A conceptual model for using action inquiry technologies to address disparities in depression

Practice-level quality improvement interventions in primary care: a review of systematic reviews

AIM

To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews.

BACKGROUND

Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care--the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting.

METHODS

DESIGN

A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions.

SCOPE

Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions.

OUTCOME MEASURES

A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions.

FINDINGS

Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions.

CONCLUSION

Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.

Theory in practice: helping providers address depression in diabetes care

INTRODUCTION

A continuing education (CE) program based on the theory of planned behavior was designed to understand and improve health care providers' practice patterns in screening, assessing, and treating and/or referring patients with diabetes for depression treatment.

METHODS

Participants completed assessments of attitudes, confidence, intentions, and behaviors regarding depression management at 3 time points: immediately prior to the CE program (baseline), immediately after the CE program (posttest) and 6 weeks after the CE program (follow-up).

RESULTS

Ninety-eight providers attended the CE program: 71 completed the baseline assessment, 66 completed the posttest assessment, and 37 completed the 6-week follow-up. Compared to baseline, at posttest providers reported significantly more favorable attitudes, fewer negative attitudes, greater confidence, and greater intention to address depression with their diabetes patients. At the 6-week follow-up, participants reported a marginally significant increase in educating patients about depression, but no other depression management practices changed. Intention to change and confidence predicted some depression practice patterns at follow-up. Fewer barriers were a consistent predictor of depression practice patterns at follow-up.

DISCUSSION

In the short term, provider attitudes, confidence, and intentions to address depression with their patients improved. Intentions, confidence, and especially barriers are important intervention targets.