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: 10538553
• 负责人: Lindsey Eileen Zimmerman
• 金额: $ 57.94万
• 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 2024-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10538553
• 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; Eligibility Determination; Engineering; Ensure; Equilibrium; Etiology; Evidence based practice; Feedback; Frontline worker; Future; Health system; Healthcare; Healthcare Systems; Impairment; Incentives; Integrated Health Care Systems; Knowledge; Learning; Measures; Mediation; Mediator; 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 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; dynamic system; effective therapy; effectiveness testing; empowerment; evidence base; health care settings; implementation science; implementation strategy; improved; innovation; meetings; multidisciplinary; opioid misuse; opioid use disorder; patient engagement; patient population; persistent symptom; prevent; program dissemination; prospective; relapse prevention; 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.

我们的广泛目的是授权所有医疗保健利益相关者为所有患者提供最高质量的护理。 我们的具体目的解决了与实施循证的复杂性和权衡 在门诊成瘾和心理卫生系统中的实践（EBP）。关于 最佳循证心理治疗和药物治疗（EBP），以满足患者的需求 阿片类药物和饮酒障碍，PTSD和抑郁症。但是，随着时间的推移，内部和 在各个提供商的多学科团队中，都很复杂且不断变化。退伍军人健康 行政（VA）政策授权，国家培训计划和激励质量措施已有 不足以达到3至28％的最高质量治疗患者。实际上， 有限的EBP覆盖范围在卫生系统中很常见，实施科学领域旨在解决它。 一种常规策略是通过提供者反馈（审核和反馈； AF）进行数据审核，但是影响 高度可变。作为替代方案，参与性系统动力学（PSD）已被用来解释原因 60年的业务管理中的复杂问题。我们使用PSD与前线工作人员合作 确定EBP覆盖范围是如何从本地资源和约束中出现的，并由系统确定 动态，例如延迟和反馈。 EBP触及范围的动力在差分中正式指定 方程模型，并根据来自国家VA SQL数据库绘制的VA数据进行了测试。我们使用了这个 现有的企业数据可针对每个护理团队量身定制模型参数。 PSD模型可访问 通过“学习”界面和培训的“建模”，在此期间，团队可以安全地评估本地变化方案 通过模拟找到满足退伍军人需求的最高收益率选择。 PSD学习模拟 向协调护理的团队提供直接的实时反馈，改善日常决策 和长期改进计划。我们提出了一个两臂，24个站点（12个位点/手臂）群集随机试验 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启动和剂量方面将优于AF（AIM 1）。我们将测试 PSD的变化理论是，PSD对改善EBP覆盖范围的影响通过团队的改善来解释 系统思考（目标2）。为了确认PSD广泛实用性的潜力，我们还将测试 PSD跨PSD和AF臂的PSD因果动力学的概括性（AIM 3）。这项研究有可能 通过确定哪些有效的改善卫生系统质量定义为EBP覆盖范围的方法，告知新范式 它为什么起作用，以及在什么条件下。如果PSD有效，研究活动将纠正国家优先事项 改善退伍军人的成瘾和心理保健，以防止慢性症状，复发，自杀和 过量。提议的有效性，因果关系和普遍性的结果也可能催化 未来的申请，以在医疗保健的连续性中产生重大的公共卫生影响。

项目成果

Addressing the mental health impact of COVID-19 through population health.

• DOI: 10.1016/j.cpr.2021.102006
• 发表时间: 2021-04
• 期刊: Clinical psychology review
• 影响因子: 12.8
• 作者: Boden M;Zimmerman L;Azevedo KJ;Ruzek JI;Gala S;Abdel Magid HS;Cohen N;Walser R;Mahtani ND;Hoggatt KJ;McLean CP
• 通讯作者: McLean CP