The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization

Who Is Practicing Expedited Partner Therapy and Why? Insights From Providers Working in Specialties With High Volumes of Sexually Transmitted Infections

BACKGROUND

Expedited partner therapy (EPT), the practice of prescribing antibiotics for sexual partners of patients, is underutilized in Georgia. This qualitative study in a large urban institution aimed to (1) characterize the clinical specialties that predominantly treat sexually transmitted infections (STIs), (2) identify perceived barriers to EPT, and (3) describe strategies to advance routine EPT use.

METHODS

Providers in obstetrics/gynecology (OB/GYN), infectious disease (ID), and emergency medicine (EM) were interviewed using a structured discussion guide. Transcripts were double-coded and iteratively analyzed using qualitative content analysis. Barriers and strategies were summarized and supported with quotes from providers (n = 23).

RESULTS

Perceived EPT barriers overlapped across OB/GYN, ID, and EM, yet the settings were diverse in their patient populations, resources, and concerns. Providers in OB/GYN were the only ones practicing EPT, yet there was a lack of standardization. Providers in ID noted that an EPT prescription from an ID provider could inadvertently disclose the HIV status of a patient to a sexual partner, posing an ethical dilemma. Providers in EM exhibited readiness for EPT, although routine empiric treatment for index patients in EM (estimated at 90%) gave some providers pause in prescribing for partners: "I do not know what I'm treating." Point-of-care testing could increase providers' confidence in prescribing EPT, yet some worried it could contribute to overutilization of the emergency department as a sexually transmitted infection clinic. All settings prioritized setting-specific training and protocols.

CONCLUSIONS

Providers in OB/GYN, ID, and EM report unique hurdles, specific to their settings and patient populations; tailored EPT implementation strategies, particularly provider training, are urgently needed to improve patient/partner outcomes.

Core Correctional Practices in Community Supervision: An Evaluation of a Policy Mandate to Increase Probation Officer Use of Skills

Community supervision officer training programs aim to translate core correctional practices into routine practice. These training programs emphasize skill-building designed to shift supervision strategies from law enforcement/compliance-oriented to a focus on promoting and supporting behavior change. Despite evidence of their effectiveness, research finds trained officers use newly learned skills infrequently. The current study examined the impact of a policy, implemented post-training, designed to encourage trained officers to use skills emphasized by the Staff Training Aimed at Reducing Rearrest (STARR) training program more frequently. The current study examined the effectiveness of this policy on the frequency and type of skills used by officers in their interactions with individuals on their caseload. Analyses suggested the policy mandate was effective in increasing skill use, however officers still used trained skills in less than half of their interactions. Implications and considerations for increasing the use of skills are discussed.

Effectiveness of personal letters to healthcare professionals in changing professional behaviours: a systematic review protocol

BACKGROUND

Letters are regularly sent by healthcare organisations to healthcare professionals to encourage them to take action, change practice or implement guidance. However, whether letters are an effective tool in delivering a change in healthcare professional behaviour is currently uncertain. In addition, there are currently no evidence-based guidelines to support health providers and authorities with advice on how to formulate the communication, what information and behaviour change techniques to include in order to optimise the potential effect on the behaviour of the receivers. To address this research gap, we seek to inform such guidance through this systematic review, which aims to provide comprehensive evidence of the effectiveness of personal letters to healthcare professionals in changing their professional behaviours.

METHODS/DESIGN

A comprehensive literature search of published and unpublished studies (the grey literature) in electronic databases will be conducted to identify randomised controlled trials (RCTs) that meet our inclusion criteria. We will include RCTs evaluating the effectiveness of personal letters to healthcare professionals in changing professional behaviours. The primary outcome will be behavioural change. The search will be conducted in five electronic databases (from their inception onwards): MEDLINE, Embase, PsycINFO, the Cochrane Library and CINAHL. We will also conduct supplementary searches in Google Scholar, hand search relevant journals, and conduct backward and forward citation searching for included studies and relevant reviews. A systematic approach to searching, screening, reviewing and data extraction will be applied in accordance with the process recommended by the Cochrane Collaboration. Two researchers will examine titles, abstracts, full-texts for eligibility independently. Risk of bias will be assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomised controlled trials. Disagreements will be resolved by a consensus procedure.

DISCUSSION

Health policy makers across government are expected to benefit from being able to increase compliance in clinical settings by applying theories of behaviour to design of policy communications. The synthesised findings will be disseminated through peer-reviewed publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020167674.

Supporting breastfeeding of small, sick and preterm neonates

Breastfeeding is associated with a risk reduction for several acute and chronic diseases in women and their infants. Health benefits of breastfeeding are especially important for small, sick and preterm infants. The objective of this article is to summarize essential steps for healthcare personnel and facilities to improve breastfeeding practices in this vulnerable population. Health facilities can support breastfeeding through the establishment of breastfeeding-supportive policies, staff training and the design of facilities to support rooming-in. Direct support to breastfeeding includes the provision of counseling to mothers at critical time points, skin-to-skin and kangaroo care, and support of responsive (on-demand) breastfeeding. Where direct breastfeeding is not possible, facilities should show mothers how to express their breastmilk and teach mothers alternative feeding modalities. Medically-indicated supplementation of small, sick and preterm may be needed in certain circumstances.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Impact of the WHO depression guideline on patient care by psychiatrists: A randomized controlled trial

Background

Scientific literature reviews aim to summarize the state of knowledge and published empirical evidence. In contrast, medical guidelines are intervention tools that aim to improve physician behaviour and patient outcome. They can have positive effects, but they can also have negative effects. Their effects must be tested by research.

Methods

In a randomized controlled trial, 103 psychiatrists in private practice were either provided with the WHO depression guideline only (information group), or provided with the WHO depression guideline and trained for one day in this guideline (intervention group), or left uninformed (control group). They then treated a total of 497 patients according to individual clinical considerations and the needs of the patients. Observation of routine treatment lasted 12 weeks. Physicians and patients documented the course of illness and treatment, including the patient–physician interaction.

Results

Psychiatrists in the intervention group saw more psychosocial stressors in their patients, prescribed higher dosages of medication, had fewer drop-outs, and rated treatment outcome as better. The ratings of patient–physician interactions indicated more strain in their relationships.

Conclusions

The results show both positive and negative effects of guideline exposure, but only in the training group and not in the information group. Guidelines should be empirically tested before being called “evidence based”. Every guideline should also explain how it can or must be implemented in order to become effective.

Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth

BACKGROUND

A model for statewide dissemination of evidence-based treatment (EBT) for traumatized youth was piloted and taken to scale across North Carolina (NC). This article describes the implementation platform developed, piloted, and evaluated by the NC Child Treatment Program to train agency providers in Trauma-Focused Cognitive Behavioral Therapy using the National Center for Child Traumatic Stress Learning Collaborative (LC) Model on Adoption & Implementation of EBTs. This type of LC incorporates adult learning principles to enhance clinical skills development as part of training and many key implementation science strategies while working with agencies and clinicians to implement and sustain the new practice.

METHODS

Clinicians (n = 124) from northeastern NC were enrolled in one of two TF-CBT LCs that lasted 12 months each. During the LC clinicians were expected to take at least two clients through TF-CBT treatment with fidelity and outcomes monitoring by trainers who offered consultation by phone and during trainings. Participating clinicians initiated treatment with 281 clients. The relationship of clinician and client characteristics to treatment fidelity and outcomes was examined using hierarchical linear regression.

RESULTS

One hundred eleven clinicians completed general training on trauma assessment batteries and TF-CBT. Sixty-five clinicians met all mastery and fidelity requirements to meet roster criteria. One hundred fifty-six (55%) clients had fidelity-monitored assessment and TF-CBT. Child externalizing, internalizing, and post-traumatic stress symptoms, as well as parent distress levels, decreased significantly with treatment fidelity moderating child PTSD outcomes. Since this pilot, 11 additional cohorts of TF-CBT providers have been trained to these roster criteria.

CONCLUSION

Scaling up or outcomes-oriented implementation appears best accomplished when training incorporates: 1) practice-based learning, 2) fidelity coaching, 3) clinical assessment and outcomes-oriented treatment, 4) organizational skill-building to address barriers for agencies, and 5) linking clients to trained clinicians via an online provider roster. Demonstrating clinician performance and client outcomes in this pilot and subsequent cohorts led to legislative support for dissemination of a service array of EBTs by the NC Child Treatment Program.

Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression

Background

Depression is a common mental health disorder for which clinical practice guidelines have been developed. Prior systematic reviews have identified complex organizational interventions, such as collaborative care, as effective for guideline implementation; yet, many healthcare delivery organizations are interested in less resource-intensive methods to increase provider adherence to guidelines and guideline-concordant practices. The objective of this systematic review was to assess the effectiveness of healthcare provider interventions that aim to increase adherence to evidence-based treatment of depression in routine clinical practice.

Methods

We searched five databases through August 2017 using a comprehensive search strategy to identify English-language randomized controlled trials (RCTs) in the quality improvement, implementation science, and behavior change literature that evaluated outpatient provider interventions, in the absence of practice redesign efforts, to increase adherence to treatment guidelines or guideline-concordant practices for depression. We used meta-analysis to summarize odds ratios, standardized mean differences, and incidence rate ratios, and assessed quality of evidence (QoE) using the GRADE approach.

Results

Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline-concordant practices met inclusion criteria. Studies evaluated diverse provider interventions, including distributing guidelines to providers, education/training such as academic detailing, and combinations of education with other components such as targeting implementation barriers. Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies. There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes. We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies. Effects on patients’ health in these RCTs were inconsistent across studies and outcomes.

Conclusions

Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines. Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research. Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence-based treatment for depression.

Trial registration

PROSPERO record CRD42017060460 on 3/29/17

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0788-8) contains supplementary material, which is available to authorized users.

Translating Evidence-Based Practice for Managing Comorbid Substance Use and Mental Illness Using a Multimodal Training Package

OBJECTIVE

Comorbid mental health and substance use problems are highly prevalent in substance use treatment settings and generally lead to poorer treatment outcomes. Pathways to Comorbidity Care (PCC) is a multimodal training program developed to encourage an integrated service approach to improve clinicians capacity to identify and manage comorbid substance use and mental health outcomes within public drug and alcohol treatment settings.

METHODS

In this paper we describe the concepts underlying the PCC package and the use of implementation science to assess and overcome potential barriers, including clinicians preferences, knowledge about best practice, and professional culture.

RESULTS

The training components include didactic seminars, group workshops run by a local clinical champion on relevant subjects such as motivational interviewing and cognitive behavioral therapy, individual clinical consultation, and feedback with a senior clinical psychologist. The PCC also includes an online portal containing comorbidity resources including manuals, guidelines, and booster webinars. Finally, we describe the evaluation of PCC implementation.

CONCLUSIONS

Drug and alcohol services need to be equipped to treat the majority of comorbid mental health conditions in their clients. We anticipate that this multimodal training package, which applies the principles of implementation science, will facilitate effective and integrated care for these vulnerable clients.

Design, development, and evaluation of printed educational materials for evidence-based practice dissemination

AIM

Printed educational materials (PEMs) are one of the most common dissemination strategies for communicating information about evidence-based practices (EBPs) to healthcare professionals and organizations; however, evidence is conflicting regarding the conditions and circumstances in which PEMs are effective in achieving desired outcomes. The effectiveness of PEMs is largely dependent on the manner in which they are developed. This article reports on the findings from a comprehensive review of the literature regarding best practices for creating PEMs for health professionals and illustrates how these practices were used to design, develop, and evaluate an informational packet to disseminate information about motivational interviewing.

METHODS

The informational packet was disseminated to 92 community health organizations not currently implementing motivational interviewing. Evaluation surveys were completed by 212 healthcare directors and providers to examine quality and perceived helpfulness of the packets, intention to use information from the packet, and sharing of the packet with others. Associations between these and individual and organizational characteristics were also assessed.

RESULTS

Overall, the packet was perceived as appropriate and helpful in making a decision to implement motivational interviewing. For example, 84.9% of participants stated that the content was 'about right'. Three-quarters (75.9%) of participants reported plans to use the information in the packet and almost half (46.7%) reported talking about the packet with others in the organizations. Higher levels of baseline interest in motivational interviewing adoption were significantly related to packet use and wanting to utilize additional resources presented in the packet. Positive attitudes toward EBPs were also significantly related to the desire to obtain resources in the packet. Perceptions of the packet did not differ by type of community health organization (i.e., community health center, community behavioral health organization) or whether the individual was a director or provider.

CONCLUSION

Results indicated that PEMs can be a useful tool to disseminate EBP information to healthcare professionals particularly if they have a prior interest in the EBP and have general attitudes supportive of EBPs. Recommendations for the improvement of future PEMs are discussed.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

A Systematic Review of Strategies for Implementing Empirically Supported Mental Health Interventions

OBJECTIVE

This systematic review examines experimental studies that test the effectiveness of strategies intended to integrate empirically supported mental health interventions into routine care settings. Our goal was to characterize the state of the literature and to provide direction for future implementation studies.

METHODS

A literature search was conducted using electronic databases and a manual search.

RESULTS

Eleven studies were identified that tested implementation strategies with a randomized (n = 10) or controlled clinical trial design (n = 1). The wide range of clinical interventions, implementation strategies, and outcomes evaluated precluded meta-analysis. However, the majority of studies (n = 7; 64%) found a statistically significant effect in the hypothesized direction for at least one implementation or clinical outcome.

CONCLUSIONS

There is a clear need for more rigorous research on the effectiveness of implementation strategies, and we provide several suggestions that could improve this research area.

Implementation strategies: recommendations for specifying and reporting

Implementation strategies have unparalleled importance in implementation science, as they constitute the 'how to' component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of 'packaged' approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and 'reproducibility.' We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

Implementation strategies: recommendations for specifying and reporting

Implementation strategies have unparalleled importance in implementation science, as they constitute the 'how to' component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of 'packaged' approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and 'reproducibility.' We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

Implementation strategies: recommendations for specifying and reporting

Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

The use of three strategies to improve quality of care at a national level

BACKGROUND

Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial.

QUESTIONS/PURPOSES

The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries.

METHODS

We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size.

RESULTS

Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results.

CONCLUSION

Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.

Using Self-Guided Treatment Software (ePST) to Teach Clinicians How to Deliver Problem-Solving Treatment for Depression

Problem-solving treatment (PST) offers a promising approach to the depression care; however, few PST training opportunities exist. A computer-guided, interactive media program has been developed to deliver PST electronically (ePST), directly to patients. The program is a six-session, weekly intervention modeled on an evidence-based PST protocol. Users are guided through each session by a clinician who is presented via hundreds of branching audio and video clips. Because expert clinician behaviors are modeled in the program, not only does the ePST program have the potential to deliver PST to patients but it may also serve as a training tool to teach clinicians how to deliver PST. Thirteen social workers and trainees used ePST self-instructionally and subsequently attended a day-long workshop on PST. Participants' PST knowledge level increased significantly from baseline to post-ePST (P = .001) and did not increase significantly further after attending the subsequent workshop. Additionally, attending the workshop did not significantly increase the participants' skill at performing PST beyond the use of the ePST program. Using the ePST program appears to train novices to a sufficient level of competence to begin practicing PST under supervision. This self-instructional training method could enable PST for depression to be widely disseminated, although follow-up supervision is still required.

The clinical reality of implementing formal risk assessment and management measures within high secure forensic care

This paper describes the successful implementation of a formal violence risk assessment and management strategy within a high secure forensic care facility. The aim of the implementation was to ensure that each patient had a formal violence risk assessment and management plan that was shared and applied to clinical practice by the patient's clinical team. The process as a whole, from risk assessment to risk management including appropriate care and treatment documentation, is outlined. In this way, this paper also describes the difficulties and problems encountered within the organizational reality of implementation projects. Suggestions and recommendations on how to avoid and manage these are made.

Assessing and treating pain in hospices: current state of evidence-based practices

The aim of this study was to report on current provider evidence-based assessment and treatment practices for older adults with cancer in community-based hospice settings. Using the Cancer Pain Practices Index, a tool developed by the researchers to measure evidence-based pain management practices, patients received an average of 32% of those key evidence-based practices (EBPs) that were applicable to their situations. When examining individual practices, most of the patients had their pains assessed at admission using a valid pain scale (69.7%) and had primary components of a comprehensive assessment completed at admission (52.7%); most patients with admission reports of pain had an order for pain medication (83.5%). However, data revealed a number of practice gaps, including additional components of a comprehensive assessment completed within 48 hours of admission (0%); review of the pain treatment plan at each reassessment (35.7%); reassessment of moderate or greater pain (5.3%); consecutive pain reports of 5 or greater followed by increases in pain medication (15.8%); monitoring of analgesic-induced side effects (19.3%); initiation of a bowel regimen for patients with an opioid order (32.3%); and documentation of both nonpharmacological therapies (22.5%) and written pain management plans (0.6%). Findings highlight positive EBPs and areas for improving the translation of EBPs into practice. Data suggest that cancer pain is not being documented as consistently assessed, reassessed, or treated in a manner consistent with current EBP recommendations for older adults with cancer in community-based hospices.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.

OBJECTIVES

To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.

SEARCH STRATEGY

For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.

MAIN RESULTS

We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.

A roadmap to computer-based psychotherapy in the United States

Computers can be used to deliver self-guided interventions and to provide access to live therapists at remote locations. These treatment modalities could help overcome barriers to treatment, including cost, availability of therapists, logistics of scheduling and traveling to appointments, stigma, and lack of therapist training in evidence-based treatments (EBTs). EBTs could be delivered at any time in any place to individuals who might otherwise not have access to them, improving public mental health across the United States. In order to fully exploit the opportunities to use computers for mental health care delivery, however, advances need to be made in four domains: (1) research, (2) training, (3) policy, and (4) industry. This article discusses specific challenges (and some possible solutions) to implementing computer-based distance therapy and self-guided treatments in the United States. It lays out both a roadmap and, in each of the four domains, the milestones that need to be met to reach the goal of making EBTs for behavioral health problems available to all Americans.

Inadequate pain management during routine childhood immunizations: the nerve of it

BACKGROUND

Immunization is regarded as one of the most significant medical achievements of all time. Recently, increasing attention has been paid to the pain resulting from routine childhood immunizations.

OBJECTIVE

This narrative review summarizes existing knowledge about: (1) the epidemiology of childhood immunization pain; (2) the pain experience of children undergoing immunization; (3) current analgesic practices; (4) barriers to practicing pain management in children; and (5) recommendations for improvements in pain management during immunization.

METHODS

We conducted a search of MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials for primary research and review articles published from inception of the databases through October 2008. Key search terms included immunization, pain, child/infant, vaccine, and intervention. Additional studies were identified through searches of the reference lists in the retrieved articles. No language restrictions were imposed regarding the type of article (eg, full article, abstract) or language.

RESULTS

Vaccine injections are the most common iatrogenic procedure performed in childhood and a major source of distress for children (of all ages), their parents, and the participating health care professionals, as well as a direct cause of vaccine nonadherence. In addition, lack of adequate pain management during immunization exposes children to unnecessary suffering and the potential for long-term consequences, such as fear of needles. Numerous pain management strategies are available to reduce vaccine injection pain, including: (1) physical interventions and injection techniques; (2) psychological interventions; and (3) phar-macologic and combined interventions. However, adoption of pain-relieving techniques into clinical practice has been suboptimal. The underutilization of pain management strategies can be attributed to a lack of knowledge about pain and effective pain prevention strategies, and the persistence of attitudes about pain that interfere with optimal clinical practices. Current analgesic practices could be improved substantially if all stakeholders involved in immunization (eg, policy makers, practitioners, consumers) participate in efforts to reduce pain. Treating pain during childhood immunization has the potential to reduce distress during the procedure and greatly improve satisfaction with the immunization experience through more positive experiences for children and their families. Other potential benefits include improved adherence to immunization schedules and reduced sequelae of untreated pain.

CONCLUSION

Immunization is a global health priority. Medical care can be improved if pain management becomes a routine aspect of the delivery of vaccine injections.

Printed educational materials: effects on professional practice and health care outcomes

BACKGROUND

Printed educational materials (PEMs) are widely used passive dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines and appear to be the most frequently adopted method for disseminating information.

OBJECTIVES

To determine the effectiveness of PEMs in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes. To explore whether the effect of characteristics of PEMs (e.g., source, content, format, mode of delivery, timing/frequency, complexity of targeted behaviour change) can influence process outcomes (including the behaviour of healthcare professionals and patient outcomes).

SEARCH STRATEGY

The following electronic databases were searched up to July 2006: (a) The EPOC Group Specialised Register (including the database of studies awaiting assessment (see 'Specialised Register'under 'Group Details'); (b) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness; (c) MEDLINE, EMBASE, CINAHL and CAB Health. An updated search of MEDLINE was done in March 2007.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) , controlled clinical trials (CCT), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) that evaluated the impact of printed educational materials on healthcare professionals' practice and/or patient outcomes. There was no language restriction. Any objective measure of professional performance (sch as number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g., blood pressure, number of caesarean sections) were included.

DATA COLLECTION AND ANALYSIS

Four reviewers undertook data abstraction independently using a modified version of the EPOC data collection checklist. Any disagreement was resolved by discussion among the reviewers and arbitrators. Statistical analysis was based upon consideration of dichotomous process outcomes, continuous process outcomes, patient outcome dichotomous measures and patient outcome continuous measures. We presented the results for all comparisons using a standard method of presentation where possible. We reported separately for each study the median effect size for each type of outcome, and the median of these effect sizes across studies.

MAIN RESULTS

Twenty-three studies were included for this review. Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice. RCTs comparing PEMs to no intervention observed an absolute risk difference median: +4.3% on categorical process outcomes (e.g., x-ray requests, prescribing and smoking cessation activities) (range -8.0% to +9.6%, 6 studies), and a relative risk difference +13.6% on continuous process outcomes (e.g., medication change, x-rays requests per practice) (range -5.0% to +26.6%, 4 studies). These findings are similar to those reported for the ITS studies, although significantly larger effect sizes were observed (relative risk difference range from 0.07% to 31%). In contrast, the median effect size was -4.3% for patient outcome categorical measures (e.g., screening, return to work, quit smoking) (range -0.4% to -4.6%, 3 studies)). Two studies reported deteriorations in continuous patient outcome data (e.g., depression score, smoking cessation attempts) of -10.0% and -20.5%. One study comparing PEMs with educational workshops observed minimal differences. Two studies comparing PEMs and education outreach did not have statistically significant differences between the groups. It was not possible to explore potential effect modifiers across studies.

AUTHORS' CONCLUSIONS

The results of this review suggest that when compared to no intervention, PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes. Despite this wide of range of effects reported for PEMs, clinical significance of the observed effect sizes is not known. There is insufficient information about how to optimise educational materials. The effectiveness of educational materials compared to other interventions is uncertain.

Research utilization among children's mental health providers

BACKGROUND

Children with emotional and behavioural disorders should be able to count on receiving care that meets their needs and is based on the best scientific evidence available, however, many do not receive these services. Implementation of evidence-based practice (EBP) relies, in part, on the research utilization practices of mental health care providers. This study reports on a survey of research utilization practices among 80 children's mental health (CMH) service provider organizations in Ontario, Canada.

METHODS

A web-based survey was distributed to 80 CMH service provider organizations, to which 51 executive directors and 483 children's mental health practitioners responded. Research utilization was assessed using questions with Likert-type responses based on the Canadian Health Services Research Foundation's Four-A's approach: access, assess, adapt, apply.

RESULTS

There was general agreement among executive directors and practitioners regarding the capacity of their organizations to use - access, assess, adapt, and apply - research evidence. Overall, both groups rated their organizations as using research information 'somewhat well.' The low response rate to the practitioner survey should be noted.

CONCLUSION

These findings provide a useful benchmark from which changes in reported research utilization in the Ontario CMH sector can be tracked over time, as a function of EBP training and implementation initiatives, for instance. The need to improve access to research evidence should be addressed because it relates to the eventual implementation and uptake of evidence-based practices. Communities of practice are recommended as a strategy that would enable practitioners to build capacity in their adaptation and application of research evidence.

[Clinical guidelines and other practices for improving quality of care by health plans from the perspective of their operators in Brazil]

This study aimed to characterize the implementation of clinical guidelines and other instruments and practices for health care quality improvement among health plan operators in Brazil. It was a national cross-sectional descriptive study, initially considering 1,573 health plan operators registered in the National Agency for Supplementary Health Care. The sample design was complex, stratified by macro-region, market segment, and number of beneficiaries. Ninety health plan operators agreed to participate and were interviewed. To obtain estimates for the universe of health plan operators, a sample expansion factor attributed per stratum was considered. Only 32.3% of the health plan operators implemented clinical guidelines, with important variation across regions and market segments. Clinical governance practices are still in the very initial stages. Challenges are presented with regard to health care incorporation as a dimension of management within health care organizations, including health plan operators. Initiatives to improve quality of care need to be integrated and conducted at the organizational level.

Identification and treatment of mental and substance use conditions: health plans strategies

BACKGROUND

Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment.

OBJECTIVES

The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies.

METHODS

In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total).

MEASURES

We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population.

RESULTS

Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies.

CONCLUSIONS

Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.

Use of surveillance data in developing geographic dissemination strategies: a study of the diffusion of olanzapine to Michigan children insured by medicaid

OBJECTIVE

The purpose of this study was to examine the diffusion of olanzapine to urban and rural children insured by Medicaid in Michigan by identifying prescribing clusters through surveillance of claims records.

METHODS

Prescription claims records for all antipsychotic medications for 3,567 children insured by Medicaid in Michigan from 1996 through 1998 were examined through the state Medicaid database. There were 29,069 pediatric prescriptions for antipsychotic medications; 2949 were for olanzapine (576 children, 510 providers). These data were linked to the Area Resource File, Provider Enrollment File, and Rural-Urban Commuting Area codes. Patient and provider locations were geocoded by ZIP code. Mixed logistic regression analysis was performed to determine the probability of a child's being prescribed olanzapine given certain community, patient, and provider characteristics. Spatial clusters were identified through the local Moron's L statistic and empirical Bayes standardized incidence rates.

RESULTS

Rural children were more likely than urban children to be prescribed olanzapine (odds ratio [OR], 1.29; P < 0.001). There were significant differences by age and sex, with older children and girls more likely than younger children and boys to be prescribed olanzapine (OR, 1.30 and 1.37, respectively; both, P < 0.001). At the county level, the number of pediatricians per primary care physician reduced the likelihood of a child's being prescribed olanzapine (OR, 0.88; P = 0.039). The effect of the number of available mental health professionals was not significant. The global Moran's L statistic was U indicating moderate clustering of the use of olanzapine.

CONCLUSION

Graphic surveillance data may be useful for studying the delivery and use of health cue services. Further research is needed to determine how this method can be used strategically to facilitate or impede the diffusion of new medications.

Effects of implementation of psychiatric guidelines on provider performance and patient outcome: systematic review

OBJECTIVE

To identify evidence from comparative studies on the effects of psychiatric guideline implementation on provider performance and patient outcome. Effects of different implementation strategies were reviewed.

METHOD

Articles published between 1966 and March 2006 were searched through electronic databases and hand search. A systematic review of comparative studies of structured implementation of specific psychiatric guidelines was performed. Rates of guideline adherence, provider performance data, illness detection and diagnostic accuracy rates were extracted in addition to patient relevant outcome data.

RESULTS

Eighteen studies (nine randomized-controlled trials, six non-randomized-controlled studies and three quasiexperimental before-and-after studies) were identified. Effects on provider performance or patient outcome were moderate and temporary in most cases. Studies with positive outcomes used complex multifaceted interventions or specific psychological methods to implement guidelines.

CONCLUSION

There is insufficient high-quality evidence to draw firm conclusions on the effects of implementation of specific psychiatric guidelines.

Coactivation of pre- and postsynaptic signaling mechanisms determines cell-specific spike-timing-dependent plasticity

Synapses may undergo long-term increases or decreases in synaptic strength dependent on critical differences in the timing between pre-and postsynaptic activity. Such spike-timing-dependent plasticity (STDP) follows rules that govern how patterns of neural activity induce changes in synaptic strength. Synaptic plasticity in the dorsal cochlear nucleus (DCN) follows Hebbian and anti-Hebbian patterns in a cell-specific manner. Here we show that these opposing responses to synaptic activity result from differential expression of two signaling pathways. Ca2+/calmodulin-dependent protein kinase II (CaMKII) signaling underlies Hebbian postsynaptic LTP in principal cells. By contrast, in interneurons, a temporally precise anti-Hebbian synaptic spike-timing rule results from the combined effects of postsynaptic CaMKII-dependent LTP and endocannabinoid-dependent presynaptic LTD. Cell specificity in the circuit arises from selective targeting of presynaptic CB1 receptors in different axonal terminals. Hence, pre- and postsynaptic sites of expression determine both the sign and timing requirements of long-term plasticity in interneurons.

Outpatient mental health utilization among commercially insured individuals: in- and out-of-network care

OBJECTIVE

This study examined the rates and correlates of out-of-network outpatient mental health specialty care.

RESEARCH DESIGN

Using administrative data from a large insurer, we examine the frequency of out-of-network utilization, analyze demographic and clinical characteristics of individuals receiving out-of-network care, and examine the types of service provided out-of-network.

RESULTS

Out-of-network outpatient mental health care was received by 15.4% of adults who used outpatient mental health services, with 11.8% of adult outpatient mental health users receiving only out-of-network care and 3.6% receiving both in-network and out-of-network care. Out-of-network users received significantly more outpatient mental health care than individuals receiving only in-network mental health care. Rates of out-of-network psychotherapy services were substantially greater than for other commonly provided mental health services.

CONCLUSION

A significant number of patients covered under this insurer received their outpatient mental health care out-of-network. This is most pronounced for individuals receiving psychotherapy. Further information is needed to improve our understanding of who seeks care from out-of-network providers and why as well as the effect of such care on clinical outcomes.

Continuing education at the cutting edge: promoting transformative knowledge translation

As the evidence-based practice movement gains momentum, continuing education practitioners increasingly confront the challenge of developing and conducting opportunities for achieving research uptake. Recent thinking invites new approaches to continuing education for health professionals, with due consideration of what knowledge merits uptake by practitioners, who should play what role in the knowledge transfer process, and what educational approach should be used. This article presents an innovative theory-based strategy that encompasses this new perspective. Through a facilitated experience of perspective transformation, clinicians are engaged in an on-the-job process of developing a deeply felt interest in research findings relevant to everyday practice, as well as ownership of that knowledge and its application. The strategy becomes a sustainable, integrated part of clinical practice, fitting naturally within its dynamic, unique environment, context, and climate and overcoming the barrier of time. Clinician experience of a top-down push toward prescribed practice change is avoided. With an expanded role encompassing facilitation of active learning partnerships for practice change, the continuing educator fosters a learning organization culture across the institution. The resultant role changes and leadership and accountability issues are elaborated.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.