Lisa V. Rubenstein

The acceptability of treatment for depression among African-American, hispanic, and white primary care patients

Background. Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. Methods. A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. Results. African Americans (adjusted OR, 0.30; 95% CI 0.19–0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26–0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35–1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08–9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. Conclusions. African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients’ cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Primary Care Patients' Involvement in Decision-Making Is Associated with Improvement in Depression

Background:Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes. Objective:The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms. Design:Prospective cohort study. Setting:Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care. Subjects:Primary care patients with current symptoms and probable depressive disorder. Measurements:Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of theCenter for Epidemiologic Studies–Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors. Results:For each 1-point increase in IDM ratings, the probability of patients’ report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004). Conclusions:Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.

What context features might be important determinants of the effectiveness of patient safety practice interventions

Background Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter. Methods Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations. Results The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description. Conclusion This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.

From Understanding Health Care Provider Behavior to Improving Health Care: The Queri Framework for Quality Improvement

Basic science and health care research provide the evidence base for the scientific practice of medicine. Over the past 2 decades, as increasingly refined tools for improving health and health care have been developed, the health care community has attempted to bridge the gap between available tools and actual health care practices. This gap can be bridged only by influencing health care provider behavior. The VA Quality Enhancement Research Initiative (QUERI) is a program designed to systematically translate research findings into better health care practices, and thus better health outcomes for enrolled veterans. Integrating provider behavior research considerations and findings into each step of the QUERI process will enhance the effectiveness of the initiative. This article presents a provider behavior research framework for planning, implementing, and evaluating quality improvement interventions within QUERI.

Quality Improvement for Depression Enhances Long-term Treatment Knowledge for Primary Care Clinicians

AbstractOBJECTIVE: We evaluated the effect of implementing quality improvement (QI) programs for depression, relative to usual care, on primary care clinicians’ knowledge about treatment.n DESIGN AND METHODS: Matched primary care clinics (46) from seven managed care organizations were randomized to usual care (mailed written guidelines only) versus one of two QI interventions. Self-report surveys assessed clinicians’ knowledge of depression treatments prior to full implementation (June 1996 to March 1997) and 18 months later. We used an intent-to-treat analysis to examine intervention effects on change in knowledge, controlling for clinician and practice characteristics, and the nested design.n PARTICIPANTS: One hundred eighty-one primary care clinicians.n INTERVENTIONS: The interventions included institutional commitment to QI, training local experts, clinician education, and training nurses for patient assessment and education. One intervention had resources for nurse follow-up on medication use (QI-meds) and the other had reduced copayment for therapy from trained, local therapists (QI-therapy).n RESULTS: Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy (by 20% for QI-meds, P=.04 and by 33% for QI-therapy, P=.004), but there were no significant increases in medication knowledge. Significant increases in knowledge scores (P=.01) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group. Clinicians were exposed to multiple intervention components.n CONCLUSIONS: Dissemination of QI programs for depression in managed, primary care practices improved clinicians’ treatment knowledge over 18 months, but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists.

Early Identification of Co-Occurring Pain, Depression and Anxiety

ABSTRACTBACKGROUNDDepression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment.OBJECTIVETo determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress.DESIGNCross-sectional interview of primary care patients and their providers participating in a Veteran’s Administration HELP-Vets study.SUBJECTSA total of 528 predominately male VeteransMEASUREMENTS AND MAIN RESULTSWe measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress.CONCLUSIONSVA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

Finding order in heterogeneity: types of quality-improvement intervention publications

Background: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. Methods: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. Results: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

How can we recognize continuous quality improvement

Objective Continuous quality improvement (CQI) methods are foundational approaches to improving healthcare delivery. Publications using the term CQI, however, are methodologically heterogeneous, and labels other than CQI are used to signify relevant approaches. Standards for identifying the use of CQI based on its key methodological features could enable more effective learning across quality improvement (QI) efforts. The objective was to identify essential methodological features for recognizing CQI. Design Previous work with a 12-member international expert panel identified reliably abstracted CQI methodological features. We tested which features met rigorous a priori standards as essential features of CQI using a three-phase online modified-Delphi process. Setting Primarily United States and Canada. Participants 119 QI experts randomly assigned into four on-line panels. Intervention(s) Participants rated CQI features and discussed their answers using online, anonymous and asynchronous discussion boards. We analyzed ratings quantitatively and discussion threads qualitatively. Main outcome measure(s) Panel consensus on definitional CQI features. Results Seventy-nine (66%) panelists completed the process. Thirty-three completers self-identified as QI researchers, 18 as QI practitioners and 28 as both equally. The features ‘systematic data guided activities,’ ‘designing with local conditions in mind’ and ‘iterative development and testing’ met a priori standards as essential CQI features. Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI. Conclusions We found consensus among a broad group of CQI researchers and practitioners on three features as essential for identifying QI work more specifically as ‘CQI.’ All three features are needed as a minimum standard for recognizing CQI methods.

Nursing staff, patient, and environmental factors associated with accurate pain assessment.

CONTEXTnAlthough pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.nnnOBJECTIVESnThis study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.nnnMETHODSnThis was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).nnnRESULTSnPain underestimation (N-NRSS-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staffs use of the full NRSxa0protocol and with a distracting environment in which patient vitals werexa0taken.nnnCONCLUSIONnDespite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System

ABSTRACTBACKGROUNDDepression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice’s choices regarding model adoption.OBJECTIVEWe examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.DESIGN1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.MAIN MEASURESWe assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.KEY RESULTSCollocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5xa0%) clinics had implemented collocation, 39 (17.3xa0%) TIDES, and 17 (7.6xa0%) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], pu2009=u20090.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], pu2009=u20090.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], pu2009<u20090.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.CONCLUSIONSBoth readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.