Trimbos-institute, Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, the Netherlands.
Implement Sci. 2012 Jan 31;7:8. doi: 10.1186/1748-5908-7-8.
Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands.
Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT).
The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process.
Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process.
自 2004 年以来，“阶梯式护理模式”已被纳入几项国际循证临床指南，以指导临床医生组织抑郁症护理。为了促进这种新治疗方法的采用，在荷兰发起了一项质量改进合作（QIC）。
在 QIC 的同时，还进行了一项使用对照前后设计的干预研究。该研究的一部分是一个过程评估，使用半结构化小组访谈，深入了解参与的临床医生对将阶梯式护理方法用于抑郁症纳入其日常工作的看法。参与者是来自荷兰八个地区的初级保健临床医生、专家临床医生和其他医疗保健人员。分析得到了规范化进程理论（NPT）的支持。
在抑郁症 QIC 的背景下，向初级保健团队引入抑郁症阶梯式护理模式受到了参与临床医生的普遍欢迎。所提出的阶梯式护理模式的三个要素（患者分层、阶梯式护理治疗和结果监测）都在当地进行了翻译和引入。临床医生报告说，他们在如何区分患者群体和不同级别的护理方面有了变化，由于有更广泛的治疗方案提供给他们的患者，因此改变了抗抑郁药物的处方习惯，并且与患者和同事的关系也有所改善。一系列复杂的因素影响了实施过程。促进因素是阶梯式护理模式本身、结构化团队会议（QIC 方法的一部分）以及患者对阶梯式护理的积极反应。多学科卫生团队对抑郁症和抑郁症护理的不同看法、资源不足和信息系统不佳，阻碍了阶梯式护理模式的快速引入。规范化进程理论的“一致性”和“认知参与”这两个结构似乎是该过程初始阶段的关键驱动因素。
抑郁症的阶梯式护理在初级保健中受到欢迎。虽然在短时间内全面实施阶梯式护理方法有困难，但临床医生可以朝着实现阶梯式护理方法的方向取得进展，特别是在 QIC 的背景下。在多学科团队中就什么是抑郁症达成共识，就抑郁症护理的内容达成共识，并分配任务，这对于解决实施过程非常重要。
