Cynthia A. Claassen

Barriers to implementation of a computerized decision support system for depression: an observational report on lessons learned in "real world" clinical settings

BackgroundDespite wide promotion, clinical practice guidelines have had limited effect in changing physician behavior. Effective implementation strategies to date have included: multifaceted interventions involving audit and feedback, local consensus processes, marketing; reminder systems, either manual or computerized; and interactive educational meetings. In addition, there is now growing evidence that contextual factors affecting implementation must be addressed such as organizational support (leadership procedures and resources) for the change and strategies to implement and maintain new systems.MethodsTo examine the feasibility and effectiveness of implementation of a computerized decision support system for depression (CDSS-D) in routine public mental health care in Texas, fifteen study clinicians (thirteen physicians and two advanced nurse practitioners) participated across five sites, accruing over 300 outpatient visits on 168 patients.ResultsIssues regarding computer literacy and hardware/software requirements were identified as initial barriers. Clinicians also reported concerns about negative impact on workflow and the potential need for duplication during the transition from paper to electronic systems of medical record keeping.ConclusionThe following narrative report based on observations obtained during the initial testing and use of a CDSS-D in clinical settings further emphasizes the importance of taking into account organizational factors when planning implementation of evidence-based guidelines or decision support within a system.

National study of ambulance transports to United States emergency departments: importance of mental health problems

INTRODUCTION Understanding ambulance utilization patterns is essential to assessing prehospital system capacity and preparedness at the national level. OBJECTIVE To describe the characteristics of patients transported to U.S. emergency departments (EDs) by ambulance and to determine predictors of ambulance utilization. METHODS Data were obtained from the National Hospital Ambulatory Medical Care Survey using mode of arrival, demographic and visit information, ICD-9-CM E and V-codes, and classified reasons for the visit. RESULTS The rates for ED visits of persons conveyed by ambulence were stable between 1997 and 2003, consisting of approximately one in every seven ED visits (14%). In 2003, there were 16.2 million ED visits for which an ambulance was used in the U.S. However, for patients with mental health visits, nearly one in three ED presentations (31%) arrived by ambulance. Significantly higher rates of ambulance use were associated with: (1) mental health visits; (2) older age; (3) African-Americans; (4) Medicare or self-pay insurance status; (5) urban ED location; (6) U.S. regions outside of the South; (7) presentation between 12 midnight to 0800 hours; (8) injury-related visits; (9) urgent visit status; and/or (10) those resulting in hospital admission. Among mental health patients, older age, self-pay insurance status, urban ED location, regions outside the southern US, and urgent visit classification predicted ambulance use. Ambulance usage within the mental health group was highest for suicide and lowest for mood and anxiety disorder-related visits. CONCLUSION Reliance on ambulance services varies by age, insurance status, geographic factors, time of day, urgency of visit, subsequent admission status, and type of mental health disorder. Even after controlling for many confounding factors, mental health problems remain an important predictor of ambulance use.

A Computerized Decision Support System for Depression in Primary Care

OBJECTIVE In 2004, results from The Texas Medication Algorithm Project (TMAP) showed better clinical outcomes for patients whose physicians adhered to a paper-and-pencil algorithm compared to patients who received standard clinical treatment for major depressive disorder (MDD). However, implementation of and fidelity to the treatment algorithm among various providers was observed to be inadequate. A computerized decision support system (CDSS) for the implementation of the TMAP algorithm for depression has since been developed to improve fidelity and adherence to the algorithm. METHOD This was a 2-group, parallel design, clinical trial (one patient group receiving MDD treatment from physicians using the CDSS and the other patient group receiving usual care) conducted at 2 separate primary care clinics in Texas from March 2005 through June 2006. Fifty-five patients with MDD (DSM-IV criteria) with no significant difference in disease characteristics were enrolled, 32 of whom were treated by physicians using CDSS and 23 were treated by physicians using usual care. The studys objective was to evaluate the feasibility and efficacy of implementing a CDSS to assist physicians acutely treating patients with MDD compared to usual care in primary care. Primary efficacy outcomes for depression symptom severity were based on the 17-item Hamilton Depression Rating Scale (HDRS(17)) evaluated by an independent rater. RESULTS Patients treated by physicians employing CDSS had significantly greater symptom reduction, based on the HDRS(17), than patients treated with usual care (P < .001). CONCLUSIONS The CDSS algorithm, utilizing measurement-based care, was superior to usual care for patients with MDD in primary care settings. Larger randomized controlled trials are needed to confirm these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00551083.

Differences between veteran suicides with and without psychiatric symptoms.

OBJECTIVES Our objective was to examine all suicides (n = 423) in 2 geographic areas of the Veterans Health Administration (VHA) over a 7-year period and to perform detailed chart reviews on the subsample that had a VHA visit in the last year of life (n = 381). METHODS Within this sample, we compared a group with 1 or more documented psychiatric symptoms (68.5%) to a group with no such symptoms (31.5%). The groups were compared on suicidal thoughts and behaviors, somatic symptoms, and stressors using the χ(2) test and on time to death after the last visit using survival analyses. RESULTS Veterans with documented psychiatric symptoms were more likely to receive a suicide risk assessment, and have suicidal ideation and a suicide plan, sleep problems, pain, and several stressors. These veterans were also more likely to die in the 60 days after their last visit. CONCLUSIONS Findings indicated presence of 2 large and distinct groups of veterans at risk for suicide in the VHA, underscoring the value of tailored prevention strategies, including approaches suitable for those without identified psychiatric symptoms.

A Strategic Approach for Prioritizing Research and Action to Prevent Suicide

It is time to strategically apply science and accountability to the public health problem of preventable suicide. U.S. suicide rates have remained stable for decades. More than 36,000 individuals now die by suicide each year. A public health-based approach to quickly and substantially reduce suicides requires strategic deployment of existing evidence-based interventions, rapid development of new interventions, and measures to increase accountability for results. The purpose of this Open Forum is to galvanize researchers to further develop and consolidate knowledge needed to guide these actions. As researchers overcome data limitations and methodological challenges, they enable better prioritization of high-risk subgroups for targeted suicide prevention efforts, identification of effective interventions ready for deployment, estimation of the implementation impact of effective interventions in real-world settings, and assessment of time horizons for taking implementation to scale. This new knowledge will permit decision makers to take strategic action to reduce suicide and stakeholders to hold them accountable for results.

Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites

BACKGROUND The terrorist attacks in the USA on 11 September 2001 affected suicide rates in two European countries, whereas overall US rates remained stable. The effect on attack site rates, however, has not been studied. AIMS To examine post-attack suicide rates in areas surrounding the three airline crash sites. METHOD Daily mortality rates were modelled using time series techniques. Where rate change was significant, both duration and geographic scope were analysed. RESULTS Around the World Trade Center, post-attack 180-day rates dropped significantly (t = 2.4, P = 0.0046), whereas comparison condition rates remained stable. No change was observed for Pentagon or Flight 93 crash sites. CONCLUSIONS The differential effect by site suggests that proximity may be less important that other event characteristics. Both temporal and geographic aspects of rate fluctuation after sentinel events appear measurable and further analyses may contribute valuable knowledge about how sociological forces affect these rates.

Alcohol withdrawal syndrome: Guidelines for management

Clinically significant symptoms of withdrawal frequently follow the abrupt cessation of alcohol use in alcohol-dependent individuals. Given alcohol-dependence point prevalence rates of at least 10 to 20% in most medical settings, as many as 1 in 5 patients may require treatment for withdrawal symptoms. Recently developed guidelines from the American Society of Addiction Medicine utilised an appraisal of the quality and quantity of research available on pharmacological management of alcohol withdrawal. In light of these guidelines, along with recent advances in the understanding of the biological mechanisms of withdrawal, the procedures for treating patients undergoing alcohol withdrawal are discussed. Inpatient management protocols should administer benzodiazepines for mild to moderate and severe withdrawal symptoms utilising a standardised rating instrument and information from past withdrawal episodes to inform treatment decisions. A symptom-triggered dose schedule can be used in settings with trained staff; a gradual taper dosage regimen is appropriate elsewhere. Carbamazepine and valproic acid (sodium valproate) represent promising pharmacotherapeutic agents, although further research is needed. Outpatient detoxification is also discussed. With appropriate and aggressive treatment, morbidity from alcohol withdrawal can be minimised.