# Presentation: 175712

## Translating Initiatives in Depression into Effective Solutions (TIDES)Regional Expansion Project

**Lisa Rubenstein, MD, MSPH**
**9/13/05**

**Notes:**
Good morning. 

## Impact of Mental Illnesses (of which depression is the most prevalent)

**Impact of Mental Illnesses ****(of which depression is the most prevalent)**

**Causes of Disability**** / **United States, Canada, and Western Europe, 2000 (WHO)

**Notes:**
Mental Illness Represents a Costly Disability

As this bar graph shows, when compared with all other diseases (such as cancer and heart disease), mental illnesses rank first in terms of causing disability in the United States, Canada, and Western Europe, according to a study by the World Health Organization (WHO, 2001). 
Depression is the most common mental illness, and impacts the health care system through primary care settings.  Most depressed patients never see a mental health specialist.

This graph shows that 24% of all the “healthy years” lost to disability are due to mental illnesses.

 In the U.S., the economy’s loss of productivity from mental illnesses amounts to $63 billion annually (DHHS, 1999).

**Efficacy**

**Effectiveness**

**Quality                            Improvement**

- Routine Care

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## Is Depression Treatment Efficacious?

**Experimental Treatment**

- 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

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## Is a Quality Improvement Intervention Effective?

**POPULATION OF DEPRESSED PATIENTS VISITING STUDY  PRACTICE**

**Researcher- Designed Intervention**

- 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

- Patient

**Notes:**
THIS SLIDE ILLUSTRATES LINES OF COMMUNICATION AND INTERACTION AMONG THE KEY PLAYERS IN THE COLLABORATIVE CARE MODEL.

IN COLLABORATIVE CARE, PRIMARY CARE CLINICIANS AND PSYCHIATRISTS RECEIVE TRAINING ON EVIDENCE-BASED CARE FOR DEPRESSION AND ON HOW TO INTERACT EFFECTIVELY WITH NURSE CARE MANAGERS.  TOOLS TO ENHANCE CLINICAL DECISION-MAKING AT THE POINT OF CARE ARE ALSO INCLUDED.  

NURSE CARE MANAGERS RECEIVE TRAINING AND TOOLS TO SUPPORT THEIR EFFORTS TO IDENTIFY PATIENT TREATMENT PREFERENCES, MONITOR TREATMENT ADHERENCE AND SIDE EFFECTS, AND ASSESS PATIENT RESPONSE TO CARE ON AN ONGOING BASIS.  THIS INFORMATION  IS SYSTEMATICALLY FED BACK TO PRIMARY CARE CLINICIANS AND MENTAL HEALTH SPECIALISTS TO STIMULATE ADJUSTMENTS TO CARE AS NEEDED.  

MATERIALS FOR PATIENT EDUCATION ON DEPRESSION AND ITS TREATMENT ARE ALSO INCLUDED.

AS THIS GRAPHIC ILLUSTRATES, THE NURSE CARE MANAGER PLAYS A CENTRAL AND CRITICAL ROLE IN COLLABORATIVE CARE BY MAINTAINING REGULAR IN-PERSON AND TELEPHONE CONTACT WITH PATIENTS TO MONITOR THEIR RESPONSE TO CARE AND FACILITATE COMMUNICATION AMONG PATIENTS, PRIMARY CARE, AND MENTAL HEALTH CLINICIANS.

**Efficacy**

**Effectiveness**

**Quality                            Improvement**

- Routine Care

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## Is Collaborative Care Cost-Effective When Adopted by Practices?

**POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICES**

**CLINICAL PARTNERS TRAINED TO CARRY OUT THE INTERVENTION**

**Researcher- Designed Intervention**

**BASELINE **

**OUTCOME **

**EXPERIMENTAL PATIENTS**

**Care Model In Place**

**POPULATION OF DEPRESSED PATIENTS VISITING USUAL CARE 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

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## 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**

## BASELINE 

**BASELINE **

**OUTCOME**

**CARE MODEL IN PLACE**

**DEPRESSED PATIENT POPULATION  VISITING USUAL CARE  PRACTICES**

**RANDOMLY ASSIGNED PRACTICES**

**DEPRESSED PATIENT POPULATION  VISITING EXPERIMENTAL  PRACTICES**

**BASELINE **

**OUTCOME**

## 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

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## 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**

## PDSA CYCLES

**CARE MODEL START-UP**

**QI DESIGN**
** ****PROCESS**

**Researcher Intervention**

**Clinical Partner Intervention**

**Researcher Support**

**CONTINUOUS PRE-POST F/U OF PATIENTS RECEIVING INTERVENTION**

- QUARTERLY REPORTS

**POPULATION OF DEPRESSED PATIENTS VISITING EXPERIMENTAL PRACTICES**

**CARE 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

## Results for First 600 Patients

**Results for First 600 Patients**

**Depressed**

**Asymptomatic**

## 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_

## 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

## Usual Care

- Experi-mental

- 01

- 02

- 01

- 02

- 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

**Notes:**
So I won’t focus on the exact definitions here, but rather on the concept of evolution of scientific knowledge about depression.  I’ll review the earlier stages of depression research, but focus particularly on the yellow area—the difficulties in crossing from effectiveness studies to quality improvement studies.

## Slide 34