Challenges in referral communication between VHA primary care and specialty care

BACKGROUND

Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA).

OBJECTIVE

The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication.

DESIGN

The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges.

PARTICIPANTS

191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed.

MAIN MEASURES/APPROACH

PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed.

KEY RESULTS

Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral.

CONCLUSIONS

Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.

Early changes in VA medical home components and utilization

OBJECTIVES

In 2010, the Veterans Health Administration (VA) began national implementation of its patient-centered medical home (PCMH) model, called Patient Aligned Care Teams (PACTs), to improve access, coordination, and patient-centered care. We evaluated changes in reported implementation of PCMH components in all VA primary care clinics, and patients' utilization of acute and non-acute care and total costs after 2 years.

STUDY DESIGN

Longitudinal study of 2,607,902 patients from 796 VA primary care clinics.

METHODS

Clinics were surveyed for their implementation of PCMH components. Patient outcomes were measured by outpatient visits for primary care, specialty care, telephone care, and emergency department (ED) care; hospitalizations for an ambulatory care-sensitive condition (ACSC); and costs of VA care in fiscal years (FYs) 2009 and 2011. Multi-level, multivariable models predicted changes in utilization and costs, adjusting for patients' health status, clinic PCMH component scores, and a patient fixed effect.

RESULTS

Clinics reported large improvements in adoption of all PCMH components from FY 2009 to FY 2011. Higher organization of practice scores was associated with fewer primary care visits (P = .012). Greater care coordination/transitions was modestly associated with more specialty care visits (P = .010) and fewer ED visits (P = .018), but quality/performance improvement was associated with more ED visits (P = .032). None of the PCMH components were significantly related to telephone visits, ACSC hospitalizations, or total healthcare costs.

CONCLUSIONS

Improvements under organization of practice and care coordination/transitions appear to have impacted outpatient care, but reductions in acute care were largely absent.

Assessing organizational readiness for depression care quality improvement: relative commitment and implementation capability

Background

Depression is a major cause of morbidity and cost in primary care patient populations. Successful depression improvement models, however, are complex. Based on organizational readiness theory, a practice’s commitment to change and its capability to carry out the change are both important predictors of initiating improvement. We empirically explored the links between relative commitment (i.e., the intention to move forward within the following year) and implementation capability.

Methods

The DIAMOND initiative administered organizational surveys to medical and quality improvement leaders from each of 83 primary care practices in Minnesota. Surveys preceded initiation of activities directed at implementation of a collaborative care model for improving depression care. To assess implementation capability, we developed composites of survey items for five types of organizational factors postulated to be collaborative care barriers and facilitators. To assess relative commitment for each practice, we averaged leader ratings on an identical survey question assessing practice priorities. We used multivariable regression analyses to assess the extent to which implementation capability predicted relative commitment. We explored whether relative commitment or implementation capability measures were associated with earlier initiation of DIAMOND improvements.

Results

All five implementation capability measures independently predicted practice leaders’ relative commitment to improving depression care in the following year. These included the following: quality improvement culture and attitudes (p = 0.003), depression culture and attitudes (p <0.001), prior depression quality improvement activities (p <0.001), advanced access and tracking capabilities (p = 0.03), and depression collaborative care features in place (p = 0.03). Higher relative commitment (p = 0.002) and prior depression quality improvement activities appeared to be associated with earlier participation in the DIAMOND initiative.

Conclusions

The study supports the concept of organizational readiness to improve quality of care and the use of practice leader surveys to assess it. Practice leaders’ relative commitment to depression care improvement may be a useful measure of the likelihood that a practice is ready to initiate evidence-based depression care changes. A comprehensive organizational assessment of implementation capability for depression care improvement may identify specific barriers or facilitators to readiness that require targeted attention from implementers.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0173-1) contains supplementary material, which is available to authorized users.

Veterans with depression in primary care: provider preferences, matching, and care satisfaction

Primary care is often the first point of care for individuals with depression. Depressed patients often have comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). Understanding variations in treatment preferences and care satisfaction in this population can improve care planning and outcomes. The design involved a cross-sectional comparison of veterans screening positive for depression. Veterans receiving primary care during the previous year were contacted (n = 10, 929) and were screened for depression using the PHQ-2/PHQ-9. Those with probable depression (n = 761) underwent a comprehensive assessment including screens for AUD and PTSD, treatment provider preferences, treatments received, and satisfaction with care. Treatment provider preferences differed based on specific mental health comorbidities, and satisfaction with care was associated with receipt of preferred care. Depressed veterans with comorbid PTSD were more likely to prefer care from more than one provider type (e.g., a psychiatrist and a primary care provider) and were more likely to receive treatment that matched their preferences than veterans without comorbid PTSD. Veterans receiving full or partial treatment matches affirmed satisfaction with care at higher rates, and veterans with comorbid PTSD were least satisfied when care did not match their preferences. Patient satisfaction with care is an increasingly important focus for health care systems. This study found significant variations in depressed patients' satisfaction with care in terms of treatment matching, particularly among those with comorbid PTSD. Delivery of care that matches patient treatment preferences is likely to improve depressed patient's satisfaction with the care provided. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Effective Implementation of collaborative care for depression: what is needed?

OBJECTIVES

To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative.

STUDY DESIGN

We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates.

METHODS

Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates.

RESULTS

Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54).

CONCLUSIONS

Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression.

A patient-centered primary care practice approach using evidence-based quality improvement: rationale, methods, and early assessment of implementation

BACKGROUND

Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread.

OBJECTIVE

To describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements.

DESIGN

Descriptive.

PARTICIPANTS

Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region.

INTERVENTION

EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites.

APPROACH

We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents.

RESULTS

Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread.

DISCUSSION

EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.

The anatomy of primary care and mental health clinician communication: a quality improvement case study

BACKGROUND

The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.

OBJECTIVE

To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.

DESIGN, PARTICIPANTS, AND APPROACH

An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.

KEY RESULTS

Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.

CONCLUSIONS

CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.

Challenges facing primary care practices aiming to implement patient-centered medical homes

BACKGROUND

While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.

OBJECTIVE

Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.

DESIGN AND PARTICIPANTS

A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).

MAIN MEASURES

PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.

KEY RESULTS

On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.

CONCLUSIONS

Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.

Predictors of primary care management of depression in the Veterans Affairs healthcare system

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.

Guidance for research-practice partnerships (R-PPs) and collaborative research

PURPOSE

The purpose of this paper is to provide evidence based guidance to researchers and practice personnel about forming and carrying out effective research partnerships.

DESIGN/METHODOLOGY/APPROACH

A review of the literature, interviews and discussions with colleagues in both research and practice roles, and a review of the authors' personal experiences as researchers in partnership research.

FINDINGS

Partnership research is, in some respects, a distinct "approach" to research, but there are many different versions. An analysis of research publications and of their research experience led the authors to develop a framework for planning and assessing the partnership research process, which includes defining expected outcomes for the partners, their roles, and steps in the research process.

PRACTICAL IMPLICATIONS

This review and analysis provides guidance that may reduce commonly-reported misunderstandings and help to plan more successful partnerships and projects. It also identifies future research which is needed to define more precisely the questions and purposes for which partnership research is most appropriate, and methods and designs for specific types of partnership research.

ORIGINALITY/VALUE

As more research moves towards increased participation of practitioners and patients in the research process, more precise and differentiated understanding of the different partnership approaches is required, and when each is most suitable. This article describes research approaches that have the potential to reduce "the research-practice gap". It gives evidence- and experience-based guidance for choosing and establishing a partnership research process, so as to improve partnership relationship-building and more actionable research.

Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months). Participants were asked about (1) openness to seeking help for emotional problems from spiritual counselors/clergy and (2) actual contact with spiritual counselors/clergy in the past 6 months. At baseline, almost half of the participants, 359 (47.2%), endorsed being "very" or "somewhat likely" to seek help for emotional problems from spiritual counselors; 498 (65.4%) were open to a primary care provider, 486 (63.9%) to a psychiatrist, and 409 (66.5%) to another type of mental health provider. Ninety-one participants (12%) reported actual spiritual counselor/clergy consultation. Ninety-five (10.3%) participants reported that their VA providers had recently asked them about spiritual support; the majority of these found this discussion helpful. Participants with current PTSD symptoms, and those with a mental health visit in the past 6 months, were more likely to report openness to and actual help-seeking from clergy. Veterans with depression and PTSD are amenable to receiving help from spiritual counselors/clergy and other providers. Integration of spiritual counselors/clergy into care teams may be helpful to Veterans with PTSD. Training of such providers to address PTSD specifically may also be desirable.

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations

BACKGROUND

As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

OBJECTIVE

We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

DESIGN

Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.

PARTICIPANTS

2,853,030 patients from 814 VHA primary care clinics

MAIN MEASURES

Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.

KEY RESULTS

The overall mean home builder score in the study clinics was 88 (SD = 13) or 69%. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3% (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).

CONCLUSION

Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.

An inventory of VHA emergency departments' resources and processes for caring for women

BACKGROUND

More women are using Veterans' Health Administration (VHA) Emergency Departments (EDs), yet VHA ED capacities to meet the needs of women are unknown.

OBJECTIVE

We assessed VHA ED resources and processes for conditions specific to, or more common in, women Veterans.

DESIGN/SUBJECTS

Cross-sectional questionnaire of the census of VHA ED directors

MAIN MEASURES

Resources and processes in place for gynecologic, obstetric, sexual assault and mental health care, as well as patient privacy features, stratified by ED characteristics.

KEY RESULTS

All 120 VHA EDs completed the questionnaire. Approximately nine out of ten EDs reported having gynecologic examination tables within their EDs, 24/7 access to specula, and Gonorrhea/Chlamydia DNA probes. All EDs reported 24/7 access to pregnancy testing. Fewer than two-fifths of EDs reported having radiologist review of pelvic ultrasound images available 24/7; one-third reported having emergent consultations from gynecologists available 24/7. Written transfer policies specific to gynecologic and obstetric emergencies were reported as available in fewer than half of EDs. Most EDs reported having emergency contraception 24/7; however, only approximately half reported having Rho(D) Immunoglobulin available 24/7. Templated triage notes and standing orders relevant to gynecologic conditions were reported as uncommon. Consistent with VHA policy, most EDs reported obtaining care for victims of sexual assault by transferring them to another institution. Most EDs reported having some access to private medical and mental health rooms. Resources and processes were found to be more available in EDs with more encounters by women, more ED staffed beds, and that were located in more complex facilities in metropolitan areas.

CONCLUSIONS

Although most VHA EDs have resources and processes needed for delivering emergency care to women Veterans, some gaps exist. Studies in non-VA EDs are required for comparison. Creative solutions are needed to ensure that women presenting to VHA EDs receive efficient, timely, and consistently high-quality care.

Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care

OBJECTIVE Family involvement and social support are associated with recovery from mental disorders. This project explored how family involvement in health care and social support among depressed veterans in primary care related to medication adherence and depression outcomes. METHODS During a longitudinal telephone survey, 761 Veterans Affairs (VA) primary care patients (mean age=60 years) with probable major depression were asked about depression symptoms, self-reported health, medication adherence, social support, family involvement with care, and satisfaction with clinicians' efforts to involve the patients' families in their care. Follow-up interviews at seven and 18 months assessed depression severity and medication adherence. RESULTS Most participants lived with others (71%) and reported moderately high social support. Most participants (62%) reported being very likely to discuss treatment of a major medical condition with family, but 64% reported that VA providers had not involved the participants' family in their care within the prior six months. In multivariate regression analyses, lower depression severity and better medication adherence over time were significantly linked to higher satisfaction with limited efforts by clinicians to involve families in care. Neither social support nor the extent of family involvement by itself was associated with outcomes. CONCLUSIONS The results suggested a link between patient satisfaction with family involvement by clinicians and clinical outcomes among depressed veterans. In addition, clinician responsiveness to patient wishes may be more important than the amount of family involvement per se. Further research is needed to clarify when and how clinicians should involve a patient's family in depression treatment in primary care.

Impact of the Northridge Earthquake on the Mental Health of Veterans: Results From a Panel Study

Objective: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center.

Methods: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact.

Results: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status.

Conclusions: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non–Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.

(Disaster Med Public Health Preparedness. 2011;5:S220-S226)

Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA Health Care System

BACKGROUND

Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice's choices regarding model adoption.

OBJECTIVE

We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.

DESIGN

1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.

MAIN MEASURES

We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.

KEY RESULTS

Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.

CONCLUSIONS

Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.

Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans

Alcohol problems may impede adaptive, proactive responses to disaster-related injury and loss, thus prolonging the adverse impact of disasters on mental health. Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders. This is the first study to estimate the impact of predisaster alcohol problems on postdisaster depressed mood among veterans, using data that were collected before and after the 1994 Northridge, CA, earthquake. The authors assessed the impact of alcohol problems on postdisaster depressed mood in an existing clinical cohort of veterans who experienced the 6.7-magnitude earthquake that struck Northridge in January 1994. One to 3 months after the disaster, interviewers contacted participants by telephone to administer a follow-up questionnaire based on a survey that had been done preearthquake. Postearthquake data were obtained on 1,144 male veterans for whom there were preearthquake data. We tested a predictive path model of the relationships between latent variables for predisaster alcohol problems, functional limitations, and depressed mood on latent variables representing postdisaster "quake impact" and depressive mood. Results showed that veterans who had more alcohol problems before the earthquake experienced more earthquake-related harms and severely depressed mood after the earthquake, compared with those who had fewer alcohol problems. Programs serving veterans with a high prevalence of alcohol problems should consider designing disaster response protocols to locate and assist these patients in the aftermath of disasters.

Relationships between mood and employment over time among depressed VA primary care patients

OBJECTIVE

Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages.

METHODS

We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models.

RESULTS

Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame.

CONCLUSIONS

Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Implementation and spread of interventions into the multilevel context of routine practice and policy: implications for the cancer care continuum

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Developing effective collaboration between primary care and mental health providers

OBJECTIVE

Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices.

METHOD

Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures.

RESULTS

The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation.

CONCLUSION

By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Suicide risk management: development and analysis of a telephone-based approach to patient safety

Research-based queries about patients' experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers' protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.

Identifying quality improvement intervention publications--a comparison of electronic search strategies

BACKGROUND

The evidence base for quality improvement (QI) interventions is expanding rapidly. The diversity of the initiatives and the inconsistency in labeling these as QI interventions makes it challenging for researchers, policymakers, and QI practitioners to access the literature systematically and to identify relevant publications.

METHODS

We evaluated search strategies developed for MEDLINE (Ovid) and PubMed based on free text words, Medical subject headings (MeSH), QI intervention components, continuous quality improvement (CQI) methods, and combinations of the strategies. Three sets of pertinent QI intervention publications were used for validation. Two independent expert reviewers screened publications for relevance. We compared the yield, recall rate, and precision of the search strategies for the identification of QI publications and for a subset of empirical studies on effects of QI interventions.

RESULTS

The search yields ranged from 2,221 to 216,167 publications. Mean recall rates for reference publications ranged from 5% to 53% for strategies with yields of 50,000 publications or fewer. The 'best case' strategy, a simple text word search with high face validity ('quality' AND 'improv*' AND 'intervention*') identified 44%, 24%, and 62% of influential intervention articles selected by Agency for Healthcare Research and Quality (AHRQ) experts, a set of exemplar articles provided by members of the Standards for Quality Improvement Reporting Excellence (SQUIRE) group, and a sample from the Cochrane Effective Practice and Organization of Care Group (EPOC) register of studies, respectively. We applied the search strategy to a PubMed search for articles published in 10 pertinent journals in a three-year period which retrieved 183 publications. Among these, 67% were deemed relevant to QI by at least one of two independent raters. Forty percent were classified as empirical studies reporting on a QI intervention.

CONCLUSIONS

The presented search terms and operating characteristics can be used to guide the identification of QI intervention publications. Even with extensive iterative development, we achieved only moderate recall rates of reference publications. Consensus development on QI reporting and initiatives to develop QI-relevant MeSH terms are urgently needed.

Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions

BACKGROUND

A systematic review of the literature on nurse-focused interventions conducted in the hospital setting informs the evidence base for implementation of pressure ulcer (PU) prevention programs. Despite the availability of published guidelines, there is little evidence about which interventions can be successfully integrated into routine care through quality improvement (QI). The two previous literature syntheses on PU prevention have included articles from multiple settings but have not focused specifically on QI.

METHODS

A search of six electronic databases for publications from January 1990 to September 2009 was conducted. Trial registries and bibliographies of retrieved studies and reviews, and Internet sites of funding agencies were also searched. Using standardized forms, two independent reviewers screened publications for eligibility into the sample; data were abstracted and study quality was assessed for those that passed screening.

FINDINGS

Thirty-nine studies met the inclusion criteria. Most of them used a before-and-after study design in a single site. Intervention strategies included PU-specific changes in combination with educational and/or QI strategies. Most studies reported patient outcome measures, while fewer reported nursing process of care measures. For nearly all the studies, the authors concluded that the intervention had a positive effect. The pooled risk difference for developing PUs was -.07 (95% confidence interval [CI]: -0.0976, -0.0418) comparing the pre- and postintervention status.

CONCLUSION

Future research can build the evidence base for implementation through an increased emphasis on understanding the mechanisms by which improved outcomes are achieved and describing the conditions under which specific intervention strategies are likely to succeed or fail.

Identifying continuous quality improvement publications: what makes an improvement intervention 'CQI'?

Background

The term continuous quality improvement (CQI) is often used to refer to a method for improving care, but no consensus statement exists on the definition of CQI. Evidence reviews are critical for advancing science, and depend on reliable definitions for article selection.

Methods

As a preliminary step towards improving CQI evidence reviews, this study aimed to use expert panel methods to identify key CQI definitional features and develop and test a screening instrument for reliably identifying articles with the key features. We used a previously published method to identify 106 articles meeting the general definition of a quality improvement intervention (QII) from 9427 electronically identified articles from PubMed. Two raters then applied a six-item CQI screen to the 106 articles.

Results

Per cent agreement ranged from 55.7% to 75.5% for the six items, and reviewer-adjusted intra-class correlation ranged from 0.43 to 0.62. ‘Feedback of systematically collected data’ was the most common feature (64%), followed by being at least ‘somewhat’ adapted to local conditions (61%), feedback at meetings involving participant leaders (46%), using an iterative development process (40%), being at least ‘somewhat’ data driven (34%), and using a recognised change method (28%). All six features were present in 14.2% of QII articles.

Conclusions

We conclude that CQI features can be extracted from QII articles with reasonable reliability, but only a small proportion of QII articles include all features. Further consensus development is needed to support meaningful use of the term CQI for scientific communication.

What context features might be important determinants of the effectiveness of patient safety practice interventions?

BACKGROUND

Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter.

METHODS

Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations.

RESULTS

The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description.

CONCLUSION

This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.

A framework for classifying patient safety practices: results from an expert consensus process

OBJECTIVE

Development of a coherent literature evaluating patient safety practices has been hampered by the lack of an underlying conceptual framework. The authors describe issues and choices in describing and classifying diverse patient safety practices (PSPs).

METHODS

The authors developed a framework to classify PSPs by identifying and synthesising existing conceptual frameworks, evaluating the draft framework by asking a group of experts to use it to classify a diverse set of PSPs and revising the framework through an expert-panel consensus process.

RESULTS

The 11 classification dimensions in the framework include: regulatory versus voluntary; setting; feasibility; individual activity versus organisational change; temporal (one-time vs repeated/long-term); pervasive versus targeted; common versus rare events; PSP maturity; degree of controversy/conflicting evidence; degree of behavioural change required for implementation; and sensitivity to context.

CONCLUSION

This framework offers a way to classify and compare PSPs, and thereby to interpret the patient-safety literature. Further research is needed to develop understanding of these dimensions, how they evolve as the patient safety field matures, and their relative utilities in describing, evaluating and implementing PSPs.

Advancing the science of patient safety

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

The role of theory in research to develop and evaluate the implementation of patient safety practices

Theories provide a way of understanding and predicting the effects of patient safety practices (PSPs), interventions intended to prevent or mitigate harm caused by healthcare or risks of such harm. Yet most published evaluations make little or no explicit reference to theory, thereby hindering efforts to generalise findings from one context to another. Theories from a wide range of disciplines are potentially relevant to research on PSPs. Theory can be used in research to explain clinical and organisational behaviour, to guide the development and selection of PSPs, and in evaluating their implementation and mechanisms of action. One key recommendation from an expert consensus process is that researchers should describe the theoretical basis for chosen intervention components or provide an explicit logic model for 'why this PSP should work.' Future theory-driven evaluations would enhance generalisability and help build a cumulative understanding of the nature of change.

Nursing staff, patient, and environmental factors associated with accurate pain assessment

CONTEXT

Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.

OBJECTIVES

This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.

METHODS

This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).

RESULTS

Pain underestimation (N-NRS<S-NRS) occurred in 25% and overestimation (N-NRS>S-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken.

CONCLUSION

Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

Identifying quality improvement intervention evaluations: is consensus achievable?

BACKGROUND

The diversity of quality improvement interventions (QIIs) has impeded the use of evidence review to advance quality improvement activities. An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practices.

AIM

To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness, impact or success.

DESIGN

Literature search with measurement of multilevel inter-rater agreement and review of disagreement.

METHODS

Ten journals (2005-2007) were searched electronically and the output was screened based on title and abstract. Three pairs of reviewers then independently rated 22 articles, randomly selected from the screened list. Kappa statistics and percentage agreement were assessed. 12 stakeholders in quality improvement, including QII experts and journal editors, rated and discussed publications about which reviewers disagreed.

RESULTS

The level of agreement among reviewers for identifying empirical evaluations of QII development, implementation or results was 73% (with a paradoxically low kappa of 0.041). Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues: no data on patient health, provider behaviour or process of care outcomes; no evidence for adaptation of an intervention to a local context; and a design using only observational methods, as correlational analyses, with no comparison group.

CONCLUSION

The level of reviewer agreement was only moderate. Reliable identification of relevant articles is an initial step in assessing published evidence. Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice

OBJECTIVE

Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices.

INTERVENTION

Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods.

EVALUATION

We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes.

RESULTS

Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support.

CONCLUSIONS

TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Wishing upon a STAR*D: the promise of ideal depression care by primary care providers

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial found that after initial treatment, depressed patients treated in primary care settings had the same or slightly better outcomes than those treated in specialty care settings. The authors describe challenges to using the STAR*D approach and protocols in usual primary care settings. These include inadequate availability of appointments, insufficient resources for care management and treatment monitoring, and lack of payment to primary care providers for providing mental health care. Substantial reengineering of payment and delivery systems is needed in order for the STAR*D approach to be viable in primary care clinics.

A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model

Abstract

Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models.

TIDES social marketing approach

The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan.

Results

Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy.

Discussion and conclusion

Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.

Early identification of co-occurring pain, depression and anxiety

BACKGROUND

Depression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment.

OBJECTIVE

To determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress.

DESIGN

Cross-sectional interview of primary care patients and their providers participating in a Veteran's Administration HELP-Vets study.

SUBJECTS

A total of 528 predominately male Veterans

MEASUREMENTS AND MAIN RESULTS

We measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress.

CONCLUSIONS

VA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

Finding order in heterogeneity: types of quality-improvement intervention publications

BACKGROUND

Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications.

METHODS

A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs.

RESULTS

By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

Organizational cost of quality improvement for depression care

OBJECTIVE

We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA.

DATA SOURCES AND STUDY SETTING

Project records and surveys from three multistate VA administrative regions and seven of their primary care practices.

STUDY DESIGN

Descriptive analysis.

DATA COLLECTION

We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan-Do-Study-Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities.

PRINCIPLE FINDINGS

Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design.

CONCLUSIONS

Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.

Clinic-level process of care for depression in primary care settings

Multi-component models for improving depression care target primary care (PC) clinics, yet few studies document usual clinic-level care. This case comparison assessed usual processes for depression management at 10 PC clinics. Although general similarities existed across sites, clinics varied on specific processes, barriers, and adherence to practice guidelines. Screening for depression conformed to guidelines. Processes for assessment, diagnosis, treatment, and follow-up varied to different degrees in different clinics. This individuality of usual care should be defined prior to quality improvement interventions, and may provide insights for introducing or tailoring changes, as well as improving interpretation of evaluation results.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice

OBJECTIVE

To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.

DATA SOURCES/STUDY SETTING

We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.

STUDY DESIGN

In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.

DATA COLLECTION

To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.

PRINCIPAL FINDINGS

Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.

CONCLUSIONS

EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Variations in practice guideline adherence for abnormal cervical cytology in a county healthcare system

BACKGROUND

Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology.

OBJECTIVES

The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up.

SUBJECTS

Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571).

MEASUREMENTS

Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up.

RESULTS

Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17-1.42), older patients (OR, 1.03, 95% CI, 1.02-1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01-1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p < .0001) and larger facility size (p = .002). Regional variations in care demonstrated the largest cluster having the lowest lost to follow-up rate and the most optimal care.

CONCLUSIONS

A significant number of women with abnormal cervical cytology are receiving less than optimal care. Further studies are required to determine the specific healthcare delivery practices that need to be targeted to improve guideline adherence for follow-up of abnormal cytology.

Human subjects protection issues in QUERI implementation research: QUERI Series

BACKGROUND

Human Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.

METHODS

In 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.

RESULTS

There are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.

DISCUSSION

Specific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.

Effect of mental health care and shared decision making on patient satisfaction in a community sample of patients with depression

This study sought to understand if shared decision making and/or receipt of mental health care was associated with patient satisfaction for patients with depression and to determine whether gender modified this relationship. The data are from the Quality Improvement for Depression study, a national collaborative study of 1,481 patients diagnosed with major depression in managed care settings. The cross-sectional analyses were performed using multiple logistic regression on a sample of 1,317 patients who answered both the baseline and month six questionnaires. Shared decision making and receipt of mental health care were both positively associated with patient satisfaction. Gender was not a moderator of this relationship. Health plans may be able to improve patient satisfaction levels by teaching physicians the importance of shared decision making. Contrary to expectations, patient gender made no difference in the effects of quality of care on patient satisfaction.

Time allocation and caseload capacity in telephone depression care management

OBJECTIVE

To document time allocated to care management activities and care manager workload capacity using data collected for studies of telephone care management of depression.

STUDY DESIGN

Cross-sectional, descriptive analysis of depression care manager (DCM) activities and workload in 2 collaborative depression care interventions (1 implementation study and 1 effectiveness study) at Department of Veterans Affairs primary care facilities.

METHODS

Each intervention tracked specific care management activities for 4 weeks, recording the number of events for each activity type and length of time for each activity. Patient workload data were obtained from the patient tracking systems for the 2 projects. We calculated the average time for each activity type, the average total time required to complete an initial assessment call and follow-up call, and the maximum patient panel for both projects.

RESULTS

The total time per successful initial assessment was 75 to 95 minutes, and the total time per successful follow-up call was 51 to 60 minutes, with more time spent on ancillary activities (precall preparation, postcall documentation, and provider communication) than on direct patient contact. A significant amount of time was spent in unsuccessful call attempts, requiring 9 to 11 minutes for each attempt. The maximum panel size per care manager per quarter was in the range of 143 to 165 patients.

CONCLUSIONS

The study found similar DCM time allocations and panel sizes across 2 studies and 3 regions with full-time DCMs. Reductions in DCM time spent on ancillary activities may be achievable through improved informatics and other support for panel management.

The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation

OBJECTIVES

Suffering from waning demand, poor quality, and reform efforts enabling veterans to "vote with their feet" and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA's transformation.

METHODS

We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery.

RESULTS

Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times.

CONCLUSIONS

Although VA's quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains.