Depression complexity prevalence and outcomes among veterans affairs patients in integrated primary care.

INTRODUCTION: The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/posttraumatic stress disorder (PTSD) and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder). METHOD: We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at 7 months. RESULTS: At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared with patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up. DISCUSSION: A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should co-ordinate and individualize care for these patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Yield of practice-based depression screening in VA primary care settings.

BACKGROUND: Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis. OBJECTIVE: We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression. DESIGN: Baseline enrollees in a group randomized trial of implementation of collaborative care for depression. PARTICIPANTS: Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states. MEASUREMENTS: PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions. RESULTS: Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months). CONCLUSIONS: Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Human subjects protection issues in QUERI implementation research: QUERI Series.

BACKGROUND: Human Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research. METHODS: In 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge. RESULTS: There are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis. DISCUSSION: Specific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.

The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation.

OBJECTIVES: Suffering from waning demand, poor quality, and reform efforts enabling veterans to "vote with their feet" and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA's transformation. METHODS: We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery. RESULTS: Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times. CONCLUSIONS: Although VA's quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains.

Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities.

National smoking cessation guidelines include recommended strategies for providers and health care organizations, but they offer little guidance on how to structure care. We conducted a cross-sectional survey at 40 Veterans Health Administration facilities, to describe the structure of smoking cessation care, to assess adherence to national guidelines, and to assess facilities' preferred approach to providing smoking cessation treatment. We categorized sites as those using a primary care approach (most smokers treated by the primary care provider) versus a specialty approach (medication restricted to smoking cessation clinics, to which most patients were referred). Nearly all sites reported systematic screening for smoking and counseling of smokers, usually by both nursing staff members and the primary care provider. Most sites used a specialty approach, restricting medication access to smokers attending a cessation program. Future research should evaluate whether this approach provides adequate access and responsiveness to patient preferences for the full population of smokers in primary care.

Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation.

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%). Forty-five percent reported a quit attempt in the prior year. While nearly two thirds of smokers reported being counseled about cessation within the past year, only 29% were referred to a cessation program, and 25% received a prescription for nicotine patches. Tobacco control efforts within this population should focus on increasing the rate of assisting patients with quitting.

What patient population does visit-based sampling in primary care settings represent?

BACKGROUND: Evaluations of outpatient interventions often rely on consecutive sampling of clinic visitors, and assume that study results generalize to the population of patients cared for. OBJECTIVE: The representativeness of such visit-based sampling compared with the population of patients seen during the same year, in terms of sociodemographic and clinical characteristics of the user groups that visit-based sampling yielded were assessed. METHODS: One thousand five hundred forty-six continuing patients visiting the primary care firms in an urban VA medical center were consecutively sampled, and visit frequencies were compared for these patients with subsets of the patient population. Administrative and survey data was then used to describe the types of patients visit-based sampling most represented compared with the types of patients sampled less frequently. RESULTS: The average sampled patient visited the firms significantly more often than patients in the reference population (18.7 vs. 9.5). Sampled patients were significantly older (>55 years), in poorer health (higher prevalence of cancer, stroke, hypertension), less likely to smoke, and more likely to be single than the average patient visiting the firms (P<0.05). Adjusting for age and sickness, frequent visitors were more apt to have experienced continuity of care during the prior year, to prefer VA care, and to be unemployed. CONCLUSIONS: Consecutive visit-based sampling actually selected patients with a visit pattern more typical of the patient population visiting four or more times a year. Studies using sampling of consecutive visitors will typically under-represent low users of care and should account for the degree to which results may not generalize to the broader practice population.