Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
Implement Sci. 2012 Apr 11;7:30. doi: 10.1186/1748-5908-7-30.
Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.
This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.
Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.
Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.
Clinical trial # NCT00317018.
协作式护理管理是改善初级保健中抑郁结局的循证实践。美国退伍军人事务部（VA）已要求在其卫星诊所（称为社区基础门诊诊所（CBOC））实施协作式护理管理。然而，CBOC 的组织特征为实施带来了额外的挑战。本研究的目的是评估循证质量改进（EBQI）作为促进 CBOC 采用协作式护理管理的策略的有效性。
这项非随机、小规模、多地点的 EBQI 评估在三个 VA 医疗中心和他们的 11 个附属 CBOC 进行。EBQI 过程的计划阶段涉及到针对每个 CBOC 对协作式护理管理计划进行本地化调整。研究人员确保了调整的证据基础。临床和行政人员负责根据当地的需求、优先事项、偏好和资源调整协作式护理管理计划。通过使用计划-实施-研究-行动循环，随着时间的推移改进该计划。评估基于 RE-AIM（可达性、有效性、采用、实施、维持）框架，并使用来自多个来源的数据：行政记录、基于网络的决策支持系统、调查和关键信息员访谈。
采用：69.0%（58/84）的初级保健提供者将患者转诊至该计划。可达性：9.0%（298/3,296）的被诊断为抑郁症且未接受专科护理的初级保健患者被纳入该计划。保真度：在基线护理经理就诊期间，为 100%（298/298）的患者提供了教育/激活，为 100%（298/298）的患者评估和解决了障碍，为 100%（298/298）的患者监测了抑郁严重程度。不到一半（42.5%，681/1603）的急性阶段随访预约在规定的时间内完成。在所有试验的急性治疗阶段，100%（681/681）的完成随访预约中使用了患者健康问卷（PHQ9）症状监测工具，在 15.3%（104/681）的完成随访预约中讨论了自我管理目标。在药物治疗和联合试验的急性治疗阶段，99.1%（575/580）的完成随访预约中评估了药物依从性，92.4%（536/580）的完成随访预约中评估了药物副作用。在心理治疗和联合试验的急性治疗阶段，83.3%（239/287）的完成随访预约中评估了咨询就诊的依从性。有效性：18.8%（56/298）的入组患者缓解（无症状），另外 22.1%（66/298）对治疗有反应（症状严重程度降低 50%）。维持：在研究资金撤出后，91.9%（10/11）的 CBOC 选择维持该计划。
提供者的采用情况良好，尽管目标人群的可达性相对较低。保真度和维持情况非常好，临床结果与随机对照试验相当。尽管存在组织障碍，但这些发现表明 EBQI 是促进 CBOC 采用的有效促进策略。
临床试验 #NCT00317018。
