Implementation and maintenance of quality improvement for treating depression in primary care.

OBJECTIVE: Little is known about the long-term success of quality improvement efforts for the treatment of depression in primary care. This study assessed factors associated with the successful implementation, maintenance, and spread of such efforts. METHODS: The authors conducted an independent process evaluation of data from monthly progress reports and 18-month telephone interviews from multidisciplinary quality improvement teams in 17 diverse primary care organizations that participated in the Institute for Healthcare Improvement's Breakthrough Series for Depression from February 2000 through March 2001. RESULTS: All sites made changes toward improving care in three of six categories: delivery system redesign, self-management strategies, and information systems. The changes that were most commonly viewed as major successes were delivery system changes (ten sites, or 59 percent) and information system changes (nine sites, or 53 percent); these types of changes were also the most often sustained over time (ten sites, or 59 percent, and 16 sites, or 94 percent, respectively). Fifteen sites made changes in decision support, community linkages, and health system support but were less likely to view these changes as major successes or to sustain them. Organizational structure and leadership support were the most common facilitators. Staff resistance, time constraints, and information technology were the most common barriers. Implementation strategies varied with sets of barriers. CONCLUSIONS: Despite substantial challenges, there was evidence of broad success at implementation and maintenance of quality improvement for depression treatment in primary care.

Experiencing interpersonal violence: perspectives of sexually active, substance-using women living in shelters and low-income housing.

As part of a larger study, the authors investigated experiences of recent violence among sexually active, substance-using women. Structured interviews were conducted with 172 women living in shelters and low-income housing, 41 of whom also completed an in-depth interview on their worst violent episode. Structured interviews indicated that rape and self-blame were more common among sheltered women. In-depth interviews suggested that sheltered women were vulnerable to instrumental aggression from a range of perpetrators, whereas housed women tended to experience hostile partner aggression. Intoxication during the violent episodes was more common among sheltered women. Implications for violence prevention and treatment services are discussed.

Functional characteristics of commercial ambulatory electronic prescribing systems: a field study.

OBJECTIVE: To compare the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations. DESIGN: A descriptive field study of ten commercially available ambulatory electronic prescribing systems, each of which had established a significant market presence. Data were collected from vendors by telephone interview and at sites where the systems were functioning through direct observation of the systems and through personal interviews with prescribers and technical staff. MEASUREMENTS: The capabilities of electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. Each recommended capability was judged as having been implemented fully, partially, or not at all by each system to which the recommendation applied. Vendors' claims about capabilities were compared with the capabilities found in the site visits. RESULTS: On average, the systems fully implemented 50% of the recommended capabilities, with individual systems ranging from 26% to 64% implementation. Only 15% of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96% sensitivity and a 72% specificity when site visit findings were considered the gold standard. CONCLUSIONS: The commercial electronic prescribing marketplace may not be selecting for capabilities that would most benefit patients. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards may need to take place where systems are installed and operating.