Primary care providers are increasingly involved in the management of patients with mental disorders, particularly as integrated models of care emerge. The recent publication of the fifth edition of ...the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents a shift in the classification of several mental disorders commonly encountered by primary care providers. With the advent of ICD-10 and the movement toward diagnostic specificity, it is crucial that primary care providers understand the rationale behind these changes. This paper provides an overview of the changes in the classification of mental disorders in DSM-5, a description of how these changes relate to frequently used screening tools in the primary care setting, and a critique of how these changes will affect mental health practice from a primary care perspective.
Cardiac rehabilitation (CR) is an evidence-based intervention that improves event-free survival in patients with cardiac conditions, yet <27% of all eligible patients use CR in the United States. CR ...is traditionally delivered in clinic-based settings where implementation barriers abound. Innovative nontraditional program designs and strategies are needed to support widespread CR uptake.
This study aimed to demonstrate how user-centered design (UCD) and implementation science (IS) principles and methods can be integrated into the early-stage development of nontraditional CR interventions.
As part of a NewYork-Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we combined UCD and IS principles and methods to design a novel home- and clinic-based telehealth-enhanced hybrid CR (THCR) program. We co-designed this program with multilevel stakeholders using an iterative 3-step UCD process to identify user and contextual barriers and facilitators to CR uptake (using semistructured interviews and contextual inquiry step 1), design an intervention prototype that targets contextual and user factors and emulates the evidence-based practice (through design workshops and journey mapping step 2), and review and refine the prototype (according to real-world usability testing and feedback step 3). The UCD process was informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research.
At step 1, we conducted semistructured interviews with 9 provider- and system-level stakeholders (female: n=6, 67%) at 3 geographically diverse academic medical centers, which revealed behavioral (eg, self-efficacy and knowledge) and contextual (eg, social distancing guidelines, physical space, staffing, and reimbursement) barriers to uptake; hybrid delivery was a key facilitator. Step 2 involved conducting 20 design workshops and 3 journey-mapping sessions with multidisciplinary NYPH stakeholders (eg, digital health team, CR clinicians, and creative director) where we identified key design elements (eg, mix of clinic- and home-based CR and synchronous remote patient monitoring), yielding an initial THCR prototype that leveraged NYPH's telehealth infrastructure. At step 3, we conducted usability testing with 2 CR clinicians (both female) administering home-based sessions to 3 CR patients (female: n=1, 33%), which revealed usability themes (eg, ease of using remote patient monitoring devices or a telehealth platform, technology disruptions, and confidence in using the telehealth platform to safely monitor patients) and design solutions (eg, onboarding sessions, safety surveys, and fully supervised remote sessions) to be included in the final THCR prototype.
Combining UCD and IS methods while engaging multidisciplinary stakeholders in an iterative process yielded a theory-informed THCR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process and guidance for incorporating UCD and IS principles and methods into the early-stage development of a nontraditional CR intervention. The feasibility, acceptability, appropriateness, and usability of the final THCR prototype is being evaluated in an ongoing study.
There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the ...factors contributing to mammography overuse.
This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.
Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.
Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.
Background
Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and ...antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts.
Methods
Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations.
Results
We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration.
Conclusion
We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact.
Plain language abstract
There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.
Background. Shared decision making (SDM) is recommended prior to initiation of statin therapy for primary prevention but is underutilized. We designed an informatics decision-support tool to ...facilitate use of the Mayo Clinic Statin Choice decision aid at the point-of-care and evaluated its impact. Methods. Using an iterative approach, we designed and implemented a single-click decision-support tool embedded within the electronic health records (EHRs) to automate the calculation of 10-year atherosclerotic cardiovascular disease (ASCVD) risk and populate the Statin Choice decision aid. We surveyed primary care providers at two clinics regarding their attitudes about SDM before and after deployment of intervention, as well as their usage of and perceived competence regarding SDM for primary prevention statin therapy. Three-month web traffic to the Statin Choice website was calculated before and after deployment of the intervention. Results. Pre–post surveys were completed by 60 primary care providers (24 40% attending physicians and 36 60% housestaff physicians). After deployment of the EHR tool, respondents were more aware of the Statin Choice decision aid (P < 0.001), reported being more competent regarding SDM (P = 0.047), and reported using decision aids more often when considering statin initiation (P = 0.043). There was no significant change in attitudes about SDM as measured through the Patient Provider Orientation Scale (pre 4.23 ± 0.40 v. post 4.16 ± 0.38, P = 0.11) and the SDM belief scale (pre 21.4 ± 2.1 v. post 21.1 ± 2.0, P = 0.35). Web-based usage rates for the Statin Choice decision aid increased from 3.4 to 5.2 per 1,000 outpatient clinic visits (P = 0.002). Conclusions. Implementation of a point-of-care decision-support tool increased the usage of decision aids for primary prevention statin therapy. This effect does not appear to be mediated by any concomitant changes in physician attitude toward SDM.
The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol recommends statin therapy for eligible patients to reduce the risk of ...atherosclerotic cardiovascular disease (ASCVD). We extracted electronic health record data for patients with at least one primary care or cardiology visit between October 2018 and January 2020 at an urban, academic medical center in New York City. Clinical and demographic data were used to identify patients eligible for primary prevention statin therapy. Statin prescription status was extracted from the electronic health record, and multivariate logistic regression was used to assess the association between statin prescription and age, gender, race, ethnicity, and other clinical and demographic covariables. In 7,550 patients eligible for primary prevention statin therapy, 3,994 (52.9%) were prescribed statins on at least 1 visit. Statin prescription was highest in patients with diabetes mellitus (73.6%) and with a 10-year ASCVD risk ≥20% (60.6%) and was lowest for those with a 10-year ASCVD risk between 5% and 7.5% (18.7%). Compared with those never prescribed statins, patients prescribed statins were less likely to be women, mainly driven by lower statin prescription rates for women with diabetes. In a fully adjusted model, women remained less likely to be prescribed statin therapy (adjusted odds ratios 0.79, 95% confidence interval 0.71 to 0.88). In conclusion, primary prevention statin therapy remains underutilized.
Management of Depression in Adults: A Review Simon, Gregory E; Moise, Nathalie; Mohr, David C
JAMA : the journal of the American Medical Association,
07/2024, Letnik:
332, Številka:
2
Journal Article
Recenzirano
IMPORTANCE: Approximately 9% of US adults experience major depression each year, with a lifetime prevalence of approximately 17% for men and 30% for women. OBSERVATIONS: Major depression is defined ...by depressed mood, loss of interest in activities, and associated psychological and somatic symptoms lasting at least 2 weeks. Evaluation should include structured assessment of severity as well as risk of self-harm, suspected bipolar disorder, psychotic symptoms, substance use, and co-occurring anxiety disorder. First-line treatments include specific psychotherapies and antidepressant medications. A network meta-analysis of randomized clinical trials reported cognitive therapy, behavioral activation, problem-solving therapy, interpersonal therapy, brief psychodynamic therapy, and mindfulness-based psychotherapy all had at least medium-sized effects in symptom improvement over usual care without psychotherapy (standardized mean difference SMD ranging from 0.50 95% CI, 0.20-0.81 to 0.73 95% CI, 0.52-0.95). A network meta-analysis of randomized clinical trials reported 21 antidepressant medications all had small- to medium-sized effects in symptom improvement over placebo (SMD ranging from 0.23 95% CI, 0.19-0.28 for fluoxetine to 0.48 95% CI, 0.41-0.55 for amitriptyline). Psychotherapy combined with antidepressant medication may be preferred, especially for more severe or chronic depression. A network meta-analysis of randomized clinical trials reported greater symptom improvement with combined treatment than with psychotherapy alone (SMD, 0.30 95% CI, 0.14-0.45) or medication alone (SMD, 0.33 95% CI, 0.20-0.47). When initial antidepressant medication is not effective, second-line medication treatment includes changing antidepressant medication, adding a second antidepressant, or augmenting with a nonantidepressant medication, which have approximately equal likelihood of success based on a network meta-analysis. Collaborative care programs, including systematic follow-up and outcome assessment, improve treatment effectiveness, with 1 meta-analysis reporting significantly greater symptom improvement compared with usual care (SMD, 0.42 95% CI, 0.23-0.61). CONCLUSIONS AND RELEVANCE: Effective first-line depression treatments include specific forms of psychotherapy and more than 20 antidepressant medications. Close monitoring significantly improves the likelihood of treatment success.
Abstract
Promoting evidence-based cancer prevention and control may require de-implementation strategies, aimed at reducing or removing interventions that have been shown as ineffective, potentially ...harmful, lacking in demonstrated effectiveness, or offering only limited health benefits. De-implementation involves a range of actions, including scaling back these interventions, narrowing their application to specific populations or settings, substituting them with more effective alternatives, or entirely discontinuing them without replacement. The evolving nature of scientific evidence and the shifting landscape of population health priorities, which contribute to changing guidelines over time, make de-implementation an important component of the broader implementation science to advance cancer prevention, control, and equity. While the field is expanding, there remains a research gap in empirical studies that elucidate the factors influencing de-implementation or effective strategies for facilitating it. Emerging data indicate that the drivers of implementation and de-implementation often differ, necessitating distinct or adapted strategies, frameworks, and outcomes. Implementation and de-implementation approaches also have varying implications and considerations for addressing health disparities. Breast cancer screening through mammography serves as a case study, exemplifying an evidence-based practice marked by both underuse and overuse — corresponding to lower and higher guideline-recommended participation, respectively — across different population groups and settings. In this educational session presentation, we will share the approaches and insights gathered from our efforts to promote appropriate screening mammography within racially and ethnically diverse and underserved communities. In this education presentation, we will highlight findings from our NIH-funded studies, focusing on two specific areas: breast density notification and mammography screening in older women. These areas represent current practices characterized by insufficient evidence regarding effectiveness, potential harms, and benefits, along with inconsistent clinical recommendations, illustrating the need for a more deliberate and well-informed approach to enhance breast cancer control and mitigate health disparities. Beyond illuminating some of the challenges at the policy, organizational, and provider levels, we emphasize the critical role that women or patients play in shaping the landscape of breast cancer screening. Their perspectives and experiences are crucial considerations when formulating de-implementation strategies aimed at optimizing breast cancer screening and promoting equity.
Citation Format: Parisa Tehranifar, Nathalie Moise, Rachel C. Shelton. Balancing act: cancer control and equity through implementation and de-implementation abstract. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA021.
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