抑郁症导致冠心病(CHD)患者的健康状况不良。尽管指南建议对患有冠心病的抑郁症患者进行筛查和治疗,很少有患者得到最佳护理。我们应用行为和实施科学方法来(1)识别可概括的,冠心病患者抑郁筛查和治疗的多层次障碍,(2)发展理论,促进指南采用的多层次实施策略。
我们对冠心病患者抑郁症筛查和治疗的障碍进行了叙述性回顾(即,药物,锻炼,心脏康复,或治疗),包括748名研究参与者的数据。由行为变更轮框架和实施变更的专家建议通知,我们定义了多层次的目标行为,表征的决定因素(能力,机会,动机),并绘制了可行的障碍,可接受,和公平的干预功能和行为改变技术,以制定多层次的实施战略,针对医疗保健系统/提供者和患者。
我们确定了系统/提供商级别的实施障碍(例如,能力:知识;机会:工作流集成;动机:所有权)和患者水平(例如,能力:知识;机会:流动性;动机:症状否认)。可接受,可行,公平的干预功能包括教育,说服,环境结构调整,和启用。实施变革战略的专家建议包括学习协作,审计,反馈,和教育材料。促进抑郁症筛查/治疗的最终多成分策略(iHeartDepCare)包括与诊所工作人员(系统)举行解决问题的会议;教育/激励视频,电子健康记录提醒/决策支持(提供者);以及具有多种功能的共享决策(电子共享决策)工具,例如,患者激活,患者治疗选择支持。
我们应用实施和行为科学方法来确定实施障碍,并制定多层次实施策略,以增加冠心病患者对抑郁症筛查和治疗的吸收。将在未来的混合II有效性实施试验中评估多级实施策略。
Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite
guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting
guideline adoption.
We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.
We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.
We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.