Measuring TIDES Implementation and Story. QUERI National Meeting, Dec 2008. Purpose. What is TIDES? Summary of the TIDES intervention/evaluation Did TIDES meet SQUIRE publication standards for quality improvement research?. What is TIDES?.
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Measuring TIDES Implementation and Story QUERI National Meeting, Dec 2008
Purpose • What is TIDES? • Summary of the TIDES intervention/evaluation • Did TIDES meet SQUIRE publication standards for quality improvement research?
What is TIDES? • TIDES is an evidence-based quality improvement project • Means Translating Initiatives in Depression into Effective Solutions • TIDES purpose • Effectiveness of new care models to improve health outcomes for depression already known (over 36 high quality randomized trials) • Can this evidence be used by VA to systematically improve routine VA care?
TIDES As A Research-Clinical Partnership • VA clinical management makes the decisions • Informed by research partners regarding the evidence • Research partners support implementation from a distance • No hands on any practice directly • Assist with development of tools, materials, and training • Assist with quality monitoring
Goals • Design and test a VA context-synchronous and evidence-based care model • Clinical managers as decision-makers • Researchers as evidence reviewers, tool developers and trainers • Use Plan Do Check Act Cycles • Alpha and beta test in 7 CBOCs in 3 VISNs • Stagger implementation by several months • Spread final stable model
Overview of TIDES Story from the Intervention Point of View • In 2000, prior to any funding, Drs. Chaney and Rubenstein began approaching VISNs • Work in the 1990’s showed what was effective • Challenge was to integrate effective models seamlessly into routine care • We conducted planning meetings in six VISNs • Out of six VISNs recruited, three decided to participate
TIDES: Initially A Two-Year QUERI-Funded Project • Began in 2001 • Purpose: Develop a successful prototype VA depression care improvement model based on evidence • Engaged VISNs in QI Planning Expert panel methodology to gain structured VISN input into design • Rubenstein, Joint Commission Journal, HSR • Spread prototype regionally and nationally
TIDES Prototypes • By design, PDSA’s implemented in 7 low complexity CBOCs • Prior research showed complex VA med centers had difficulty implementing high quality primary care • Limited number engaged • Engagement of VISNs and CBOCs was successive, not simultaneous • Theory was to reduce design time for later sites
Comparison Built In • Anticipated a randomized trial • We asked VISNs to identify three to four matched CBOC’s each, and randomly selected two as intervention sites • We later applied for and received HSR&D funding for WAVES • Goal of WAVES was to test the effectiveness of TIDES across representative patients and providers
Success of TIDES and WAVES • TIDES: intervention as developed by VISNs proved viable • Synchronous with VA policies, procedures, and CPRS • Sustained on no research funding for over 1 yr after end of TIDES • Spread throughout one entire VISN on VISN funding alone
ReTIDES (Regional Spread) • Funded 2004 • Goal: Prepare for national implementation • Finalize tools for spread (see poster) • Finalize engagement of Patient Care Services and EES • Assist revision of depression guidelines to address care model issues • Spread to one new VISN
National Implementation • Model taken up nationally in 2006 • Combined with White River Junction collocated care and Behavioral Health Lab method in a national RFP • New mandate (the mental health Uniform Services Package) includes key TIDES and BHL elements (2008) • TIDES is currently active in over 70 practices • 120 clinicians trained in 2007-2008
TIDES Quality Improvement Method: Evidence-Based Quality Improvement • Design choices by VISN leadership based on evidence • Expert panel meeting: Like a collaborative, but focused on regional leadership, key design choices, and evidence • VISN leadership picks sites, hires care managers, engages VISN leadership team who engage local medical center and CBOC leadership & local QI “teams”
Work Groups • Mirrored the Chronic Illness Care Model • Senior leaders, IT, Education and Decision Support, Care Management and Self-Management Support, Collaboration (MH/PC/Nursing) • Supported administratively and technically by researcher team acting as technical experts • Across-VISN work groups support training, tool development
Qualitative and Quantitative Evaluations of TIDES • A series of projects with PI’s/CoPIs including • Ed Chaney, Fen Liu (Seattle) • JoAnn Kirchner, Rick Owen, Mona Ritchie (Little Rock) • John Williams (Durham) • Lisa Rubenstein, Becky Yano, Jackie Fickel (GLA) • Clinical Leaders Randy Petzel, Mike Davies, Cathy Henderson, Clyde Parkis, Susan McCutcheon, Skye McDougal, Ken Clark, Ron Norby, and many others
Data Describing the Intervention and Outcomes • Historical data • Study files kept systematically; ACCESS data bases • E-mails kept and classified • Document review undertaken • Qualitative data • Semi-structured interviews • Site visits • Randomized trial data • Quality improvement data • Performance measure type data • Provider survey data • Organizational administrative and survey data
A C C O U N T A B I L I T Y T I D E S W A V E S C O V E S R I P P L E RET I D E S H I T I D E S QUERI Water PIPELINE Revise Guidelines Depression Care Guidelines Depression Collaborative Care Model PIC, MHAP, MOOD,IMPACT, RESPECT, TEAM Implementation Science Implementation Policy HSR
Cost Data • Planned distribution of labor between clinical partners and technical experts occurred • High number of clinical partners involved • Researchers did more labor • Staggered implementation occurred with somewhat decreasing time to implementation • Intervention costs $$’s
Phases of Quality Improvement Process First Contact Date Expert Panel Date Site Visit Date TIDES1 Implementation Date PDSA Cycle Maintenance BasicDesign Practice Engagement Preparation 6 months 6 months Implementation Design 1Date of first patient referral
Goals and Methods Used to Meet Them (cont) • Model fidelity • Semi-structured qualitative data collection • QI data collection • Document review • Effectiveness across representative patients and providers • Randomized trial • Program quality and safety • Quality improvement data
TIDES Quality Improvement Outcomes • QI data collected by care managers • Care managers trained to administer depression symptom measure (PHQ 9) • Data entered into Excel spreadsheets • Analyzed in SPSS
Results #1: Enrollment & F/U • Among 858 pts referred to TIDES, 738 (87%) were eligible for initial assessment • 24 refused (2.8%) • 86 could not be contacted (10%) • 10 misc. (e.g., too sick) (1%) • Of 738 eligibles, 86% (636) got a full initial assessment by the DCM • 81% of these (516) completed 6 mos.PHQ f/u
#2: Depression Symptom Outcomes • PHQ 9 > 10 = probable major depression • PHQ 9 < 5 = probably no significant depression • Baseline PHQ 9 mean = 12.2 • F/u PHQ 9 at 24 weeks = 7.4 ___________________________________ • Mean pre-post drop in PHQ 9 = 5.8 points
#3: Mean PHQ Change: Referral Type (TIDES vs WAVES) • P=.002, controlling for baseline PHQ, VISN, pt complexity, interactions • Interactions not significant (VISN, pt complexity)
#4: Mean PHQ Change: VISNs (includes TIDES and WAVES pts) • P=.02, controlling for referral type, pt complexity, int. • No significant interactions (referral type, pt complexity)
#5:Contact New Referrals Promptly • 81% enrolled within 1 month (48% in 1 wk) • TIDES referral: 81 % enrolled in 1 month • WAVES referral: 74% enrolled in 1 month • VISN #1: 91% • VISN #2: 81% • VISN #3: 78%
#6: Enrollment and f/u calls • Mean enrollment calls/pt = 3.7 • TIDES and WAVES were equivalent • Proportion of pts completing adequate TIDES care (at least 4 treatment contacts) was significantly lower for WAVES-referred pts (p = .01) • Pts receiving at least 4 calls had significantly better outcomes (p < .05)
TIDES QI Formative Findings: Reach • Reach: • Clinics varied from 46% to 100% of clinicians who referred to TIDES at least once; 0% to 36% who referred at least 10 pts • Sustainability: • Least ready site performed, but did not sustain (in a favorable VISN) • Most ready site did not perform or sustain (in an unfavorable VISN)
Additional Data • Meta-analysis of trials to identify program features for use in national guidelines • Performance measure data on ReTIDES sites (pre-post with comparision) • Qualitative data pre-post on sites, consumers • Provider survey data on sites with comparison • Document review with educational theory on provider education approach
Standards for QI Research: The SQUIRE Guidelines • Published Oct. 2008 Ogrinc: Quality and Safety in Health Care Davidoff: Annals of Internal Medicine • Provides criteria for quality improvement publication • Used here to look at what types of data need to be incorporated into QI studies • Does TIDES have the data to meet these criteria?