Expert panel on Major Depressive Disorder
Quality Standards and Clinical Handbook
AGHPS Summit
November 13, 2015
Peter Voore MD
CAMH, Medical Director, Ambulatory Care and Structured Treatments Program
Health Quality Ontario
The provincial advisor on the quality of health care in Ontario
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Objectives
1. Project scope
2. Methods for the development of quality statements
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Identification of key areas for quality improvement
Prioritization of key areas
Review of evidence for each prioritized key area
Drafting of quality statements
Finalization of quality statements
3. Prioritization of key areas for quality statements
– Results of topic prioritization survey
– Potential guidelines for inclusion
– Prioritization of key areas from survey and potential guidelines
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PROJECT SCOPE
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Project Scope
Population and topic in scope
• Adults and adolescents (13 years and older)
experiencing Major Depression.
• Primary, secondary and tertiary care of patients
experiencing Major Depression.
• Pharmacological and non-pharmacological
management of Major Depression.
Population and topics out of scope
• Young children (<13 years old) and geriatric population
(elderly aged >80 years) including adults in long term
care; pregnant women.
• Prevention and screening of major depression.
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First Name
Last Name
Affiliation
Specialization
Pierre
Blier
The Royal's Institute of Mental Health Research (Royal Ottawa)
Psychiatry
Peter
Voore
Centre for Addiction and Mental Health (CAMH)
Psychiatry
Andrew
Wiens
The Royal
Geriatric Psychiatry
Pauline
Pariser
Taddle Creek Family Health Team, UHN
Primary Care
Sidney
Kennedy
University Health Network, University of Toronto, St. Michael's Hospital
Research
Sonu
Gaind
Humber River Hospital, Canadian Psychiatric Association, University of Toronto
Psychiatry
Neil
Rector
Forest Hill Centre for Cognitive Behavioural Therapy
Psychology
Marie-Hélène
Chomienne
University of Ottawa, Hôpital Montfort
Primary Care
Crystal
Kaukinen
Lakehead NPLC
Nursing
Kathryn
Leferman
Erie St. Clair CCAC
Admin
Paul
Links
St. Joseph's Health Care
Psychiatry
Gillian
Young
CAMH
Admin
Ari
Zaretsky
Sunnybrook Health Sciences Centre
Psychiatry
Raj
Rasasingham
University of Toronto - Division of Child Psychiatry, Humber River Hospital
Psychiatry
Debbie
Bauer
Private Practice
Private Practice
Sonja
Grbevski
Hotel Dieu Grace Healthcare
Admin
Sandie
Leith
CMHA - Sault Ste. Marie Branch
Admin
Rachel
Cooper
St. Michael's Hospital, Stella's Place
Patient Advocate
Alicia
Raimundo
Student
Patient Advocate
Anita
Barnes
Neighbourhood Legal Services
Patient Advocate
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METHODS FOR THE
DEVELOPMENT OF QUALITY
STANDARDS
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Methods: Identification of Key Areas
Topic Prioritization Survey
• Aimed to engage panel members to identify key areas
for quality improvement
• Modelled on NICE’s method of stakeholder
engagement during their Quality Standard
development process
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Methods: Identification of Key Areas
Health Quality Ontario
Topic Prioritization Survey for Major Depression Quality Standard
We are looking for suggestions from panel members about key areas for quality improvement in the
care of people with major depression in Ontario, in advance of our first panel meeting on October 8,
2015. This process will help to provide greater focus for the panel’s work and is based on the topic
engagement exercise used by the National Institute for Health and Care Excellence (NICE) in the
UK to develop their own quality standards.
Please identify up to five areas for quality improvement that you believe have the greatest potential
to improve the quality of care for people with major depression in Ontario and which you would like
the expert panel to consider. There is an optional field provided for you to describe emergent areas
of practice that may be developmental in nature, but have the potential to be widely adopted and
drive quality improvements in the longer term.
Please list up to 5 key areas for quality improvement that you would want to see covered by the expert panel.
Key area for
quality
improvement
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Why is this important?
Why is this a key area for
quality improvement?
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Supporting information
(e.g., guidelines, reviews,
studies, reports, data sources)
Methods: Prioritization of Key Areas
• Clinical epidemiologist (CE) summarized key areas
identified in the topic survey, along with areas
identified by CE through scoping exercise
• Panel will prioritize up to 10 key areas for quality
improvement
• Considerations for prioritization:
1. Potential to improve health outcomes or health resources
2. Variation in current practice
3. Maintenance of important current standards of care
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Methods: Review of Evidence
For each prioritized key area:
Summary of relevant
recommendations and
guidance statements
Evidence review
Establishment
of consensus
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CE will identify recommendations or statements from
relevant guidelines (such as NICE or NICE-accredited
guidelines, guidelines used in current practice, or those
otherwise identified through scoping exercise) that support
potential quality statement development.
If limited or no evidence exists for a key area, the CE will
ideally conduct an evidence review using the most
appropriate review method.
If there is no evidence, the panel may wish to:
• Use expert consensus
• Note prioritized key area for future consideration
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Methods: Review of Evidence
Identification and Inclusion of Clinical Guidelines
• Identify relevant guidelines covering the population(s) and
setting(s) of interest, with guidance from the medical librarians
and input from the advisory panel
• Use the AGREE II instrument to select 4–5 highest quality clinical
guidelines, including at least 1 contextually relevant (Canadian)
guideline
Appraisal of Guidelines for Research & Evaluation II
1) Scope and Purpose
2) Stakeholder Involvement
3) Rigour of Development
4) Clarity of Presentation
5) Applicability
6) Editorial Independence
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Methods: Review of Evidence
Acceptable Evidence Threshold
• Recommendations or statements identified from
relevant guidelines will be examined by the CE to
determine whether they meet an acceptable evidence
threshold
• Suggested thresholds:
– Moderate to high quality of evidence for diagnostic or
therapeutic interventions
– Expert consensus when the quality of evidence is low for
certain principles, processes, or system-level interventions
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Methods: Drafting of Quality Statements
• 5–10 quality statements will be drafted, based on
either recommendations from relevant guidelines or an
evidence review
• Quality statements are not verbatim restatements of
the relevant recommendations from source
guideline(s)
• One quality statement may map to recommendations
from one or more guidelines, and/or may be derived by
rewording one or more recommendations into a single
statement
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Methods: Drafting of Quality Statements
A ‘good’ quality statement should be:
1. Measurable
2. Specific (e.g., clearly defined population)
3. Concise
4. Patient-oriented
Adults with non-ST-segmentelevation myocardial infarction
or unstable angina are
assessed for their risk of
future adverse cardiovascular
events using an established
risk scoring system that
predicts 6-month mortality to
guide clinical management.
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vs
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Adults with myocardial
infarction or unstable angina
are assessed for their risk of
future adverse cardiovascular
events.
Methods: Finalization of
Quality Statements
• The panel will agree upon 5–10 quality statements for
publication within the quality standard and clinical
handbook
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RESULTS OF TOPIC
PRIORITIZATION SURVEY
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Results of Topic Prioritization Survey
Topic Area
Key Area
Assessment
•
•
•
Structured assessment
Identification of patient at risk for suicide
Multidisciplinary group assessment of patients with
comorbidities
Pharmacological
interventions
•
•
Adequate course of medications
Monitoring of course of medications
Nonpharmacological
interventions
•
•
•
Psychotherapy
Neurostimulation therapy
Complementary or alternative therapy
Promoting recovery
•
•
•
Recovery principles
Peer support
Family/caregiver support
Miscellaneous
•
•
•
•
Continuity of care
Stepped care approach
Early and timely interventions after diagnosis
Safety plans to mitigate suicide
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Potential Guidelines for Inclusion
Organization(s)
Country
Guideline
Year
CANMAT guidelines
Canada
Canadian Network for Mood and Anxiety
Treatments (CANMAT) Clinical
guidelines for the management of major
depressive disorder in adults
2009
National Institute for Health and
Care Excellence
UK
The treatment and management of
depression in adults
2009
Scottish Intercollegiate Guidelines
Network
UK
Non-pharmaceutical management
of depression in adults
2010
British Association of
Psychopharmacology
UK
Evidence-based guidelines for treating
depressive disorders with antidepressants: A
revision of the 2008 British Association for
Psychopharmacology guidelines
2015
American Psychiatric Association
USA
Treatment of Patients With
Major Depressive Disorder
2010
VA/DoD Clinical Practice Guideline
USA
Management of Major Depressive Disorder
2008
Melbourne: beyondblue: the
national depression initiative
Australia
Clinical practice guidelines for adolescents
and young adults
2011
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PRIORITIZATION OF KEY
AREAS FOR QUALITY
STANDARD
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Interventions
Population
People with
major
depression
aged 18 to 64
years
Assessment and Education
Education and
information
dissemination
Continuity of care
between different levels
of care
Stepped care approach
Non-pharmacological
interventions
Early intervention
services
Timely access to
intervention
Neurostimulation
therapy
Complementary or
alternative therapies
Safety plans to mitigate
suicide
Out of scope
Post partum
depression
Pharmacological
interventions
Adequate course of
treatment
Monitoring of
intervention
Treatment of relapse
Sequencing
antidepressants
Self management
strategies
Young children
Peer support/caregiver
support
Recovery principles
Psychotherapy
Elderly with
major
depression
≥65 years
Promoting recovery
Transition of care
Suicide risk assessment
Multidisciplinary group
for co-morbidities
Adolescents
with major
depression
Miscellaneous
Prevention of
depression
Screening of
depression
Secondary Key Areas
Primary Key Areas for
Quality Standard
(Max. 10)
Considerations for prioritization:
1. Potential to improve health outcomes
or health resources
2. Variation in current practice
3. Maintenance of important current
standards of care
Out of Scope
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Secondary Key Areas
Patient preferences to
therapy
Caregiver support
Peer support
Recovery principles
Transition of care
Complementary
therapies
Self management
strategies
Primary Key Areas
Assessing response and
adequacy of treatment
Comorbidities
Safety plans to mitigate
suicide
Psychotherapy
Timely access to care
Neurostimulation
therapy
Young children
Adolescent
management
Stepped care approach
Suicide risk
assessment
Prevention of
depression
Continuity of care
Assessment &
Monitoring
Sequencing
antidepressants
Screening for
depression
Treatment of relapse
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Antenatal / Post
partum depression
Key priority areas identified by expert
panels for developing quality statements:
Depression
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Timely access to care
Assessment – including suicide risk
Monitoring and timing of treatment
Safety plans to mitigate suicide risk
Psychotherapy – including CBT, IPT
Sequencing antidepressants – including
dosage, augmentation, frequency of
assessment, adjunctive therapy, switching
Psychosocial support
Neurostimulation therapy – including rTMS,
ECT
Preventing relapse
Transitions and continuity of care – including
adolescent management
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