Randomized trial of a leadership and organizational change strategy to improve the implementation and sustainment of digital measurement-based care in youth mental health services

对领导和组织变革策略进行随机试验，以改善青少年心理健康服务中基于数字测量的护理的实施和维持

• 批准号: 10166946
• 负责人: Nathaniel J. Williams
• 金额: $ 76.42万
• 依托单位: BOISE STATE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-06-01 至 2023-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10166946
• 关键词: Accounting; Address; Administrator; Adopted; Age; Algorithms; Big Data; Caring; Child Mental Health; Childhood; Climate; Clinic; Clinical; Clinical Research; Communities; Computer software; Consultations; Country; Data; Diagnosis; Electronic Health Record; Evidence based practice; Exhibits; Expenditure; Feedback; Funding; Health Services; Health Technology; Health system; Impairment; Income; Infrastructure; Intervention; Investments; Leadership; Link; Measurement; Mediating; Medical; Mental Health; Mental Health Services; Mental disorders; Modality; Motivation; Organizational Change; Outcome; Outpatients; Patient-Focused Outcomes; Patients; Pattern; Personal Satisfaction; Phase; Protocols documentation; Provider; Psychotherapy; Randomized Controlled Trials; Recommendation; Research; Research Personnel; Scientist; Service setting; Services; Social Environment; Symptoms; System; Testing; Time; Training; Training Programs; Treatment outcome; United States National Institutes of Health; Youth; base; behavior change; behavioral health; burden of illness; care systems; career; community setting; digital; digital health; disability; effective intervention; evidence base; experience; implementation efforts; implementation intervention; implementation strategy; improved; improved outcome; leadership development; mortality; organizational climate; provider behavior; randomized trial; social; social organization; symptomatic improvement; theories

PROJECT SUMMARY/ ABSTRACT Psychiatric disorders are the leading cause of mortality and disability among youth in high income countries, accounting for 21% of total disease burden, and afflicting 1 in 10 youths in the US with severe impairment. Over 1,200 effective interventions, or evidence-based practices (EBPs), have been shown to improve the well-being of youth with psychiatric disorders. However, despite these advances, less than half of youths treated in community settings experience symptom improvement, a situation largely attributed to the low rates at which community providers adopt EBPs and, even when adopted, the low fidelity with which EBPs are implemented and sustained. Digital measurement-based care (MBC) systems, which collect treatment outcome data from patients and provide clinicians with real-time feedback and recommendations based on ‘big data’ actuarial algorithms, are a high-impact digital health technology EBP shown in 29 RCTs to generate improvements in clinical outcomes (i.e., d=.3-.5) across patient ages, diagnoses, and treatment modalities. Despite this, digital MBC systems are rarely used in community settings for youth, and when they are, fidelity and sustainment are often poor. Recent reviews indicate that many of these implementation and sustainment deficits can be traced to a lack of organization-level ‘social infrastructure’ or social contexts and leadership that do not support and motivate clinicians to adopt and use MBC systems; without this organizational social infrastructure, many implementation efforts fail. These observations are consistent with organizational climate theory and theories of behavior change which we have integrated to generate our primary hypothesis: achieving effective implementation and sustainment of MBC in community settings requires mechanisms of a strong organizational implementation climate and high clinician motivation generated through effective clinic leadership. With NIH support, we have pilot tested a highly transportable implementation strategy called Leadership and Organizational Change for Implementation (LOCI) that targets these mechanisms. Preliminary studies in mental health clinics show that LOCI is feasible, acceptable, and improves implementation leadership and climate. We propose a randomized controlled trial of LOCI in 20 children’s mental health clinics, incorporating 120 clinicians and a total of 720 youth outpatients, to test LOCI’s effects relative to implementation as usual (IAU) on clinician fidelity and youth clinical outcomes of a well-established digital MBC intervention during two phases of initial implementation and sustainment. This project brings together an early career/new investigator (Williams) collaborating with experienced, NIH funded implementation scientists (Aarons, Ehrhart) to advance programmatic research on the leadership, organizational, and clinician mechanisms that improve digital MBC implementation and sustainment. The study will (1) test LOCI’s effects on clinician fidelity to MBC and youth clinical outcomes during initial implementation, and (2) sustainment; and (3) test the multilevel mechanisms that link LOCI to MBC fidelity.

项目概要/摘要 精神疾病是高收入青年死亡和残疾的主要原因 占总疾病负担的 21%，美国十分之一的青少年患有严重的疾病 损害。超过 1,200 种有效干预措施或循证实践 (EBP) 已被证明可以 改善患有精神疾病的青少年的福祉。然而，尽管取得了这些进步，但只有不到一半的人 在社区环境中接受治疗的青少年症状有所改善，这种情况很大程度上归因于 社区提供者采用 EBP 的比率较低，即使采用了，EBP 的保真度也较低 得到实施和持续。基于数字测量的护理 (MBC) 系统，收集治疗数据 来自患者的结果数据，并为临床医生提供基于“大数据”的实时反馈和建议 data 的精算算法是一种高影响力的数字健康技术 EBP 在 29 项随机对照试验中显示，可生成 不同患者年龄、诊断和治疗方式的临床结果（即 d=.3-.5）得到改善。 尽管如此，数字 MBC 系统很少在青少年社区环境中使用，即使使用，保真度 和维持往往很差。最近的审查表明，其中许多实施和维持 缺陷可以追溯到组织层面的“社会基础设施”或社会环境和领导力的缺乏 不支持和激励临床医生采用和使用 MBC 系统；如果没有这种组织性的社会 基础设施方面，许多实施努力都失败了。这些观察结果与组织氛围一致 我们将其整合以产生我们的主要假设： 在社区环境中实现 MBC 的有效实施和维持需要建立以下机制： 通过有效的诊所产生强大的组织实施氛围和高度的临床医生积极性 领导。在 NIH 的支持下，我们试点测试了一种高度可移植的实施策略，称为 针对这些机制的领导力和组织实施变革 (LOCI)。初步的 精神卫生诊所的研究表明 LOCI 是可行的、可接受的，并且可以改善实施 领导力和氛围。我们建议在 20 个儿童心理健康诊所开展一项 LOCI 随机对照试验， 纳入 120 名临床医生和总共 720 名青少年门诊患者，以测试 LOCI 相对于 照常实施（IAU），以评估成熟的数字 MBC 的临床医生保真度和青年临床结果 在初始实施和维持两个阶段进行干预。 该项目汇集了一位早期职业/新研究者（威廉姆斯）与经验丰富的 NIH 合作 资助实施科学家（Aarons、Ehrhart）推进领导力的规划研究， 改善数字 MBC 实施和维持的组织和临床机制。研究 (1) 在最初实施期间测试 LOCI 对临床医生对 MBC 忠诚度和青少年临床结果的影响， (2) 维持； (3) 测试将 LOCI 与 MBC 保真度联系起来的多级机制。