Frank Hannah E, Milgram Lauren, Freeman Jennifer B, Benito Kristen G
Warren Alpert Medical School of Brown University, Providence, RI, United States.
Bradley Hospital, East Providence, RI, United States.
Front Health Serv. 2022 Jul 22;2:892294. doi: 10.3389/frhs.2022.892294. eCollection 2022.
Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research.
Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy.
Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice.
Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.
心理健康障碍的循证干预措施（EBIs）在常规临床实践中未得到充分利用。焦虑症的暴露疗法是一种特别难以实施的循证干预措施，但有强有力的实证支持。先前的研究考察了公共资助心理健康机构中循证干预措施实施的决定因素，但很少有研究考察私人执业环境中循证干预措施实施的决定因素。私人执业临床医生在实施过程中可能面临独特的障碍，包括特定环境下使用循证干预措施的背景障碍。政策生态框架考虑了广泛的系统决定因素，包括组织、监管、社会和政治背景，这些因素可能与私人执业环境中循证干预措施的实施相关，但之前的研究尚未对其进行考察。
采用定性访谈，运用政策生态框架评估私人执业临床医生对循证干预措施实施决定因素的看法。临床医生被问及广泛实施心理健康循证干预措施，特别是暴露疗法的情况。混合方法分析比较了在个体私人执业与团体私人执业中工作的临床医生，以及报告对暴露疗法组织支持程度高与低的临床医生的回答。
回答突出了私人执业中循证干预措施实施的几个障碍和促进因素。例如包括与组织支持相关的决定因素（如同事使用循证干预措施）、支付方限制（如长时间治疗缺乏报销）、财政激励措施（如参加培训的报酬）以及消费者对循证干预措施的需求。与个体私人执业的临床医生相比，团体私人执业的临床医生面临的障碍存在显著差异。个体私人执业临床医生描述了他们的执业环境限制同事支持程度的方式（如咨询或暴露疗法规划方面），同时也允许他们有团体执业临床医生可能没有的灵活性（如在日程安排和执业地点方面）。
运用政策生态框架能让我们广泛了解影响私人执业临床医生使用循证干预措施（包括暴露疗法）的背景因素。研究结果指出了可能解决私人执业临床医生所特有的障碍的潜在实施策略。
