Health Quality Ontario The provincial advisor on the quality of health care in Ontario 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

1 Objectives 1.Project scope 2.Methods for the development of quality statements –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

PROJECT SCOPE

3 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 ( 80 years) including adults in long term care; pregnant women. Prevention and screening of major depression. Project Scope

First NameLast NameAffiliationSpecialization PierreBlierThe Royal's Institute of Mental Health Research (Royal Ottawa)Psychiatry PeterVooreCentre for Addiction and Mental Health (CAMH)Psychiatry AndrewWiensThe RoyalGeriatric Psychiatry PaulinePariserTaddle Creek Family Health Team, UHNPrimary Care SidneyKennedyUniversity Health Network, University of Toronto, St. Michael's HospitalResearch SonuGaindHumber River Hospital, Canadian Psychiatric Association, University of TorontoPsychiatry NeilRectorForest Hill Centre for Cognitive Behavioural TherapyPsychology Marie-HélèneChomienneUniversity of Ottawa, Hôpital MontfortPrimary Care CrystalKaukinenLakehead NPLCNursing KathrynLefermanErie St. Clair CCACAdmin PaulLinksSt. Joseph's Health CarePsychiatry GillianYoungCAMHAdmin AriZaretskySunnybrook Health Sciences CentrePsychiatry RajRasasinghamUniversity of Toronto - Division of Child Psychiatry, Humber River HospitalPsychiatry DebbieBauerPrivate Practice SonjaGrbevskiHotel Dieu Grace HealthcareAdmin SandieLeithCMHA - Sault Ste. Marie BranchAdmin RachelCooperSt. Michael's Hospital, Stella's PlacePatient Advocate AliciaRaimundoStudentPatient Advocate AnitaBarnesNeighbourhood Legal ServicesPatient Advocate

METHODS FOR THE DEVELOPMENT OF QUALITY STANDARDS

6 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 Methods: Identification of Key Areas

7 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, 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. Key area for quality improvement Why is this important? Why is this a key area for quality improvement? Supporting information (e.g., guidelines, reviews, studies, reports, data sources) Please list up to 5 key areas for quality improvement that you would want to see covered by the expert panel.

8 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

9 For each prioritized key area: Summary of relevant recommendations and guidance statements 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. Evidence review If limited or no evidence exists for a key area, the CE will ideally conduct an evidence review using the most appropriate review method. Establishment of consensus If there is no evidence, the panel may wish to: Use expert consensus Note prioritized key area for future consideration Methods: Review of Evidence

10 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 Methods: Review of Evidence 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

11 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 Methods: Review of Evidence

12 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 Methods: Drafting of Quality Statements

13 A ‘good’ quality statement should be: 1.Measurable 2.Specific (e.g., clearly defined population) 3.Concise 4.Patient-oriented Adults with non-ST-segment- elevation 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. Adults with myocardial infarction or unstable angina are assessed for their risk of future adverse cardiovascular events. vs Methods: Drafting of Quality Statements

14 The panel will agree upon 5–10 quality statements for publication within the quality standard and clinical handbook Methods: Finalization of Quality Statements

RESULTS OF TOPIC PRIORITIZATION SURVEY

16 Results of Topic Prioritization Survey Topic AreaKey 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

17 Potential Guidelines for Inclusion Organization(s)CountryGuidelineYear CANMAT guidelinesCanadaCanadian 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 UKThe treatment and management of depression in adults 2009 Scottish Intercollegiate Guidelines Network UKNon-pharmaceutical management of depression in adults 2010 British Association of Psychopharmacology UKEvidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines 2015 American Psychiatric AssociationUSATreatment of Patients With Major Depressive Disorder 2010 VA/DoD Clinical Practice GuidelineUSAManagement of Major Depressive Disorder2008 Melbourne: beyondblue: the national depression initiative AustraliaClinical practice guidelines for adolescents and young adults 2011

PRIORITIZATION OF KEY AREAS FOR QUALITY STANDARD

People with major depression aged 18 to 64 years Population Non-pharmacological interventions Complementary or alternative therapies Psychotherapy Neurostimulation therapy Out of scope Post partum depression Young children Adolescents with major depression Pharmacological interventions Monitoring of intervention Adequate course of treatment Assessment and Education Education and information dissemination Suicide risk assessment Multidisciplinary group for co-morbidities Miscellaneous Early intervention services Continuity of care between different levels of care Stepped care approach Safety plans to mitigate suicide Timely access to intervention Promoting recovery Transition of care Recovery principles Elderly with major depression ≥65 years Interventions Peer support/caregiver support Prevention of depression Screening of depression Treatment of relapse Self management strategies Sequencing antidepressants

20 Out of Scope 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

21 Primary Key Areas Secondary Key Areas Comorbidities Safety plans to mitigate suicide Timely access to care Adolescent management Treatment of relapse Sequencing antidepressants Psychotherapy Caregiver support Assessment & Monitoring Transition of care Suicide risk assessment Complementary therapies Patient preferences to therapy Recovery principles Neurostimulation therapy Stepped care approach Peer support Young children Antenatal / Post partum depression Prevention of depression Screening for depression Assessing response and adequacy of treatment Continuity of care Self management strategies

22 Key priority areas identified by expert panels for developing quality statements: Depression –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