Comparative effectiveness study of practice based vs telemedicine based depression collaboratives
This presentation is the property of its rightful owner.
Sponsored Links
1 / 24

John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD PowerPoint PPT Presentation


  • 44 Views
  • Uploaded on
  • Presentation posted in: General

Comparative Effectiveness Study of Practice-Based vs. Telemedicine-Based Depression Collaboratives. John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD Division of Health Services Research Department of Psychiatry University of Arkansas for Medical Sciences.

Download Presentation

John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Comparative effectiveness study of practice based vs telemedicine based depression collaboratives

Comparative Effectiveness Study of Practice-Based vs. Telemedicine-BasedDepression Collaboratives

John Fortney, PhD

Jeff Pyne, MD

Dinesh Mittal, MD

Teresa Hudson, PharmD

Division of Health Services Research

Department of Psychiatry

University of Arkansas for Medical Sciences


Funding

Funding

  • National Institute of Mental Health

    • R01 MH076908


Partnership

Partnership

  • Community Health Centers of Arkansas

    • Boston Mountain Rural Health Centers Inc.

    • Community Clinic at St Francis House

    • Corning Area Healthcare Inc.

    • East Arkansas Family Health Center Inc.

    • Jefferson Comprehensive Healthcare System Inc.

  • University of Arkansas for Medical Sciences

    • Department of Psychiatry

      • Division of Health Services Research


Practice based depression collaborative

Practice-Based Depression Collaborative

  • 20/28 randomized trials of depression collaboratives significantly improved outcomes1:

    • Median effect for response: +18%

    • Median effect for remission: +16%

      1) Williams J et. al. Systematic review of multifaceted interventions to improve depression care. General Hospital Psychiatry, 29, 91-116, 2007


Components of practice based depression collaborative

Components of Practice-Based Depression Collaborative

  • Provider education

  • Screening

  • Patient education, activation, and self-management

  • Regularly scheduled follow-up assessments

  • Use of clinical information systems and TX guidelines

  • Delegation of key clinical activities to non-physician members of a practice team

  • Ready access to mental health specialists

  • Stepped care


Barriers to implementing practice based depression collaborative in chcs

Barriers to Implementing Practice-Based Depression Collaborative in CHCs

  • On-site mental health specialists are typically unavailable.

  • Linkages to off-site mental health specialists are weak.

  • Depression Collaboratives are more effective if they include MH services1.

  • Depression Collaborative is effective in urban practices, but NOT rural practices.2

    1) Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine 2006;166:2314-21.

    2) Adams S, Xu S, Dong F, Fortney J, Rost K. Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients, Journal of Rural Health, 2006 22(4):343-50.


Telemedicine based depression collaborative

Telemedicine-Based Depression Collaborative

  • Offsite depression care team at UAMS Dept. of Psychiatry

    • Nurse care manager

    • Pharmacist

    • Psychologist

    • Psychiatrist

  • Telephones

    • Care manager encounters with patients at home

  • Interactive Video

    • Evidence-Based Psychotherapy with patients at CHC

    • Psychiatric evaluations with patients at CHC

  • Web-based Decision Support System for Care Manager

    • NetDSS


Netdss https www netdss net

NetDSS - https://www.NetDSS.net/

  • NetDSS has the following functional capabilities:

    • patient registry and panel management

    • trial and phase management

    • encounter scheduler

    • decision support

    • progress note generator

    • Workload/Outcomes report generator

  • NetDSS guides the care manager through a self-documenting and evidence-based patient encounter using scripts and self-scoring instruments which support:

    • patient education and activation

    • barrier assessment

    • comorbidity assessment

    • depression severity monitoring

    • suicide risk assessment

    • adherence monitoring

    • side-effect monitoring

    • self-management activities


Comparison of models

Comparison of Models


Advantages and disadvantages of telemedicine based depression collaborative

Advantages and Disadvantages of Telemedicine-Based Depression Collaborative


Research question

Research Question

  • Compare outcomes of telemedicine-based depression collaborative to practice-based depression collaborative.


Exclusion criteria

Exclusion Criteria

  • Self-reported treatment with MH specialist

  • Self-reported Schizophrenia

  • Self-reported bereavement

  • Self-reported pregnancy/post partum

  • Bipolar Disorder (MDQ)

  • Substance Dependence (MINI)

  • Cognitive Impairment (Blessed)

  • Acute Suicide Ideation (HRSA risk assessment)

  • No phone


Enrollment flowchart

9 Primary Care Practices

54,145 Patient Visits

PHQ9 Screens

19,285 (36%)

Positive Screens

2,863 (15%)

Eligible/enrolled

364 (55%)

Consented

829 (62%)

6-Month Follow-Up

316 (87%)

Ineligible

316 (45%)

12-Month Follow-Up

271 (82%)

Not located/refused

134 (16%)

18-Month Follow-Up

193 (88%)

Enrollment Flowchart


Demographic characteristics

Demographic Characteristics


Clinical characteristics

Clinical Characteristics


Face to face service utilization

Face to Face Service Utilization

Specialty MH Encounters

Depression PC Encounters


Tele mental health utilization

Tele-Mental Health Utilization

  • Tele - Cognitive Behavioral Therapy

    • 30 (17%) had an interactive video encounter

      • 33% Completed CBT manual

      • 47% Attended ≥ 8 sessions

      • 53% Dropped out and attended <8 sessions

    • 422 scheduled interactive-video sessions

      • 57% Interactive-video sessions attended

      • 40% Interactive-video sessions canceled by patients

      • 3% Canceled due to technical difficulties

  • Tele - Psychiatric Evaluations

    • 22 (12%) following two failed trials

      • 45% had an interactive video encounter

      • 55% had a telephone encounter

    • 5 (3%) for telephone suicide risk assessment


Care manager fidelity telemedicine based depression collaborative

Care Manager FidelityTelemedicine-Based Depression Collaborative

  • Completed Baseline Assessments – 94.5%

  • Completed Follow-ups

    • Acute Stage – 1,191 (74%)

      • Mean days between assessments = 24 days

    • Continuation Stage – 295 (86%)

      • Mean days between assessments = 32 days

  • Final Disposition

    • 49% - Remitted and completed continuation phase

    • 12% - Responded and completed continuation phase

    • 12% - Did not respond within twelve months or relapsed

    • 2% - Requested deactivation

    • 25% - Baseline assessment not completed or lost to follow-up


Care manager fidelity practice based depression collaborative

?Care Manager Fidelity?Practice-Based Depression Collaborative

  • NetDSS

    • Only 3 sites Used NetDSS

  • HRSA Patient Electronic Care System

    • Only 4 Sites Reporting Data

  • Patient Self-Report

    • Inaccurate

  • Chart Review

    • Currently underway


Six month follow up response and remission rates n 318

Six Month Follow-upResponse and Remission Rates (n=318)

OR=6.0

p<0.0001

OR=10.5

P<0.0001


Twelve month follow up response and remission rates n 269

Twelve Month Follow-upResponse and Remission Rates (n=269)

OR=5.3

p<0.0001

OR=3.6

P=0.0003


Eighteen month follow up response and remission rates n 192

Eighteen Month Follow-upResponse and Remission Rates (n=192)

OR=16.7

p<0.0001

OR=10.8

P<0.0001


Conclusions

Conclusions

  • Telemedicine-based depression collaborative required few PC visits than practice-based depression collaborative.

  • Telemedicine-based depression collaborative is more clinically effective than practice-based depression collaborative.

  • CHCs and CHCA should consider pooling resources to fund off-site depression care team.


Future research

Future Research

  • Partnership for Implementation of Evidence-Based Practices (EBPs)

    • NIMH R24 MH085104

  • Objectives

    • Develop and sustain an Implementation Partnership to promote the adaptation, adoption, and evaluation of EBPs

    • In two Demonstration Projects, use QI methods to implement EBPs for Bipolar Disorder and Alcohol Use Disorders


  • Login