A Fidelity Measure for Integrated Management of Depression in Primary Care

Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
Medical Care (Impact Factor: 3.23). 12/2006; 44(11):1030-7. DOI: 10.1097/01.mlr.0000233683.82254.63
Source: PubMed


Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure.
We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model.
Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months.
3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity.
Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

13 Reads
  • Source
    • "In other words, programs that are higher in fidelity will have better outcomes. This hypothesis has been examined in a wide range of practices, with generally moderate to strong support for the fidelity-outcome relationship (e.g., Blakely et al., 1987; Henggeler, Pickrel, & Brondino, 1999; Jerrell & Ridgely, 1999; McDonnell, Nofs, Hardman, & Chambless, 1989; Oxman et al., 2006). This hypothesis has been strongly supported in four supported employment studies (Becker, Smith, Tanzman, Drake, & Tremblay, 2001; Becker, Xie, McHugo, Halliday, & Martinez, 2006; Gowdy, Carlson, & Rapp, 2003; McGrew & Griss, 2005), three of which used the SE Fidelity Scale used in the current study. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: The National Evidence-Based Practices (EBPs) Project developed and tested a model for facilitating the implementation of five psychosocial EBPs for adults with severe mental illness in the United States. Methods: The implementation model was tested in 53 sites in 8 states. In each site, one of the five EBPs was adopted for implementation and then studied for a 2-year period using a combination of qualitative and quantitative methods. Findings: At baseline, none of the sites had programs attaining high fidelity. Four factors were identified as influencing fidelity: (a) EBP-specific factors, (b) governmental factors, (c) leadership factors, and (d) fidelity review factors. Conclusion: A multipronged implementation strategy was effective in achieving high fidelity in over half of the sites seeking to implement a new EBP.
    Research on Social Work Practice 08/2009; 19(5):569-581. DOI:10.1177/1049731509335531 · 1.53 Impact Factor
  • Source
    • "Consequently, determining feasibility and treatment fidelity are necessary early in the development of an intervention protocol in such settings. For more than 20 years, behavioral scientists have identified serious problems associated with treatment fidelity (Bellg et al., 2004; Horner, Rew, & Torres, 2006; Oxman et al., 2006; Perrin et al., 2006; Resnick et al., 2005; Santacroce, Maccarelli, & Grey, 2004). If researchers cannot ascertain that a proposed treatment is delivered as intended, intervention efficacy cannot be assessed accurately. "
    [Show abstract] [Hide abstract]
    ABSTRACT: As the U.S. population ages and chronic illness prevalence increases, new approaches to care are needed. Although large health systems have begun to respond to this challenge, most Americans seek care from practitioners functioning in small office settings. Implementing systematic sustainable changes for quality improvement in this setting remains an unresolved challenge. In this study, trained Nurse Coaches (NCs) were employed to assist practices in adopting a new model of patient care called Virtual Integrated Practice (VIP). The feasibility and treatment fidelity of this approach were assessed through process measures and interviews in three practices. Findings document high acceptance of the NC approach and consistent delivery of the intervention. Enactment of the VIP model took place across practices, although to a variable degree. The study suggests that NCs may be an effective delivery method for quality and organizational improvements in small primary care practices.
    Western Journal of Nursing Research 03/2008; 30(6):690-703. DOI:10.1177/0193945907311321 · 1.03 Impact Factor
  • Source
    • "Furthermore, during the intervention the adherence of the OP-care managers to the intervention will be checked and, with the consent of the patient, audio-tapes of PST sessions will be discussed in group (peer) supervision sessions together with other OP-care managers and the PST trainer. Also, an instrument developed by Oxman et al. in order to monitor treatment integrity will be used [72]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Major depressive disorder (MDD) has major consequences for both patients and society, particularly in terms of needlessly long sick leave and reduced functioning. Although evidence-based treatments for MDD are available, they show disappointing results when implemented in daily practice. A focus on work is also lacking in the treatment of depressive disorder as well as communication of general practitioners (GPs) and other health care professionals with occupational physicians (OPs). The OP may play a more important role in the recovery of patients with MDD. Purpose of the present study is to tackle these obstacles by applying a collaborative care model, which has proven to be effective in the USA, with a focus on return to work (RTW). From a societal perspective, the (cost)effectiveness of this collaborative care treatment, as a way of transmural care, will be evaluated in depressed patients on sick leave in the occupational health setting. A randomised controlled trial in which the treatment of MDD in the occupational health setting will be evaluated in the Netherlands. A transmural collaborative care model, including Problem Solving Treatment (PST), a workplace intervention, antidepressant medication and manual guided self-help will be compared with care as usual (CAU). 126 Patients with MDD on sick leave between 4 and 12 weeks will be included in the study. Care in the intervention group will be provided by a multidisciplinary team of a trained OP-care manager and a consultant psychiatrist. The treatment is separated from the sickness certification. Data will be collected by means of questionnaires at baseline and at 3, 6, 9 and 12 months after baseline. Primary outcome measure is reduction of depressive symptoms, secondary outcome measure is time to RTW, tertiary outcome measure is the cost effectiveness. The high burden of MDD and the high level of sickness absence among people with MDD contribute to the relevance of this study. The intervention is an innovative approach, with trained OPs in a new role as care managers in the treatment of MDD. If this intervention proves to be cost-effective, implementation will be very relevant for individual patients as well as for society. ISRCTN78462860.
    BMC Health Services Research 02/2008; 8(1):99. DOI:10.1186/1472-6963-8-99 · 1.71 Impact Factor
Show more