Implementing a stepped-care approach in primary care: results of a qualitative study
Implementing a stepped-care approach in primary care: results of a qualitative study
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DOI：
10.1186/1748-5908-7-8
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发表时间：
2012-01-31
影响因子：
7.2
通讯作者：
Grol, Richard
中科院分区：
文献类型：
--
作者：
Franx, Gerdien;Oud, Matthijs;Grol, Richard
背景：自2004年以来，“阶梯式护理模式”已被一些国际循证临床指南所采用，以指导临床医生组织抑郁症护理。为了加强这种新的治疗方法的采用，荷兰发起了质量改进协作（QIC）。方法：除QIC外，采用前后对照设计进行干预研究。研究的一部分是过程评估，利用半结构化的小组访谈，以深入了解参与临床医生对日常抑郁症的阶梯式护理的看法。参与者是来自荷兰8个地区的初级保健临床医生、专科临床医生和其他保健工作人员。分析得到了正常化过程理论（NPT）的支持。结果：在抑郁症QIC的背景下，初级保健团队对抑郁症的阶梯式护理模式的引入普遍受到参与临床医生的好评。所提出的逐步护理模式的所有三个要素（患者分化、逐步护理治疗和结果监测）都被翻译并在当地引入。临床医生报告说，在学习如何区分患者群体和不同级别的护理方面发生了变化，改变了抗抑郁药的处方程序，因为他们可以为患者提供更广泛的治疗方案，并与患者和同事建立了更好的工作关系。一系列复杂的因素影响了执行过程。阶梯式护理模式本身、结构化的团队会议（QIC方法的一部分）以及患者对阶梯式护理的积极反应是促进因素。多学科卫生团队对抑郁症和抑郁症治疗的不同看法、资源的缺乏和信息系统的落后阻碍了分步治疗模式的快速引入。《不扩散核武器条约》构建的“一致性”和“认知参与”似乎是该进程初始阶段的关键驱动因素。结论：抑郁症的阶梯式护理在初级保健中得到了积极的接受。虽然很难在短时间内实施完整的分步治疗方法，但临床医生可以在实现分步治疗方法方面取得进展，特别是在QIC的背景下。在处理实施过程时，在多学科团队中建立对抑郁症构成的共同理解，就抑郁症护理的内容达成共识，以及任务分工是很重要的。
Background: Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands.Methods: Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT).Results: The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process.Conclusions: Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process.