Translating Initiatives in Depression into Effective Solutions (TIDES) Regional Expansion Project
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Translating Initiatives in Depression into Effective
Solutions (TIDES)Regional Expansion Project
Lisa Rubenstein, MD, MSPH9/13/05
Quality Enhancement Research Initiative
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0% 4% 8% 12%
16% 20% 24%
All Other Causes of DisabilityMigraineDiabetes
Cancer (Malignant neoplasms)Communicable Diseases
Digestive DiseasesInjuries (Disabling)
Sense Organ DiseasesCardiovascular Diseases
Respiratory DiseasesMusculoskeletal Diseases
Alzheimer’s Disease and DementiasAlcohol and Drug Use DisordersMental IllnessesMental Illnesses
Impact of Mental Illnesses (of which depression is the most
prevalent)Causes of DisabilityCauses of Disability / United States, Canada, and
Western Europe, 2000 (WHO)
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Efficacy
Effectiveness Quality Improvement
Routine Care
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Experimental Treatment
BASELINE OUTCOME
EXPERIMENTAL PATIENTS
Care Model In Place
USUAL CARE PATIENTS
Is Depression Treatment Efficacious?
Patients Randomized
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Depression Efficacy Research
• Two types of treatment efficacious in randomized clinical trials– Antidepressants– Short-term, manualized psychotherapy
• CBT, IPT
• But studies showed low quality of care, variations, disparities
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Efficacy
QII Effectiveness Quality
Improvement
Routine Care
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POPULATION OF DEPRESSED PATIENTS
VISITING STUDY PRACTICE
Researcher- Designed
Intervention BASELINE OUTCOME
EXPERIMENTAL PATIENTS
Care Model In Place
USUAL CARE PATIENTS
Is a Quality Improvement Intervention Effective?
Patients Randomized
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Effectiveness of QII’s for Depression
• Studies randomized at the patient level• Interventions that don’t improve quality
– Clinician education– Screening and feedback– Computer reminders
• Collaborative care is effective– A multicomponent model– Works for elderly, adolescents, minorities
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Collaborative Care for Depression
Primary Care
Mental Health Specialty
Nurse Care Manager Patien
t
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Efficacy
Effectiveness Quality Improvement
Routine Care
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POPULATION OF DEPRESSED PATIENTS
VISITING EXPERIMENTAL
PRACTICESCLINICAL PARTNERS TRAINED TO CARRY OUT THE INTERVENTION
Researcher- Designed
InterventionBASELINE OUTCOME
EXPERIMENTAL PATIENTS
Care Model In Place
POPULATION OF DEPRESSED PATIENTS VISITING USUAL CARE
PRACTICES
USUAL CARE PATIENTS
Is Collaborative Care Cost-Effective When Adopted by Practices?
Practices Randomized
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Between Effectiveness and Quality Improvement
• Collaborative care is effective and cost-effective– True for large, small, rural, urban,
managed care and other types of practices
– Researchers developed the tools and trained organizations
– Practices implemented the intervention for randomized patients
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Efficacy
Effectiveness Quality Improvement
Routine Care
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Do Outcomes Improve When Practices Design and Implement Improved
Depression Care?• If a QI process (e.g., CQI) is
convened by researchers, can practices improve?– Without specific attention to the QII
evidence base– When effective QII tools, consultation
are made available
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Clinical Partner Intervention
QI DESIGN
PROCESS
Researcher Intervention
CARE MODEL START-UP
BASELINE OUTCOME
CARE MODEL IN PLACE
DEPRESSED PATIENT POPULATION VISITING USUAL CARE PRACTICES
RANDOMLY ASSIGNED PRACTICES
DEPRESSED PATIENT POPULATION VISITING
EXPERIMENTAL PRACTICES
BASELINE OUTCOME
EXPERIMENTAL SAMPLE
USUAL CARE SAMPLE
USUAL CARE SAMPLE
EXPERIMENTAL SAMPLE
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Quality Improvement Process Success
• Can sites design effective depression care improvement?– Using local CQI-- NO– By reviewing and adapting tools and
literature on collaborative care-- +
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Efficacy
Effectiveness Quality Improvement
Routine Care
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Can System-Designed Collaborative Care Improve
Clinical Outcomes?• Connected to business and strategic
plans• Technical and communication
assistance still needed– Researcher role envisioned as presaging
consultant role
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CARE MODEL START-UPQI DESIGN
PROCESS
Researcher Intervention
Clinical Partner Intervention
Researcher Support PDSA CYCLES
CONTINUOUS PRE-POST F/U OF
PATIENTS RECEIVING INTERVENTION
QUARTERLY REPORTS
POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICESCARE MODEL IN PLACE
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Between Quality Improvement and Routine
Care• VA VISN design and implementation
– TIDES (intervention)– WAVES (randomized substudy)– COVES (stakeholder cost and value)– CHIACC (informatics)
• Can TIDES be spread and sustained?– ReTIDES (regional spread of TIDES)
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TIDES Short List• Mental Health QUERI: Rick Owen • PI’s: Lisa Rubenstein, Edmund Chaney,
JoAnn Kirchner • Investigators: Elizabeth Yano, John
Williams, Fen Liu, Mona Ritchie, Susan Vivell, Louise Parker, Laura Bonner, Barbara Simon, Martin Lee
• Organizational Leaders: Randy Petzel, Clyde Parkis, Kathy Henderson, Ken Clark, Susan McCutcheon
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02468
101214
Baseline 1 month 3 months 6 months
Baseline1 month3 months6 months
Results for First 600 Patients
DepressedDepressed
AsymptomaticAsymptomatic
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Regional TIDES Expansion (ReTIDES)
• Expand TIDES to – Medical centers/practices – One new VISN
• Initiate national implementation– Business case– Tools– Connections to appropriate national
leadership bodies
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Top Down, Bottom Up
• Top down approach only effective in VA when the bottom up has already been built
• Continuous interaction between local and national initiatives– There is no “hand off” from research to
a clinical entity
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Congress
Undersecretary for Health, Veterans Health
Administration
National Leadership
Council
Employee Education
Information Services
Nursing Service
Patient Care Services
Primary Care Mental Health Specialty
Office of Care Coordination
National Guideline Council
Office of Quality and
Performance
Seriously Mentally Ill Committee
22 Veterans Integrated
Service Networks
VA National Groups Working with TIDES
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VAMC(3,836 PC Patients)
VAMC(5,470 PC Patients)
VAMC(12,963 PC Patients)
CBOC(4,906 PC Patients)
CBOC(5,856 PC Patients)
CBOC(10,122 PC Patients)
CBOC(7,604 P PC Patients)
CBOC(12,329 PC Patients)
CBOC(7,700 PC Patients)
VAMC(5,355 PC Patients)
Intervention Sites
Control Sites
TIDES Primary Care Clinic Sites
2 new VAMC’s (90,000 PC Patients)
9 New VAMC’s (90,000 PC Patients)
2 New VAMC’s (40,000 PC Patients)
2 New VAMC’s (40,000 PC Patients)
ReTIDES Spread
VISN MAP of TIDES and ReTIDES
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ReTIDES Evaluation Measures
• Semi-structured stakeholder interviews
• Clinician web-based survey• System utilization and costs • Performance measure-based
evaluation
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Performance Measure Evaluation
• Electronic data only• Includes
– HEDIS measures– Fine-tuned measures
• Comparison group– Matched practices from a usual care
VISN
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ReTIDES Performance Measure Evaluation Design
• Untreated non-equivalent control group design, pretest & postest measures at multiple time intervals
O1 02 X 03 04 O1 02 03 04
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CARE MODEL START-UP
QI DESIGN PROCESS
Researcher Intervention
Clinical Partner Intervention
Researcher Support
Usual Care
Usual Care
PERFORMANCE MEASURES
PERFORMANCE MEASURES
Experi-mental
01 02
01 02
03 04
03 04
Care Model In Place
Experi-mental
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Threats to Current Design• Performance measures are imprecise
relative to the intervention– Positive only if scope and quality of QII
are high– Negative if intervention was “good” but
too small to affect full practices• Usual threats of non-randomized
designs– Mitigated by multiple measures and
comparison group
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Why Better than Randomized for the Purpose?
• Previous randomized trials provide a strong evidence base– Low gain of one more randomized trial
vs. learning about and fostering system implementation
• Randomization is artificial– Constrains naturalistic decision-making
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Efficacy
Effectiveness Quality Improvement
Routine Care
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