BackgroundThe prevalence of comorbid anxiety and depressive disorders is high among patients with chronic diseases in primary care, and is associated with increased morbidity and mortality rates. The detection and treatment of common mental disorders in patients with chronic diseases can be challenging in the primary care setting. This study aims to explore the perceived needs, barriers and facilitators for the delivery of mental health care for patients with coexisting common mental disorders and chronic diseases in primary care from the clinician and patient perspectives.MethodsIn this qualitative descriptive study, we conducted semi-structured interviews with clinicians (family physician, nurse, psychologist, social worker; n = 18) and patients (n = 10) from three primary care clinics in Quebec, Canada. The themes explored included clinician factors (e.g., attitudes, perception of roles, collaboration, management of clinical priorities) and patient factors (e.g., needs, preferences, access to care, communication with health professionals) associated with the delivery of care. Qualitative data analysis was conducted based on an interactive cyclical process of data reduction, data display and conclusion drawing and verification.ResultsClinician interviews highlighted a number of needs, barriers and enablers in the provision of patient services, which related to inter-professional collaboration, access to psychotherapy, polypharmacy as well as communication and coordination of services within the primary care clinic and the local network. Two specific facilitators associated with optimal mental health care were the broadening of nurses’ functions in mental health care and the active integration of consulting psychiatrists. Patients corroborated the issues raised by the clinicians, particularly in the domains of whole-person care, service accessibility and care management.ConclusionsThe results of this project will contribute to the development of quality improvement interventions to increase the uptake of organizational and clinical evidence-based practices for patients with chronic diseases and concurrent common mental disorders, in priority areas including collaborative care, access to psychotherapy and linkages with specialized mental health care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0531-y) contains supplementary material, which is available to authorized users.
Background: Anxiety and depressive disorders are increasingly recognized as a health care policy priority. Reducing the treatment gap for common mental disorders requires strengthening the quality of primary mental health care. We developed a knowledge application program designed to improve the organization and delivery of care for anxiety and depression in community-based primary mental health care teams in Quebec, Canada. The principal objectives of the study are: to implement and evaluate this evidence-based knowledge application program; to examine the contextual factors associated with the selection of local quality improvement strategies; to explore barriers and facilitators associated with the implementation of local quality improvement plans; and to study the implementation of local quality monitoring strategies.
The ADAPTE methodology provided structure, rigour and efficiency to the trans-contextual adaptation of guideline recommendations. We will share the challenges associated with the adaptation of clinical recommendations and organizational strategies for a mental health guideline, and the dissemination of the practice protocol in primary care.
MethodsWe searched the WHO website for GRC-approved guidelines published between 2008 and November 2012. Two individuals independently appraised the guidelines using AGREE II. Scores were standardised across six domains and overall quality was determined through consensus. Results Eighty guidelines fulfilled inclusion criteria and were appraised. Twenty-seven guidelines were recommended, 47 were recommended with modifications, and six were not recommended. Two domains of AGREE scored highly across all guidelines: scope and purpose and clarity of presentation. The rigour of development and applicability domains were variable across guidelines. The lowest scoring domains were stakeholder involvement and editorial independence. Discussion WHO guidelines still need improvement in the following areas: stakeholder engagement, use of systematically reviewed evidence, defining the funder's role, consideration of barriers and resources (including costs) when implementing recommendations, and providing monitoring criteria. Most issues may be resolved through increased transparency and better reporting of the recommendation development process by more closely following the standards set forth in the WHO guideline development handbook. Implications for Guideline Developers/Users Guideline developers need to ensure systematic guideline development processes are followed and adequately reported in each guideline. P133 APPROACHING ECONOMIC EVALUATION IN SOCIAL CARE GUIDANCET Smith, E Shaw, N Baillie. National Institute for Health and Care Excellence, Manchester, UK 10:1136/bmjqs-2013-002293.176Background We have a statutory responsibility to produce social care guidance. For economic evaluation challenges include: 1. Methodology for a multi-stakeholder perspective (costs and outcomes), and determining measures of effects using standardised outcomes. 2. Decision making in the absence of accepted willingness to pay thresholds, and alignment with principles used for health guidelines. Objectives To define an economic reference case for social care guidance. Methods A workshop on methods identified potential approaches. Health economists who work on clinical and public health guidelines were consulted to ensure consistency. Methodological issues were discussed with academic experts. Results A reference case for social care economic evaluation was produced within a methods manual before commencing guidance development. It recognises the need for flexibility as methodology develops. Discussion Social care economic evaluation is constrained by the quality of evidence, and the transferability of studies. Equity considerations in the context of means-tested service provision, and the issue of unpaid care, represent examples of how decision making on cost-effectiveness must take account of factors not usually considered for clinical and public health guidelines. Implications for Guideline Developers/Users Consistent decision-making principles must be applied across all guidance development programmes, including social care cost-effectiv...
Background The Dutch College of General Practitioners (NHG) has produced almost 100 guidelines. Guideline adherence is on average 70-75%, but varies between general practitioners and between guideline recommendations. A computerised decision support system (CDSS) could improve guideline adherence. Objectives To describe the development and implementation of a CDSS (NHGDoc) for general practice in the Netherlands. Methods NHGDoc is a collaborative effort between the NHG and ExpertDoc, the company that developed the CDSS. Relevant recommendations of eight NHG guidelines were translated into algorithms, generating specific alerts. All alerts were reviewed and authorised by guideline developers of the NHG. NHGDoc was integrated in two out of seven electronic health record systems used in Dutch general practice. Since 2008, users were regularly interviewed regarding their experiences with NHGDoc. Results Integration of eight guidelines in NHGDoc generated alerts in approximately 30% of all patient records. Alert frequency varied in accordance with disease prevalence. Currently, 1100 general practices (appr. 25% of Dutch general practices) are using NHGDoc. Users highly appreciated the content and lay out of the alerts, but preferred more control regarding the timing and frequency of the alerts. Discussion NHGDoc is well received and appreciated in general practice. To enhance the success of NHGDoc the user-friendliness of the system could be further improved. Future research should provide evidence on the effectiveness of NHGDoc in terms of improving quality of care. Implications for Guideline Developers To improve guideline adherence, CDSSs should have user-friendly designs, including options to personalise the decision support to meet the needs of individual users.
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