Aiming for quality: a global compass for national learning systems

Supporting Quality Integrated Care for Adolescent Depression in Primary Care: A Learning System Approach

Background

Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach.

Methods

Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups.

Results

The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%).

Discussion

While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines.

Conclusion

Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.

Country learning on maintaining quality essential health services during COVID-19 in Timor-Leste: a qualitative analysis

OBJECTIVE

This case study examines the enabling factors, strengths, challenges and lessons learnt from Timor-Leste (TLS) as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic.

DESIGN

A qualitative case study triangulated information from 22 documents, 44 key informant interviews and 6 focus group discussions. The framework method was used to thematically examine the factors impacting quality EHS in TLS.

SETTING

National, municipal, facility levels in Baucau, Dili and Ermera municipalities in TLS.

RESULTS

Based on the TLS National Health Statistics Reports, a reduction in outpatient, emergency department and primary care service delivery visits was observed in 2020 when compared with 2019. However, in contrast, maternal child health services simultaneously improved in the areas of skilled birth attendants, prenatal coverage and vitamin A distribution, for example. From the thematic analysis, five themes emerged as contributing to or impeding the maintenance of quality EHS including (1) high-level strategy for maintaining quality EHS, (2) measurement for quality and factors affecting service utilisation, (3) challenges in implementation of quality activities across the three levels of the health system, (4) the impact of quality improvement leadership in health facilities during COVID-19 and (5) learning systems for maintaining quality EHS now and for the future.

CONCLUSION

The maintenance of quality EHS is critical to mitigate adverse health effects from the COVID-19 pandemic. When quality health services are delivered prior to and maintained during public health emergencies, they build trust within the health system and promote healthcare-seeking behaviour. Planning for quality as part of emergency preparedness can facilitate a high standard of care by ensuring health services continue to provide a safe environment, reduce harm, improve clinical care and engage patients, facilities and communities.

Applying learning health systems thinking in codeveloping integrated tuberculosis interventions in the contexts of COVID-19

The COVID-19 pandemic reversed much of global progress made in combatting tuberculosis, with South Africa experiencing one of the largest impacts on tuberculosis detection. The aim of this paper is to share our experiences in applying learning health systems (LHS) thinking to the codevelopment of an intervention improving an integrated response to COVID-19 and tuberculosis in a South African district. A sequential partially mixed-methods study was undertaken between 2018 and 2021 in the district of Amajuba in KwaZulu-Natal. Here, we report on the formulation of a Theory of Change, codesigning and refining proposed interventions, and piloting and evaluating codesigned interventions in primary healthcare facilities, through an LHS lens. Following the establishment and formalisation of a district Learning Community, diagnostic work and a codevelopment of a theory of change, intervention packages tailored according to pandemic lockdowns were developed, piloted and scaled up. This process illustrates how a community of learning can generate more responsive, localised interventions, and suggests that the establishment of a shared space of research governance can provide a degree of resilience to facilitate adaption to external shocks. Four main lessons have been gleaned from our experience in adopting an LHS approach in a South African district, which are (1) the importance of building and sustaining relationships, (2) the utility of colearning, coproduction and adaptive capacity, (3) the centrality of theory-driven systems strengthening and (4) reflections on LHS as a framework.

Identifying transient ischemic attack (TIA) patients at high-risk of adverse outcomes: development and validation of an approach using electronic health record data

Background

Risk-stratification tools that have been developed to identify transient ischemic attack (TIA) patients at risk of recurrent vascular events typically include factors which are not readily available in electronic health record systems. Our objective was to evaluate two TIA risk stratification approaches using electronic health record data.

Methods

Patients with TIA who were cared for in Department of Veterans Affairs hospitals (October 2015—September 2018) were included. The six outcomes were mortality, recurrent ischemic stroke, and the combined endpoint of stroke or death at 90-days and 1-year post-index TIA event. The cohort was split into development and validation samples. We examined the risk stratification of two scores constructed using electronic health record data. The Clinical Assessment Needs (CAN) score is a validated measure of risk of hospitalization or death. The PREVENT score was developed specifically for TIA risk stratification.

Results

A total of N = 5250 TIA patients were included in the derivation sample and N = 4248 in the validation sample. The PREVENT score had higher c-statistics than the CAN score across all outcomes in both samples. Within the validation sample the c-statistics for the PREVENT score were: 0.847 for 90-day mortality, 0.814 for 1-year mortality, 0.665 for 90-day stroke, and 0.653 for 1-year stroke, 0.699 for 90-day stroke or death, and 0.744 for 1-year stroke or death. The PREVENT score classified patients into categories with extreme nadir and zenith outcome rates. The observed 1-year mortality rate among validation patients was 7.1%; the PREVENT score lowest decile of patients had 0% mortality and the highest decile group had 30.4% mortality.

Conclusions

The PREVENT score had strong c-statistics for the mortality outcomes and classified patients into distinct risk categories. Learning healthcare systems could implement TIA risk stratification tools within electronic health records to support ongoing quality improvement.

Registration

ClinicalTrials.gov Identifier: NCT02769338.

The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

BACKGROUND

To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems.

METHODS

Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment.

RESULTS

The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement.

CONCLUSIONS

Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT02769338 ).

Achieving Quality Integrated Care for Adolescent Depression: A Scoping Review

Introduction:

While primary care is often the first point of contact for adolescents with depression, more than half of depressed adolescents are either untreated or undertreated. A scoping review had been completed to summarize approaches for achieving quality integrated care in primary care focused on adolescent depression.

Methods:

The scoping review followed the methodological framework for scoping studies from Arksey and O’Malley. Articles were grouped into themes and mapped to 6 quality domains for integrated care from the practice integration profile survey and 3 levels of stakeholders based on WHO’s definition for health systems (patient/family, primary care team, and national/sub-national health system).

Results:

A total of 868 records were screened resulting in 22 articles at the patient/family-level (5/22), the primary care team-level (18/22), and the national/sub-national health system-level (16/22). The results highlighted multilevel approaches to support the delivery of quality integrated care for adolescent depression in primary care: (1) population-focused using patient registries, routine screening based on standardized algorithms, and patient-centered strategies, (2) team-driven where primary care clinicians collaborate with mental health clinicians as part of a primary care team, (3) evidence-based delivery of mental health services across the integrated care pathway from screening to follow-up visits, and (4) measurement-guided by leveraging the electronic health record infrastructure to learn from patient outcomes.

Conclusion:

More research is needed on how to provide quality integrated care for adolescent depression, specifically on patient engagement and retention, grounded in the frontline experiences of patients, families, and clinicians and supported by national and/or sub-national guidelines. A learning system could help integrate mental health services in primary care in a way that is consistent across the national and/or sub-national health system.