Applying Frameworks for
Implementation Research
to RealReal-World Examples:
Improving Care For
Depression
Lisa Rubenstein,
Rubenstein MD,
MD MSPH
6/28/09
Academy Health, Chicago
This Talk





Purpose of implementation/QI
research
Moving from efficacy to routine care
Depression
p
example
p
Other examples (in brief)
Next talks will explain how the
pathway works (theory) and how to
learn on the wayy ((evaluation))
Implementation
p
Research
is about Impact


We want patients or community
populations
p
p
to experience
p
better
health
We achieve this by understanding
what should be done (evidence), &
figuring out how to achieve it in the
real world
Successful Systems
y
Embed
Health Services Researchers



Eg., VA, Kaiser, Group Health, Mayo
Clinic, Harvard Community Health Plan,
Geisinger, Rocky Mountain, National
Health Service (Britain)
Health services researchers help
systems function as learning
organizations
Purpose of implementation science/QI
research is to support this process
But HSR Must Deliver
Deliver…

Success requires theory & methods
– Partnership, teamwork
– Understanding pathways into practice
– Linking methods to real world conditions
A Guiding
G idi
Framework
Efficacy and Effectiveness

What actions, maneuvers, processes
p
patient
p
health in “laboratories”
improve
run by researchers?
– Efficacy research

Which of these efficacious actions work
(are effective),
effective) or can be made to work
work,
in real world settings run by managers?
– Effectiveness research
Effectiveness Versus QI



In effectiveness, the intervention aims
generalizable models
to create g
In QI, the goal is to make the
intervention work within a site or sites
In truth, it is a spectrum
Efficacy
Routine
Care
Effectiveness
Quality
Improvement
Efficacy
Routine
Care
Effectiveness
Quality
Improvement
Clinical
ProblemSolving
VA HSR&D Center for the Study of
Of HealthCare Provider Behavior
Efficacy
Routine
Care
Problems,
Adverse
Outcomes
Effectiveness
Quality
Improvement
Clinical
ProblemSolving
VA HSR&D Center for the Study of
Of HealthCare Provider Behavior
Efficacy
Basic Science,
Epidemiology
Routine
Care
Problems,
Adverse
Outcomes
Effectiveness
Quality
Improvement
Clinical
ProblemSolving
VA HSR&D Center for the Study of
Of HealthCare Provider Behavior
Depression: an Elephant
in the Living
g Room…
Patient Factor: Depressed people are poor
consumers…
Provider & Organizational
g
Factors




No systematic method of detecting
depression
p
or assessing
g symptoms
y p
Primary care doctors not trained
Mental health specialists and primary
care not linked/collaborative
Pi
Primary
care practice
ti structure
t t
nott
adequate for depression
1990 – 2000:
Effectiveness Phase 1

What didn’t work in randomized trials
– Depression screening in primary care
– Depression education
– Computer decision support in primary care

What did work
– Practice redesign for collaborative care
– Katon: ResearcherResearcher-delivered care
management, patient selfself-management
support active collaboration with MHS
support,
Effectiveness Randomized Trials
Stage 1: Katon, Group Health (1996)
Intervention
6 mos
88
Usual Care
6 mos
57
% Satisfaction
93
75
% Reduced
depression
p
scores by 50%
74
44
% Approp.
Antidepressants
Effectiveness Randomized
Trials Stage 2: Less Researcher
Control


Researchers did not directly touch the
p
practices
However, intervention was still prepre-set
– Tools and protocols designed by
researchers
– Researchers trained champions
– Researchers evaluated
Effectiveness Randomized Trials
Ph
Phase
2
2: AHRQ P
Partners
t
iin Care
C
Study
Int
Cont
 Mean mental health41**
39
related QOL (MCS-12)
 % with symptoms of
42***
52
major depression
 % still working
84
90*
Rubenstein, Health
_________________________
Services Research
Research, 1999
*p<.05; **p<.005; ***p<.001 (intervention); Wells,
JAMA, 2000 (evaluation)
Additional Effectiveness
Studies of Collaborative Care



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Meta-analysis of 36 randomized trials
Metashows effectiveness (Gilbody,2006)
Meta--analysis of over 10 randomized
Meta
trials shows costcost-effectiveness
(Gilbody,2006)
Collaborative care is a “Best Practice”
However, still not incorporated into
routine care
1995-2005: Q
1995QI Trials
Phase 1

Hands--off CQI for depression: negative
Hands

St t d CQI with
Structured
ith access to
t experts:
t
(Goldberg H,1998, J of QI; Solberg L,2001, J of Effective Clin Practice)
– IHI Breakthrough Series inconclusive
M, 2006, Psych Services)
(Meredith
– EvidenceEvidence-Based QI Kaiser/VA
Kaiser/VA---Collaborative
Collaborative
care tools, structured QI, senior leader
guidance:
id
Modest
M d t + (Rubenstein LV, 2006, JGIM; Parker L,
2007, Qual Health Res)

Our theory: QI teams needed more
technical support
Implementation and
Spread:
d QI Phase
h
2

VA QUERI EBQI for depression 2001
– Translating Initiatives for Depression into
Effective Solutions (TIDES)

Eventually a series (WAVES, COVES,
PONDS, HiTIDES, RIPPLES, AQUADEP,
ReTIDES)
– Chaney, Kirchner, Yano, Fortney, Owen,
Williams, Liu, Ritchie
EBQI: PDSA Cycles of Research-Based
Approaches
Plan the
•Improvement
•Data
D t collection
ll ti
Do the
•Improvement
•Data collection
•Analysis
•Hold gains
Plan
D
Do
Act
Study •Interpret
Data
23
Researcher Role In EBQI
EBQI:
Q Clinical Management
g
as Decision
Decision--Makers



Senior leader expert panel to set
g priorities
p
design
Local sites PDSA to adapt the model
Researchers support
TIDES Work Group
p Structure:
Chronic Care Model

Workgroups supported implementation
– Informatics
– Care management and patient self
self-management support
– Senior leaders
– Provider education/decision support
– Collaboration
Felker BL,, 2006,, Prim
Care Companion J
Clin Psychiatry
Research/Clinical
/
Partnership


Majority of >100 project leaders were
/
g , not researchers
clinical/managers,
Majority of hours spent were by
researchers
Liu CF,
CF 2009,
2009 Health Services
Research
Theories Underlying
y g
TIDES


Quality improvement (Demming, IHI)
Social Marketing (Andreasen) (Luck,
(Luck
Implementation Science, after July 2009)



Innovations (Rogers)
Re--Engineering (Goldratt)
Re
A ti research
Action
h (Kirchner, Parker, Yano et al)
TIDES
Primary
Careand
Clinic
Sites 2006
VISN MAP
of TIDES
ReTIDES
CBOC
(4,906 PC Patients)
VAMC
VAMC
(5,470 PC Patients)
(12,963 PC Patients)
VAMC
(3,836 PC Patients)
CBOC
(7,604 P PC Patients)
9 New VAMC’s
(90,000 PC Patients)
CBOC
(5 856 PC Patients)
(5,856
2 New VAMC’s
(40,000 PC Patients)
CBOC
(10,122 PC Patients)
2 New VAMC’s
(40,000 PC Patients)
2 new VAMC’s
(90,000 PC Patients)
VAMC
(5 355 PC Patients)
(5,355
CBOC
(12,329 PC Patients)
CBOC
(7,700 PC Patients)
ReTIDES Spread
Intervention Sites
Control Sites
TIDES Spread Results



In 2005,
2005 spread TIDES to 50 sites in 4
VA multistate regions (some
spontaneous)
In 2006, TIDES/BHL became an official
VA Central Office priority (Primary
Care/Mental Health Integration Initiative)
In 2008,
2008 TIDES/BHL became VA policy
– “Handoff” to clinical care (Post, Katz,
Agarwal)
g
)
– Minimal continued support by research team
Triangulation:
g
Example
p #1,, VA
Patient Centered Medical Home

Began as one pilot site 1989
– Evidence review for design



Researcher local and national primary care
evaluation
Research/manager assistance teams
National Directive 1994
– 40% implemented by 1996 (early adopters/early
majority)

Mandated 1998
Example
p #2: VA
Electronic Medical Record

Developed in four pilot sites 1990 1994
– Extensive clinician & health services
researcher involvement

Merged CPRS system 1994
– 30 % adoption 1996

Mandated adoption 1998
Example
p #3: Smoking
g
Cessation


Randomized trials showed effectiveness
g cessation clinics
of meds,, smoking
EBQI for depression resulted in
emphasis on smoking cessation clinics
– Low impact on primary care population in
randomized trial (Yano, Sherman)

Revised intervention emphasizing
telephone support underway
Efficacy
Routine
Care
Effectiveness
Quality
Improvement