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Antle BF, Owen JJ, Eells TD, Wells MJ, Harris LM, Cappiccie A, Wright B, Williams SM, Wright JH. Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care. Contemp Clin Trials 2019; 78:46-52. [PMID: 30572162 DOI: 10.1016/j.cct.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/30/2018] [Accepted: 11/02/2018] [Indexed: 01/17/2023]
Abstract
Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care - a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients - a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care.
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Affiliation(s)
- Becky F Antle
- Kent School of Social Work, University of Louisville, United States.
| | - Jesse J Owen
- Department of Counseling Psychology, Denver University, United States
| | - Tracy D Eells
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, United States
| | - Michael J Wells
- Department of Social Work, Western Kentucky University, United States
| | - Lesley M Harris
- Kent School of Social Work, University of Louisville, United States
| | - Amy Cappiccie
- Department of Social Work, Western Kentucky University, United States
| | - Brent Wright
- Department of Counseling Psychology, Denver University, United States
| | - Sara M Williams
- Kent School of Social Work, University of Louisville, United States
| | - Jesse H Wright
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, United States
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Miake-Lye IM, Chuang E, Rodriguez HP, Kominski GF, Yano EM, Shortell SM. Random or predictable?: Adoption patterns of chronic care management practices in physician organizations. Implement Sci 2017; 12:106. [PMID: 28836996 PMCID: PMC5571615 DOI: 10.1186/s13012-017-0639-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/16/2017] [Indexed: 11/21/2022] Open
Abstract
Background Theories, models, and frameworks used by implementation science, including Diffusion of Innovations, tend to focus on the adoption of one innovation, when often organizations may be facing multiple simultaneous adoption decisions. For instance, despite evidence that care management practices (CMPs) are helpful in managing chronic illness, there is still uneven adoption by physician organizations. This exploratory paper leverages this natural variation in uptake to describe inter-organizational patterns in adoption of CMPs and to better understand how adoption choices may be related to one another. Methods We assessed a cross section of national survey data from physician organizations reporting on the use of 20 CMPs (5 each for asthma, congestive heart failure, depression, and diabetes). Item response theory was used to explore patterns in adoption, first considering all 20 CMPs together and then by subsets according to disease focus or CMP type (e.g., registries, patient reminders). Mokken scale analysis explored whether adoption choices were linked by disease focus or CMP type and whether a consistent ordering of adoption choices was present. Results The Mokken scale for all 20 CMPs demonstrated medium scalability (H = 0.43), but no consistent ordering. Scales for subsets of CMPs sharing a disease focus had medium scalability (0.4 < H < 0.5), while subsets sharing a CMP type had strong scalability (H > 0.5). Scales for CMP type consistently ranked diabetes CMPs as most adoptable and depression CMPs as least adoptable. Within disease focus scales, patient reminders were ranked as the most adoptable CMP, while clinician feedback and patient education were ranked the least adoptable. Conclusions Patterns of adoption indicate that innovation characteristics may influence adoption. CMP dissemination efforts may be strengthened by encouraging traditionally non-adopting organizations to focus on more adoptable practices first and then describing a pathway for the adoption of subsequent CMPs. Clarifying why certain CMPs are “less adoptable” may also provide insights into how to overcome CMP adoption constraints. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0639-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isomi M Miake-Lye
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA. .,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA.
| | - Emmeline Chuang
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Hector P Rodriguez
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Elizabeth M Yano
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA.,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA
| | - Stephen M Shortell
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
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Di Capua P, Wu B, Sednew R, Ryan G, Wu S. Complexity in Redesigning Depression Care: Comparing Intention Versus Implementation of an Automated Depression Screening and Monitoring Program. Popul Health Manag 2016; 19:349-56. [PMID: 27028043 DOI: 10.1089/pop.2015.0084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Health care technology promises to improve quality and decrease costs while improving the patient experience. A recent trial tested a novel health technology that sought to reduce barriers to guideline-recommended depression care by coupling automated telephonic patient assessment with provider notification and decision support. This study compares the intended effects and the end users' experience with using this technology. Responses to semi-structured interviews with the leadership and design team (the intention group) were compared with responses from health professionals in clinics using the technology (the implementation group). Qualitative methods were applied to compare perspectives on the role of technology in care delivery and on the technology's impact on barriers to providing guideline-recommended care. Four members of the intention group and 17 members of the implementation group were interviewed. The 2 groups had similar notions of technology's role in care delivery. The technology increased provider awareness, empowered midlevel providers, and facilitated collaboration among care team members. However, the implementation group identified gaps in care processes and in the informatics system that the technology did not address, and for which providers remained responsible. The 2 groups had comparable perspectives on the value and limits of technology in improving adherence to guideline-recommended care. However, the intention group did not discuss many of the shortcomings identified by the implementation group. Also, the interviews suggest that although some barriers persisted and a few new ones arose, the technology succeeded in reducing barriers to guideline-recommended care.
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Affiliation(s)
- Paul Di Capua
- 1 Baptist Health Medical Group , Coral Gables, Florida.,2 Department of Family Medicine, Herbert Wertheim College of Medicine at Florida International University , Miami, Florida.,3 Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Brian Wu
- 4 Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Renee Sednew
- 5 UCLA Fielding School of Public Health , Los Angeles, California
| | - Gery Ryan
- 6 Pardee RAND Graduate School, RAND Corporation , Santa Monica, California
| | - Shinyi Wu
- 7 School of Social Work and Epstein Department of Industrial and Systems Engineering, University of Southern California , RAND Corporation, Los Angeles, California
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Ramirez M, Wu S, Jin H, Ell K, Gross-Schulman S, Myerchin Sklaroff L, Guterman J. Automated Remote Monitoring of Depression: Acceptance Among Low-Income Patients in Diabetes Disease Management. JMIR Ment Health 2016; 3:e6. [PMID: 26810139 PMCID: PMC4736285 DOI: 10.2196/mental.4823] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 09/11/2015] [Accepted: 09/22/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Remote patient monitoring is increasingly integrated into health care delivery to expand access and increase effectiveness. Automation can add efficiency to remote monitoring, but patient acceptance of automated tools is critical for success. From 2010 to 2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)-a quasi-experimental comparative effectiveness research trial aimed at accelerating the adoption of collaborative depression care in a safety-net health care system-tested a fully automated telephonic assessment (ATA) depression monitoring system serving low-income patients with diabetes. OBJECTIVE The aim of this study was to determine patient acceptance of ATA calls over time, and to identify factors predicting long-term patient acceptance of ATA calls. METHODS We conducted two analyses using data from the DCAT technology-facilitated care arm, in which for 12 months the ATA system periodically assessed depression symptoms, monitored treatment adherence, prompted self-care behaviors, and inquired about patients' needs for provider contact. Patients received assessments at 6, 12, and 18 months using Likert-scale measures of willingness to use ATA calls, preferred mode of reach, perceived ease of use, usefulness, nonintrusiveness, privacy/security, and long-term usefulness. For the first analysis (patient acceptance over time), we computed descriptive statistics of these measures. In the second analysis (predictive factors), we collapsed patients into two groups: those reporting "high" versus "low" willingness to use ATA calls. To compare them, we used independent t tests for continuous variables and Pearson chi-square tests for categorical variables. Next, we jointly entered independent factors found to be significantly associated with 18-month willingness to use ATA calls at the univariate level into a logistic regression model with backward selection to identify predictive factors. We performed a final logistic regression model with the identified significant predictive factors and reported the odds ratio estimates and 95% confidence intervals. RESULTS At 6 and 12 months, respectively, 89.6% (69/77) and 63.7% (49/77) of patients "agreed" or "strongly agreed" that they would be willing to use ATA calls in the future. At 18 months, 51.0% (64/125) of patients perceived ATA calls as useful and 59.7% (46/77) were willing to use the technology. Moreover, in the first 6 months, most patients reported that ATA calls felt private/secure (75.9%, 82/108) and were easy to use (86.2%, 94/109), useful (65.1%, 71/109), and nonintrusive (87.2%, 95/109). Perceived usefulness, however, decreased to 54.1% (59/109) in the second 6 months of the trial. Factors predicting willingness to use ATA calls at the 18-month follow-up were perceived privacy/security and long-term perceived usefulness of ATA calls. No patient characteristics were significant predictors of long-term acceptance. CONCLUSIONS In the short term, patients are generally accepting of ATA calls for depression monitoring, with ATA call design and the care management intervention being primary factors influencing patient acceptance. Acceptance over the long term requires that the system be perceived as private/secure, and that it be constantly useful for patients' needs of awareness of feelings, self-care reminders, and connectivity with health care providers. TRIAL REGISTRATION ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 (Archived by WebCite at http://www.webcitation.org/6e7NGku56).
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Affiliation(s)
- Magaly Ramirez
- Daniel J Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, CA, United States
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Bao Y, Eggman AA, Richardson JE, Sheeran TF, Bruce ML. Practices of Depression Care in Home Health Care: Home Health Clinician Perspectives. Psychiatr Serv 2015; 66:1365-8. [PMID: 26423098 PMCID: PMC4666762 DOI: 10.1176/appi.ps.201400481] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study assessed gaps between published best practices and real-world practices of treating depression in home health care (HHC) and barriers to closing gaps. METHODS The qualitative study used semistructured interviews with nurses and administrators (N=20) from five HHC agencies in five states. Audio-recorded interviews were transcribed and analyzed by a multidisciplinary team using grounded theory method to identify themes. RESULTS Routine HHC nursing overlapped with all functional areas of depression care. However, gaps were noted between best and real-world practices. Gaps were associated with perceived scope of practice by HHC nurses, knowledge gaps and low self-efficacy in depression treatment, stigma attached to depression, poor quality of antidepressant management in primary care, and poor communication between HHC and primary care clinicians. CONCLUSIONS Strategies to close gaps between typical and best practices include enhancing HHC clinicians' knowledge and self-efficacy with depression treatment and improving the quality of antidepressant management and communication with primary care.
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Affiliation(s)
- Yuhua Bao
- Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bao and Dr. Bruce are with the Department of Psychiatry, all at Weill Cornell Medical College, New York City and White Plains, New York (e-mail: ). Dr. Sheeran is with the Department of Psychiatry and Human Behavior, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ashley A Eggman
- Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bao and Dr. Bruce are with the Department of Psychiatry, all at Weill Cornell Medical College, New York City and White Plains, New York (e-mail: ). Dr. Sheeran is with the Department of Psychiatry and Human Behavior, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Joshua E Richardson
- Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bao and Dr. Bruce are with the Department of Psychiatry, all at Weill Cornell Medical College, New York City and White Plains, New York (e-mail: ). Dr. Sheeran is with the Department of Psychiatry and Human Behavior, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Thomas F Sheeran
- Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bao and Dr. Bruce are with the Department of Psychiatry, all at Weill Cornell Medical College, New York City and White Plains, New York (e-mail: ). Dr. Sheeran is with the Department of Psychiatry and Human Behavior, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Martha L Bruce
- Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bao and Dr. Bruce are with the Department of Psychiatry, all at Weill Cornell Medical College, New York City and White Plains, New York (e-mail: ). Dr. Sheeran is with the Department of Psychiatry and Human Behavior, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Bao Y, Shao H, Bruce ML, Press MJ. Antidepressant Medication Management Among Older Patients Receiving Home Health Care. Am J Geriatr Psychiatry 2015; 23:999-1006. [PMID: 25158915 PMCID: PMC4291306 DOI: 10.1016/j.jagp.2014.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 07/03/2014] [Accepted: 07/09/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay. METHODS Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients aged 65 years or older who received HHC in 2006-2007 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (versus discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy. RESULTS About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10- to 20-percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change. CONCLUSIONS Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions.
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Affiliation(s)
- Yuhua Bao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY.
| | - Huibo Shao
- Department of Healthcare Policy and Research, Weill Cornell Medical College,Baptist Memorial Health Care Corporation, Department of Quality
| | | | - Matthew J. Press
- Department of Healthcare Policy and Research, Weill Cornell Medical College,Department of Medicine, Weill Cornell Medical College
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Chang ET, Wells KB, Young AS, Stockdale S, Johnson MD, Fickel JJ, Jou K, Rubenstein LV. The anatomy of primary care and mental health clinician communication: a quality improvement case study. J Gen Intern Med 2014; 29 Suppl 2:S598-606. [PMID: 24715400 PMCID: PMC4070235 DOI: 10.1007/s11606-013-2731-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Evelyn T Chang
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA,
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Chang ET, Magnabosco JL, Chaney E, Lanto A, Simon B, Yano EM, Rubenstein LV. Predictors of primary care management of depression in the Veterans Affairs healthcare system. J Gen Intern Med 2014; 29:1017-25. [PMID: 24567200 PMCID: PMC4061347 DOI: 10.1007/s11606-014-2807-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 12/17/2013] [Accepted: 01/29/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Evelyn T Chang
- Department of General Internal Medicine, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA,
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Menear M, Duhoux A, Roberge P, Fournier L. Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions. Gen Hosp Psychiatry 2014; 36:302-9. [PMID: 24629824 DOI: 10.1016/j.genhosppsych.2014.01.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/26/2014] [Accepted: 01/28/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions. METHOD Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions. RESULTS Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46). CONCLUSIONS Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.
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Affiliation(s)
- Matthew Menear
- Department of Social and Preventive Medicine, University of Montreal; Research Centre of the Centre hospitalier de l'Université de Montréal
| | | | - Pasquale Roberge
- Department of Family Medicine and Emergency Medicine, Sherbrooke University
| | - Louise Fournier
- Department of Social and Preventive Medicine, University of Montreal; Research Centre of the Centre hospitalier de l'Université de Montréal.
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Dadich A, Hosseinzadeh H. Healthcare reform: implications for knowledge translation in primary care. BMC Health Serv Res 2013; 13:490. [PMID: 24274773 PMCID: PMC3893505 DOI: 10.1186/1472-6963-13-490] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 10/31/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The primary care sector represents the linchpin of many health systems. However, the translation of evidence-based practices into patient care can be difficult, particularly during healthcare reform. This can have significant implications for patients, their communities, and the public purse. This is aptly demonstrated in the area of sexual health. The aim of this paper is to determine what works to facilitate evidence-based sexual healthcare within the primary care sector. METHODS 431 clinicians (214 general practitioners and 217 practice nurses) in New South Wales, Australia, were surveyed about their awareness, their use, the perceived impact, and the factors that hindered the use of six resources to promote sexual healthcare. Descriptive statistics were calculated from the responses to the closed survey items, while responses to open-ended item were thematically analyzed. RESULTS All six resources were reported to improve the delivery of evidence-based sexual healthcare. Two resources - both double-sided A4-placards - had the greatest reach and use. Barriers that hindered resource-use included limited time, limited perceived need, and limited access to, or familiarity with the resources. Furthermore, the reorganization of the primary care sector and the removal of particular medical benefits scheme items may have hampered clinician capacity to translate evidence-based practices into patient care. CONCLUSIONS Findings reveal: (1) the translation of evidence-based practices into patient care is viable despite reform; (2) the potential value of a multi-modal approach; (3) the dissemination of relatively inexpensive resources might influence clinical practices; and (4) reforms to governance and/or funding arrangements may widen the void between evidence-based practices and patient care.
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Affiliation(s)
- Ann Dadich
- School of Business, University of Western Sydney, Locked Bag 1797, Parramatta, NSW, Australia 2751
| | - Hassan Hosseinzadeh
- School of Business, University of Western Sydney, Locked Bag 1797, Parramatta, NSW, Australia 2751
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11
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Duhoux A, Fournier L, Gauvin L, Roberge P. What is the association between quality of treatment for depression and patient outcomes? A cohort study of adults consulting in primary care. J Affect Disord 2013; 151:265-74. [PMID: 23876194 DOI: 10.1016/j.jad.2013.05.097] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The main objective of this study was to examine the association between receiving at least one minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6- and 12-months. Associations with receiving pharmacotherapy and/or psychotherapy and the role of severity of depression were examined. METHODS This cohort study included 908 adults meeting criteria for previous-year MDE and consulting at one of 65 primary care clinics in Quebec, Canada. Multilevel analyses were performed. RESULTS Results show that (i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; (ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and (iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. LIMITATIONS Measures are self-reported. Participants were recruited at different stages over the course of their MDE. CONCLUSIONS This study shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions, but that those with more severe depressive symptoms are more likely to receive adequate treatment and improve across time.
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Affiliation(s)
- A Duhoux
- CRCHUM (Centre de recherche du Centre Hospitalier de l'Université de Montréal), Edouard-Asselin Pavilion, 264 René-Lévesque Blvd. East, Montreal, QC, Canada.
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Whitebird RR, Solberg LI, Margolis KL, Asche SE, Trangle MA, Wineman AP. Barriers to improving primary care of depression: perspectives of medical group leaders. QUALITATIVE HEALTH RESEARCH 2013; 23:805-814. [PMID: 23515301 DOI: 10.1177/1049732313482399] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.
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Affiliation(s)
- Robin R Whitebird
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota 55440-1524, USA.
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Chang ET, Rose DE, Yano EM, Wells KB, Metzger ME, Post EP, Lee ML, Rubenstein LV. Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA Health Care System. J Gen Intern Med 2013; 28:353-62. [PMID: 23054917 PMCID: PMC3579970 DOI: 10.1007/s11606-012-2217-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 07/26/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Evelyn T Chang
- VA Greater Los Angeles, General Internal Medicine, Los Angeles, CA, USA.
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Duhoux A, Fournier L, Gauvin L, Roberge P. Quality of care for major depression and its determinants: a multilevel analysis. BMC Psychiatry 2012; 12:142. [PMID: 22985262 PMCID: PMC3544698 DOI: 10.1186/1471-244x-12-142] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 08/09/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Numerous studies highlight an important gap in the quality of care for depression in primary care. However, basic indicators were often used. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The purpose of this study was to estimate the proportion of primary care patients with a major depressive episode (MDE) who receive adequate treatment and to examine the individual and organizational (i.e., clinic-level) characteristics associated with the receipt of at least one minimally adequate treatment for depression. METHODS The sample used for this study included 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for MDE during the 12 months preceding the survey (T1), and nested within 65 primary care clinics. Data reported in this study were obtained from the "Dialogue" project. Adherence rates for 27 quality indicators selected to cover the most important components of depression treatment were estimated. Multilevel analyses were conducted. RESULTS Adherence to guidelines was high (>75%) for one third of the quality indicators that were measured but was low (<60%) for nearly half of the measures. Just over half of the sample (52.2%) received at least one minimally adequate treatment for depression. At the individual level, determinants of receipt of minimally adequate care included age, having a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and the severity of depression. At the clinic level, determinants included the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration. CONCLUSIONS Our findings suggest that interventions are needed to increase the extent to which primary mental health care conforms to evidence-based recommendations. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration.
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Affiliation(s)
- Arnaud Duhoux
- CRCHUM (Centre de recherche du Centre Hospitalier de l'Université de Montréal), Edouard-Asselin Pavilion, 264, René-Lévesque Blvd, East, Montreal, QC, Canada H2X 1P1.
| | - Louise Fournier
- CRCHUM (Centre de recherche du Centre Hospitalier de l’Université de Montréal), Edouard-Asselin Pavilion, 264, René-Lévesque Blvd. East, Montreal, QC, Canada H2X 1P1,Université de Montréal, C.P. 6128, succursale Centre-ville, H3C 3 J7, Montreal, QC, Canada,Institut National de Santé Publique du Québec, 190 Crémazie Blvd. East, H2P 1E2, Montreal, QC, Canada
| | - Lise Gauvin
- CRCHUM (Centre de recherche du Centre Hospitalier de l’Université de Montréal), Edouard-Asselin Pavilion, 264, René-Lévesque Blvd. East, Montreal, QC, Canada H2X 1P1,Université de Montréal, C.P. 6128, succursale Centre-ville, H3C 3 J7, Montreal, QC, Canada
| | - Pasquale Roberge
- CRCHUM (Centre de recherche du Centre Hospitalier de l’Université de Montréal), Edouard-Asselin Pavilion, 264, René-Lévesque Blvd. East, Montreal, QC, Canada H2X 1P1,Institut National de Santé Publique du Québec, 190 Crémazie Blvd. East, H2P 1E2, Montreal, QC, Canada,Université de Sherbrooke, 3001, 12e Avenue Nord, J1H 5 N4, Sherbrooke, QC, Canada
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Becker MA, Martinez-Tyson D, DiGennaro J, Ochshorn E. Do Latino and non-Latino White Medicaid-enrolled adults differ in utilization of evidence-based treatment for major depressive disorder? J Immigr Minor Health 2012; 13:1048-54. [PMID: 21805165 DOI: 10.1007/s10903-011-9508-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although evidence-based practice guidelines have been developed to achieve greater consistency and quality in mental health care, insufficient research exists on implementing these guidelines among different racial/ethnic groups and the impact of guideline adherence on treatment outcomes. This study compared mental health care received by community dwelling Latino and non-Latino White Medicaid enrollees in Florida with a diagnosis of major depressive disorder (MDD) and examined predictors of adherence to American Psychiatric Association (APA) guidelines for the treatment of MDD. Latinos were more likely than Whites to receive guideline adherent treatment (OR = 1.21, P < .0001). Enrollees receiving combination drug therapy were most likely to receive treatment consistent with APA guidelines (OR = 4.25, P < .0001). Despite research demonstrating the efficacy of evidence-based practices, many study participants did not receive guideline adherent treatment. Policies and practices targeted at increasing adherence to approved guidelines and improving treatment outcomes are recommended.
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Affiliation(s)
- Marion A Becker
- Department of Aging and Mental Health Disparities, University of South Florida, Tampa, FL 33612-3807, USA.
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Liberman KM, Meah YS, Chow A, Tornheim J, Rolon O, Thomas DC. Quality of Mental Health Care at a Student-Run Clinic: Care for the Uninsured Exceeds that of Publicly and Privately Insured Populations. J Community Health 2011; 36:733-40. [DOI: 10.1007/s10900-011-9367-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zubkoff L, Lorenz KA, Lanto AB, Sherbourne CD, Goebel JR, Glassman PA, Shugarman LR, Meredith LS, Asch SM. Does screening for pain correspond to high quality care for veterans? J Gen Intern Med 2010; 25:900-5. [PMID: 20229139 PMCID: PMC2917664 DOI: 10.1007/s11606-010-1301-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 10/07/2009] [Accepted: 02/08/2010] [Indexed: 10/24/2022]
Abstract
BACKGROUND Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. OBJECTIVE To assess adherence to measures of pain management quality and identify associated patient and provider factors. DESIGN A cross-sectional visit-based study. PARTICIPANTS One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. MEASUREMENT AND MAIN RESULTS We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. CONCLUSIONS Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.
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Affiliation(s)
- Lisa Zubkoff
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Collaborative depression treatment in older and younger adults with physical illness: pooled comparative analysis of three randomized clinical trials. Am J Geriatr Psychiatry 2010; 18:520-30. [PMID: 20220588 PMCID: PMC2875343 DOI: 10.1097/jgp.0b013e3181cc0350] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There have been few comparisons of the effectiveness of collaborative depression care between older versus younger adults with comorbid illness, particularly among low-income populations. DESIGN Intent-to-treat analyses are conducted on pooled data from three randomized controlled trials that tested collaborative care aimed at improving depression, quality of life, and treatment receipt. SETTINGS Trials were conducted in oncology and primary care safety net clinics and diverse home healthcare programs. PARTICIPANTS Thousand eighty-one patients with major depressive symptoms and cancer, diabetes, or other comorbid illness. INTERVENTION Similar intervention protocols included patient, provider, sociocultural, and organizational adaptations. MEASUREMENTS The Patient Health Questionnaire (PHQ)-9 depression, Short-Form Health Survey-12/20 quality of life, self-reported hospitalization, ER, intensive care unit utilization, and antidepressant, psychotherapy treatment receipt are assessed at baseline, 6, and 12 months. RESULTS There are no significant differences in reducing depression symptoms (p ranged 0.18-0.58), improving quality of life (t = 1.86, df = 669, p = 0.07 for physical functioning at 12 months, and p ranged 0.23-0.99 for all others) patients aged between >/=60 years versus 18-59 years. Both age group intervention patients have significantly higher rates of a 50% PHQ-9 reduction (older: Wald chi[df = 1] = 4.82, p = 0.03; younger: Wald chi[df = 1] = 6.47, p = 0.02), greater reduction in major depression rates (older: Wald chi[df = 1] = 7.72, p = 0.01; younger: Wald chi[df = 1] = 4.0, p = 0.05) than enhanced-usual-care patients at 6 months and no significant age group differences in treatment type or intensity. CONCLUSION Collaborative depression care in individuals with comorbid illness is as effective in reducing depression in older patients as younger patients, including among low-income, minority patients. Patient, provider, and organizational adaptations of depression care management models may contribute to positive outcomes.
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