Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Implement Sci. 2019 Jun 21;14(1):67. doi: 10.1186/s13012-019-0912-4.
Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static.
Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia's public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years (n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised.
Clinicians were 80% female and averaged 37.52 years of age (SD = 11.40); there were no significant differences in clinician characteristics across waves (all ps > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 (M = 3.18) to wave 3 (M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques (p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use (p = .019) but no change in psychodynamic technique use (p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048).
System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.
很少有研究调查行为健康系统努力增加使用基于证据的实践的效果，或者组织特征如何调节这些努力的效果。本研究的目的是调查在一个鼓励实施基于证据的实践的系统中，临床医生在 5 年内的实践变化，以及组织特征如何调节这种效果。我们假设随着时间的推移，基于证据的技术会增加，而使用非基于证据的技术将保持不变。
本研究采用重复的横断面设计，于 2013 年至 2017 年期间在费城的公共行为健康系统中进行了三次数据收集。调查了为年轻人服务的 20 个行为健康门诊诊所的 340 名临床医生，共进行了 5 年的三次调查（总体应答率为 60%）。所有组织和临床医生都在 2013 年至 2017 年期间接受了来自循证实践创新中心提供的系统级支持。此外，大约一半的临床医生参加了由城市资助的基于证据的实践培训计划。主要结果包括临床医生自我报告的使用认知行为和心理动力学技术，由治疗程序检查表修订版（Therapy Procedures Checklist-Family Revised）测量。
临床医生 80%为女性，平均年龄为 37.52 岁（标准差=11.40）；各波次间的临床医生特征无显著差异（均 p>.05）。在控制组织和临床医生协变量后，与第 1 波次（M=3.18）相比，第 3 波次（M=3.37，p=.021，d=.29）中 CBT 技术的平均使用率增加了 6%，而心理动力学技术的使用率没有变化（p=.570）。临床医生参与的每一项基于证据的实践培训计划都预示着 CBT 使用的增加 3%（p=.019），而心理动力学技术的使用没有变化（p=.709）。在基线时文化程度较高的组织中，临床医生的 CBT 使用增加幅度大于文化程度较低的组织（增加 8%，减少 2%，p=.048）。
系统实施基于证据的实践与临床医生实践的适度变化相关；这些效果受组织特征的调节。研究结果确定了改善实施的初步目标。
