC PMC3563126
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Abstract

Objectives: To determine the effectiveness of collaborative care in reducing depression in primary care patients with diabetes or heart disease using practice nurses as case managers. Design: A two-arm open randomised cluster trial with wait-list control for 6 months. The intervention was followed over 12 months. Setting: Eleven Australian general practices, five randomly allocated to the intervention and six to the control. Participants: 400 primary care patients (206 intervention, 194 control) with depression and type 2 diabetes, coronary heart disease or both. Intervention: The practice nurse acted as a case manager identifying depression, reviewing pathology results, lifestyle risk factors and patient goals and priorities. Usual care continued in the controls. Main outcome measure: A five-point reduction in depression scores for patients with moderate-to-severe depression. Secondary outcome was improvements in physiological measures. Results: Mean depression scores after 6 months of intervention for patients with moderate-to-severe depression decreased by 5.7±1.3 compared with 4.3±1.2 in control, a significant (p=0.012) difference. (The plus–minus is the 95% confidence range.) Intervention practices demonstrated adherence to treatment guidelines and intensification of treatment for depression, where exercise increased by 19%, referrals to exercise programmes by 16%, referrals to mental health workers (MHWs) by 7% and visits to MHWs by 17%. Control-practice exercise did not change, whereas referrals to exercise programmes dropped by 5% and visits to MHWs by 3%. Only referrals to MHW increased by 12%. Intervention improvements were sustained over 12 months, with a significant (p=0.015) decrease in 10-year cardiovascular disease risk from 27.4±3.4% to 24.8±3.8%. A review of patients indicated that the study's safety protocols were followed. Conclusions: TrueBlue participants showed significantly improved depression and treatment intensification, sustained over 12 months of intervention and reduced 10-year cardiovascular disease risk. Collaborative care using practice nurses appears to be an effective primary care intervention. Trial registration: ACTRN12609000333213 (Australia and New Zealand Clinical Trials Registry).

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  • Seventeen studies targeting diabetes reported mean changes in HbA1c, with seven reporting significant improvements in the intervention compared with usual care.

    “Seventeen studies targeting diabetes reported mean changes in HbA1c, with seven reporting significant improvements in the intervention compared to usual care”

    From Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice (2019) · cites this paper as [112]

    Results, Phase 1 (Table 2; page unavailable) reports a significant between-group difference in HbA1c at six months (p=0.049), so this trial can serve as an example of an intervention study reporting improvement relative to control. It is a single trial, however, and does not substantiate the claim that 17 studies reported HbA1c changes or that seven found significant improvements. (LLM, conf=0.84)

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  • The collaborative care trials were not fully powered for major cardiac outcomes, and absolute rates of cardiac events or mortality were highly similar in intervention and control conditions, suggesting that even substantially larger trials may have observed no effect.

    “Although these trials were not fully powered for major cardiac outcomes, absolute rates of cardiac events or mortality were highly similar in intervention and control conditions in these studies, suggesting that even substantially larger trials may have observed no effect.”

    From Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association (2021) · cites this paper as [188]

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Research works printed but not linked: 22

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Authors
Morgan, M. A. J., Coates, M. J., Dunbar, J. A., Reddy, P., Schlicht, K., & Fuller, J.
Affiliations
  • Deakin University (AU)
  • University of Newcastle Australia (AU)
  • School of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia
Corresponding author
Dunbar, James A
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2013
Volume
3
Issue
1
Pages
e002171
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2012-002171
PMC
PMC3563126
OpenAlex
W2122192742
Cited by
123
References
8
Citations by year
2026: 2 · 2025: 7 · 2024: 9 · 2023: 8 · 2022: 10 · 2021: 16 · 2020: 7 · 2019: 13 · 2018: 11 · 2017: 3 · 2016: 8 · 2015: 9 · 2014: 13 · 2013: 7
FWCI
9.70
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • BMJ Open (publishedVersion, cc-by-nc)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • OPUS - Open Publications of UTS Scholars (University of Technology Sydney) (submittedVersion, cc-by-nc)
  • Deakin Research Online (Deakin University) (submittedVersion)
  • Figshare (submittedVersion, cc-by-nc)
  • Swinburne figshare (Swinburne University of Technology) (submittedVersion, cc-by-nc)
  • NOVA (University of Newcastle Australia) (submittedVersion)
  • Swinburne figshare (Swinburne University of Technology)
Funders
University of Washington
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
Keywords
collaborative care, practice nurses, case management, depression, type 2 diabetes, coronary artery disease, primary care, exercise referral, cardiovascular risk, guideline adherence

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