Participatory System Dynamics vs Audit and Feedback: A Cluster Randomized Trial of Mechanisms of Implementation Change to Expand Reach of Evidence-based Addiction and Mental Health Care

参与式系统动态与审计和反馈：实施变更机制的集群随机试验，以扩大循证成瘾和心理健康保健的范围

• 批准号: 10314046
• 负责人: Lindsey Eileen Zimmerman
• 金额: $ 56.99万
• 依托单位: PALO ALTO VETERANS INSTIT FOR RESEARCH
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-02-01 至 2023-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10314046
• 关键词: Achievement; Address; Appointment; Behavioral; Businesses; Calculi; Caring; Chronic; Clinic; Cluster randomized trial; Code; Cognitive; Complex; Computer Assisted; Consensus; Data; Databases; Decision Making; Diagnosis; Differential Equation; Dose; Electronic Health Record; Engineering; Ensure; Equilibrium; Etiology; Evidence based practice; Feedback; Frontline worker; Future; Health; Health system; Healthcare; Healthcare Systems; Impairment; Incentives; Integrated Health Care Systems; Knowledge; Learning; Measures; Mediation; Mediator of activation protein; Medication Management; Mental Depression; Mental Health; Mental Health Services; Methods; Modeling; Outcome; Outpatients; Overdose; Patients; Performance; Pharmacotherapy; Policies; Policy Maker; Population; Post-Traumatic Stress Disorders; Probability; Provider; Psychotherapy; Public Health; Quality of Care; Randomized; Relapse; Research; Resources; Science; Scientific Advances and Accomplishments; Scientist; Site; Specific qualifier value; Suicide; Surveys; System; Systems Analysis; Systems Theory; Testing; Theory of Change; Thinking; Time; Training; Training Programs; Validation; Veterans; Veterans Health Administration; Visit; Visual; Weight; Work; addiction; alcohol misuse; alcohol use disorder; arm; burnout; care coordination; cost; design; effective therapy; effectiveness testing; empowered; evidence base; health care settings; implementation science; implementation strategy; improved; innovation; meetings; multidisciplinary; opioid misuse; opioid use; opioid use disorder; patient population; persistent symptom; prevent; program dissemination; prospective; research study; simulation; success; virtual experiments

Our broad aim is to empower all healthcare stakeholders to provide the highest quality care to all patients. Our specific aims address the complexities and tradeoffs associated with implementing evidence-based practices (EBPs) in outpatient addiction and mental health systems. There is scientific consensus about the best evidence-based psychotherapies and pharmacotherapies (EBPs) to meet the needs of patients with opioid and alcohol use disorder, PTSD and depression. However, EBP coordination over time, within and across multidisciplinary teams of providers, is complex and constantly changing. Veterans Health Administration (VA) policy mandates, national training programs, and incentivized quality measures, have been insufficient for reaching more than 3 to 28% of patients with the highest quality treatments. In fact, limited EBP reach is common in health systems and the field of implementation science seeks to address it. One routine strategy is data auditing with provider feedback (audit-and-feedback; AF), however, the impact is highly variable. As an alternative, participatory system dynamics (PSD) has been used to explain causes of complex problems in business management for 60 years. We partnered with frontline staff using PSD to determine how EBP reach emerges from local resources and constraints, and is determined by system dynamics, such as delays and feedback. The dynamics of EBP reach were formally specified in differential equation models, and tested against VA data drawn from a national VA SQL database. We used this existing enterprise data to tailor model parameters to each care team. PSD models were made accessible via a `Modeling to Learn' interface and training, during which teams safely evaluated local change scenarios via simulation to find the highest yield options for meeting Veterans' needs. PSD learning simulations produce immediate, real-time feedback to the teams who coordinate care, improving day-to-day decisions and long-term improvement plans. We propose a two-arm, 24-site (12 sites/arm) cluster randomized trial to test the effectiveness of PSD simulation as compared to more standard team AF data review. We hypothesize that PSD will be superior to AF for improving EBP initiation and dose (Aim 1). We will test the PSD theory of change that the effect of PSD on improved EBP reach is explained by improvement in team systems thinking (Aim 2). To confirm the potential for widespread usefulness of PSD, we will also test the generalizability of PSD causal dynamics across PSD and AF arms (Aim 3). This study has the potential to inform a new paradigm, by determining what works to improve health system quality defined as EBP reach, why it works, and under what conditions. If PSD is effective, study activities will address a national priority to improve Veterans' addiction and mental health care to prevent chronic symptoms, relapse, suicide and overdose. Findings from the proposed tests of effectiveness, causality, and generality, could also catalyze future applications to make a significant public health impact across the continuum of healthcare.

我们的总体目标是使所有医疗保健利益相关者能够为所有患者提供最高质量的护理。 我们的具体目标解决了与实施基于证据的相关的复杂性和权衡 门诊成瘾和心理健康系统的实践（EBP）。科学界对此已达成共识 最好的循证心理治疗和药物治疗（EBP），以满足患者的需求 阿片类药物和酒精使用障碍、创伤后应激障碍和抑郁症。然而，随着时间的推移，EBP 在内部和外部的协调 跨越多学科的提供商团队，是复杂且不断变化的。退伍军人健康 行政部门 (VA) 的政策授权、国家培训计划和激励性质量措施已 不足以让超过 3% 至 28% 的患者获得最高质量的治疗。实际上， EBP 覆盖范围有限在卫生系统中很常见，实施科学领域致力于解决这个问题。 一种常规策略是根据提供商反馈进行数据审核（审核和反馈；AF），但是，影响 是高度可变的。作为替代方案，参与系统动力学（PSD）已被用来解释原因 60年来企业管理中的复杂问题。我们与一线员工合作，使用 PSD 确定 EBP 范围如何从本地资源和约束中产生，并由系统决定 动态，例如延迟和反馈。 EBP 到达的动态在微分中正式指定 方程模型，并根据从国家 VA SQL 数据库中提取的 VA 数据进行测试。我们用这个 现有的企业数据可以为每个护理团队定制模型参数。 PSD 模型变得易于访问 通过“建模学习”界面和培训，在此期间团队安全地评估本地变更场景 通过模拟找到满足退伍军人需求的最高产量选项。 PSD 学习模拟 向协调护理、改进日常决策的团队提供即时、实时的反馈 和长期改进计划。我们提出了一项双臂、24 个站点（12 个站点/臂）的集群随机试验，以 与更标准的团队 AF 数据审查相比，测试 PSD 模拟的有效性。我们 假设 PSD 在改善 EBP 起始时间和剂量方面优于 AF（目标 1）。我们将测试 PSD 变革理论，PSD 对提高 EBP 范围的影响可以通过团队的改进来解释 系统思维（目标 2）。为了确认 PSD 广泛使用的潜力，我们还将测试 PSD 因果动态在 PSD 和 AF 组中的普遍性（目标 3）。这项研究有潜力 通过确定什么可以有效改善卫生系统质量（定义为 EBP 达到），提供新的范式， 为什么它有效，以及在什么条件下有效。如果 PSD 有效，研究活动将解决国家优先事项 改善退伍军人的毒瘾和心理保健，以预防慢性症状、复发、自杀和 过量。所提议的有效性、因果性和普遍性测试的结果也可能会促进 未来的应用将对整个医疗保健领域的公共卫生产生重大影响。