OBJECTIVE AND DESIGN: This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline‐concordant acute‐phase care for patients with current major depression. PARTICIPANTS AND SETTING: Two hundred thirty‐nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty‐six (27.6%) patients identified as failing to meet criteria for guideline‐concordant treatment 8 weeks following the index visit were the focus of this analysis. METHODS: The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline‐concordant acute‐phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles. RESULTS: The cluster analysis produced a 5‐cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient‐centered barriers. Physician‐centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty‐eight percent of the patients not initiating guideline‐concordant acute‐stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters. CONCLUSIONS: Current interventions fail to address barriers to initiating guideline‐concordant acute‐stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute‐stage care, additional work is also needed to develop new intervention components that address these barriers.

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OBJECTIVE: To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression. DESIGN:Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales. SETTING:Twelve community primary care practices across the country employing no onsite mental health professional.PATIENTS: Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up. INTERVENTION:Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression. MAIN RESULTS:In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P = .04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P = .007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P = .07), and satisfaction with care (P = .02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention. CONCLUSIONS:In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Purpose Practice Based Research Networks (PBRNs) are a part of many National Institutes of Health (NIH) funded Clinical and Translational Science Award (CTSA) sites. PBRNs, groups of primary care practices committed to collaborating on practice-relevant research, are unfamiliar to many CTSA leaders. Conversely, the CTSAs, as new research structures designed to transform clinical research, are unfamiliar to many PBRN Directors. This study examined the extent to which these programs have congruent goals and expectations, and whether their engagement is likely to be mutually beneficial. Method The authors sent a web-based survey to 38 CTSA Community Engagement Directors and a similar survey to 114 PBRN Directors during Fall 2008. Results The investigators received responses from 66% (25/38) of CTSA Community Engagement Directors and 61% (69/114) of PBRN Directors. Two-thirds of responding CTSAs reported working with PBRNs and over half of responding PBRNs reported a CTSA affiliation. Both groups indicated this relationship was important. CTSAs looked to PBRNs for access to patients and expertise in engaging communities and clinical practices. PBRNs reported seeking stable infrastructure support and greater collaboration and visibility in the academic research community. PBRN infrastructure support from CTSAs was highly variable. Both groups perceived considerable promise for building sustainable relationships and a bi-directional flow of information and research opportunities. Conclusions With less than three years of experience, the PBRN/CTSA relationship remains in the discovery phase, and the participants are still negotiating expectations. If these collaborations prove mutually beneficial, they may advance the community engagement goals of many academic health centers (AHCs).

PURPOSEWe compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an offi ce-based patient interview survey conducted within the American Academy of Family Physicians National Research Network. METHODSWe asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form fi rst. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data.RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical diffi culties experienced with electronic data collection and stolen or lost handheld computers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electronically had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms.CONCLUSIONS Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical diffi culties with the handheld computers or loss or theft. Other hardware solutions, such as tablet computers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.

Purpose To test the effect of an Appreciative Inquiry (AI) quality improvement strategy, on clinical quality management and practice development outcomes. AI enables discovery of shared motivations, envisioning a transformed future, and learning around implementation of a change process. Methods Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical record review assessed change in PSD rates. Ethnographic fieldnotes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. Results PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited one or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. Conclusions An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.