Scott Ober

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

OBJECTIVE Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Organizational Cost of Quality Improvement for Depression Care

OBJECTIVE We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA. DATA SOURCES AND STUDY SETTING Project records and surveys from three multistate VA administrative regions and seven of their primary care practices. STUDY DESIGN Descriptive analysis. DATA COLLECTION We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan-Do-Study-Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities. PRINCIPLE FINDINGS Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of

Gender differences in the association between antidepressant use and restless legs syndrome.

84,438. Technical experts spent 2,147 hours costing

Dual perinephric and prostatic abscesses from methacillin-resistant Staphylococcus aureus.

197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design. CONCLUSIONS Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.

Quality Improvement in Heart Failure: A Randomized Educational Intervention to Change Provider Behavior

Contradictory results have been reported for the association between antidepressant use and Restless Legs Syndrome (RLS). Our aim was to clarify the relationship and examine possible gender differences. We interviewed 1,693 veterans receiving primary care from the Cleveland VA Medical Center and obtained prescription drug information from their medical records. Overall, use of an antidepressant was associated with RLS for men (RR = 1.77, CI = 1.26, 2.48) but not for women (RR = 0.79, CI = 0.43, 1.47). Analyses of individual antidepressants revealed an association between RLS and fluoxetine for women (RR = 2.47, CI = 1.33, 4.56), and associations between RLS and citalopram, (RR = 2.09, CI = 1.20, 3.64), paroxetine (RR = 1.97, CI = 1.02, 3.79), and amitriptyline (RR = 2.40, CI = 1.45, 4.00) for men. We conclude that RLS may be associated with antidepressant use, but the association varies by gender and type of antidepressant. Antidepressant use is more strongly associated with RLS in men than in women.

Developing effective collaboration between primary care and mental health providers.

Perinephric and prostatic abscesses may present with protean symptoms and often arise from ascending urinary tract infections. Both abscesses are often caused by uropathogens, and only on rare occasions is the etiology due to methacillin-resistant Staphylococcus aureus (MRSA). Perinephric and prostatic abscesses have never been reported to occur together. We present a 56-year-old male with poorly controlled diabetes that had recently begun performing daily self-digital rectal examinations, who presented with a three day history of urinary symptoms. The patient had bilateral costovertebral angle tenderness and a boggy, tender, enlarged prostate. Blood and urine cultures showed MRSA. CT scan of the abdomen and pelvis demonstrated right perinephric abscess and prostatic abscess. This case report illustrates the potential for simultaneous perinephric and prostatic abscesses by MRSA.

Insulin use in elderly diabetic patients.

UNLABELLED Whether provider education changes practice for HF has not been reported. (NHeFT)™ uses didactic and experiential training of primary care providers (PCP) to optimize treatment of HF. We randomized PCPs in the Cleveland VA clinics to training (T) vs control (C). ENDPOINTS Primary - the number of patients with EF < 40% treated with ACEI/ARB and Beta Blocker, +/- diuretic post T vs pre T; Secondary - the number of patients with increase in ACEI/ARB or a decrease in diuretic post T vs. pre T. Of 641 patients, 216 (85 C,131 T) had EF < 40%; 188 (85%) did not meet the primary endpoint at baseline. After T, a similar proportion (64.2% C, 74.4%,T) met the endpoint at end of study (P = 0.14). The odds of a patient meeting the primary endpoint by care of a T provider, was not significantly higher than C (OR 1.496, 95% CI (0.751, 2.982)). Patients seen by T were more likely to have the diuretic dose decreased vs patients under C, without increases in ACEI or ARB (P < 0.03). Thus, a didactic program of HF plus a preceptorship changed practice modestly. Studies should address provider readiness of change and self efficacy to adhere to evidenced-based care.