Abstract
BackgroundMeta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.MethodsThe study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.ResultsInterviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).ConclusionsDepression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.Trial RegistrationClinicalTrials.gov: NCT00105820
Highlights
Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression
We evaluate implementation by asking the intent to treat question: did depressed Evidence-based quality improvement (EBQI)-CCM practice patients enrolled in the randomized evaluation and referred to CCM have better care than depressed patients at practices not implementing CCM? We asked the contextual subgroup question: do EBQI-CCM site patients of early adopter clinicians experience different CCM participation outcomes than those of clinicians with a low predilection to adopt CCM? Because our purpose was to study and formatively evaluate the implementation of a well-researched technology [5], our grant proposal powered the study on a process of care change
EBQI-CCM site patients were significantly more likely to have an adequate dosage of antidepressant prescribed than were non-EBQI-CCM patients (65.7% for EBQI-CCM versus 43.4% for non-EBQI CCM, p < 0.01)
Summary
Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. There is ample randomized trial evidence that collaborative care management (CCM) for depression is an effective [4,5,6] and costeffective [7] approach to improving treatment and outcomes for these patients. This study aimed to use a cluster-randomized design to formatively evaluate the success of evidence-based quality improvement (EBQI) methods in implementing effective CCM as part of routine Veteran Affairs (VA) care. Problems detected through our rigorous evaluation could be used to support higher quality model development for sustaining and spreading CCM in VA primary care practices nationally. The study’s major goals were : to learn about the process of implementing research in practice, including effects of context; to test the effectiveness of EBQI for adapting research-based CCM while maintaining its effectiveness; and to provide information for improving the implemented model
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