1. Translating Initiatives in Depression into Effective Solutions (TIDES) Regional Expansion Project Lisa Rubenstein, MD, MSPH 9/13/05 Quality Enhancement Research Initiative

2. Impact of Mental Illnesses (of which depression is the most prevalent) Causes of Disability Causes of Disability / United States, Canada, and Western Europe, 2000 (WHO)

3. Efficacy EffectivenessQuality Improvement Routine Care

4. Experimental Treatment BASELINEOUTCOME EXPERIMENTAL PATIENTS Care Model In Place USUAL CARE PATIENTS Is Depression Treatment Efficacious? Patients Randomized

5. 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

6. Efficacy QII Effectiveness Quality Improvement Routine Care

7. POPULATION OF DEPRESSED PATIENTS VISITING STUDY PRACTICE Researcher- Designed Intervention BASELINEOUTCOME EXPERIMENTAL PATIENTS Care Model In Place USUAL CARE PATIENTS Is a Quality Improvement Intervention Effective? Patients Randomized

8. 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

9. Collaborative Care for Depression Primary Care Mental Health Specialty Nurse Care Manager Patien t

10. Efficacy EffectivenessQuality Improvement Routine Care

11. POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICES CLINICAL PARTNERS TRAINED TO CARRY OUT THE INTERVENTION Researcher- Designed Intervention BASELINEOUTCOME 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

12. 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

13. Efficacy EffectivenessQuality Improvement Routine Care

14. 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

15. Clinical Partner Intervention QI DESIGN PROCESS Researcher Intervention CARE MODEL START-UP BASELINEOUTCOME CARE MODEL IN PLACE DEPRESSED PATIENT POPULATION VISITING USUAL CARE PRACTICES RANDOMLY ASSIGNED PRACTICES DEPRESSED PATIENT POPULATION VISITING EXPERIMENTAL PRACTICES BASELINEOUTCOME EXPERIMENTAL SAMPLE USUAL CARE SAMPLE EXPERIMENTAL SAMPLE

16. 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-- +

17. Efficacy EffectivenessQuality Improvement Routine Care

18. 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

19. CARE MODEL START-UP QI 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 PRACTICES CARE MODEL IN PLACE

20. 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)

21. 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

22. Results for First 600 Patients Depressed Asymptomatic

23. 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

24. 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

25. 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

26. 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

27. ReTIDES Evaluation Measures Semi-structured stakeholder interviews Clinician web-based survey System utilization and costs Performance measure-based evaluation

28. Performance Measure Evaluation Electronic data only Includes –HEDIS measures –Fine-tuned measures Comparison group –Matched practices from a usual care VISN

29. ReTIDES Performance Measure Evaluation Design Untreated non-equivalent control group design, pretest & postest measures at multiple time intervals O102 X 03 04 O1020304

30. CARE MODEL START-UP QI DESIGN PROCESS Researcher Intervention Clinical Partner Intervention Researcher Support Usual Care PERFORMANCE MEASURES Experi- mental 0102 0102 0304 0304 Care Model In Place Experi- mental

31. 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

32. 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

33. Efficacy EffectivenessQuality Improvement Routine Care