Translating Initiatives in Depression into Effective

Solutions (TIDES)Regional Expansion Project

Lisa Rubenstein, MD, MSPH9/13/05

Quality Enhancement Research Initiative

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)

Efficacy

Effectiveness Quality Improvement

Routine Care

Experimental Treatment

BASELINE OUTCOME

EXPERIMENTAL PATIENTS

Care Model In Place

USUAL CARE PATIENTS

Is Depression Treatment Efficacious?

Patients Randomized

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

Efficacy

QII Effectiveness Quality

Improvement

Routine Care

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

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

Collaborative Care for Depression

Primary Care

Mental Health Specialty

Nurse Care Manager Patien

t

Efficacy

Effectiveness Quality Improvement

Routine Care

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

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

Efficacy

Effectiveness Quality Improvement

Routine Care

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

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

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-- +

Efficacy

Effectiveness Quality Improvement

Routine Care

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

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

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)

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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101214

Baseline 1 month 3 months 6 months

Baseline1 month3 months6 months

Results for First 600 Patients

DepressedDepressed

AsymptomaticAsymptomatic

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

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

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

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

ReTIDES Evaluation Measures

• Semi-structured stakeholder interviews

• Clinician web-based survey• System utilization and costs • Performance measure-based

evaluation

Performance Measure Evaluation

• Electronic data only• Includes

– HEDIS measures– Fine-tuned measures

• Comparison group– Matched practices from a usual care

VISN

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

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

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

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

Efficacy

Effectiveness Quality Improvement

Routine Care