Implementation Study Example

1
Implementation Study Example

• Geoffrey M. Curran, PhD
• Associate Professor, Department of Psychiatry,
  UAMS
• Research Health Scientist, CAVHS

2
But First

• QUERI (Quality Enhancement Research Initiative
• Within HSRD Service To enhance the quality,
  outcomes, and efficiency of VA health care by
  systematically facilitating the implementation of
  evidence-based research findings into routine
  clinical practice.
• Focus on Implementation Research
• Service Directed Project (SDP)
• Own mechanism for Implementation Research!
• Own solicitation and review criteria!
• People in Little Rock review for this committee!

3
SDP Solicitation3 Years for 900,000 max

• Evaluate specific programs and strategies
• Develop evidence and insight about effective
  implementation approaches
• Create sustainable tools, processes, and
  infrastructure that support improved quality
  and/or adoption of best practices

Also an RRP for 50,000
4
QUERI Phases of Implementation Research
Implementation Research
Phase 1 Pilot Projects
Phase 2 Small-Scale Demonstrations
Phase 3 Regional Demonstrations
Phase 4 National Rollout
Multiple Sites 1 VISN
Multiple Sites Multiple VISNs
1 Site
5
Translating Depression Guidelines into SUD
Treatment

• This study tested a change process for the
  adoption of EBPs to manage MDD in VA SUT
• 2 intervention/2 comparison sites
• Intervention sites
• Program collaboration to customize practices and
  implementation strategy (Development panel)
• Needs/barriers/facilitators assessment
• Expert panel input
• Development of educational tools (staff/patient)
• Clinical Reminder
• Local champion
• Comparison sites
• passive dissemination of guidelines/tools

6
So, the change process tried to help programs

• Introduce formalized screening for non-substance
  induced depression (NSID??) using PHQ-9 (or
  similar) augmented by additional questions
  concerning history of depression
• 2-stage screening (intake and 2-3 weeks later for
  minority of cases)
• Introduce system of routing persons with
  positive screens to psychiatrist for assessment
  and medication initiation as recommended in
  guidelines

7
We measured

• Implementation quality/speed
• Stakeholders thoughts/feelings
• Patient outcomes

8
Implementation at Site A

• 30 days 30 misses on intake, multiple miscodes
  and misreferrals, re-screens 0, some staff
  confusion
• 60 days coding issue fixed, intake up to
  85-90 , re-screens unreliable, Docs like
  reminders
• 6 months the same as 60 days

9
Implementation at Site B

• First 2 weeks Initial screens 95,
  re-screens most done incorrectly
• 30 days intake still good, re-screens working ,
  referrals working smoothly
• 60 days stable part of routine care

10
Qualitatively speaking These issues appeared
linked adoption success

• Positive Leadership structure, intensity,
  frequency, and validity
• Less Turnover (especially management)
• Non-redundant structuring of patient care
• Involved and accessible local champion

11

• A manuscript from this study with multiple
  lessons learned is in the works, but one issue to
  definitely consider is

• How to choose which sites to consider/ approach?
• Curran Hold em or Fold em 2-item Implementation
  Screener
• Might not work for research projects, but perhaps
  for dissemination/implementation projects

12

• Ask the Chief of Service
• 1) How long have you been in your current
  position?
• 2) How long was your predecessor in their
  position?

If the sum of the answers to these questions is
less than 2 years
13
Fold em
14
New SDP

• Training SUD Counselors CBT for Depression
• Web-based manual for SUD counselors
• Original manual from RAND group in LA
• Accompanying supervision plan
• MyHealheVet workbook for vets in group