Implementation of collaborative care for depression in VA HIV clinics: Translating Initiatives for Depression into Effective Solutions (HITIDES)

项目摘要/摘要 背景：艾滋病毒将抑郁的倡议转化为有效的解决方案(HITIDES)是一种合作 护理干预，使抑郁症治疗的初级保健协作护理模式适应艾滋病毒诊所。 在一项随机对照试验中，HITIDES显著改善退伍军人的抑郁症状 艾滋病毒(VLWH)并实现了成本节约。然而，没有VHA艾滋病毒诊所实施HITIDES。目标是 这项研究的目的是通过测试两个适当的方法来支持HITIDES干预措施的广泛实施 实施策略：来自每个站点的一名临床冠军，在学习协作的帮助下 同行将与当地临床医生和领导层合作，在其网站上与和实施HITIDES干预 在没有执行专家提供外部协助的情况下。 意义/影响：初步工作已经完成，以确定可接受的执行战略 VLWH和艾滋病毒护理提供者；然而，这些实施战略的相对有效性和成本 是未知的。而HITIDES抑郁症护理团队(DCT)位于异地，可以提供服务 始终保持高质量和保真度，DCT与艾滋病毒护理提供者对接和接触的能力 地点尚不清楚。此外，REACH和REACH等现场一级实施成果的中介作用 目前尚不清楚干预措施的有效性。因为DCT可以为多个 对于艾滋病毒诊所，在考虑在全国推广之前，需要小规模地推出干预措施。 创新：本研究采用创新的混合研究设计，同时检查实施情况和 有效性结果。使用执行成功作为干预的中介因素 有效性也是新奇的。执行活动对弱势群体护理产生影响的相对能力 人口是一个鲜为人知的研究领域。VHA HIV诊所是检查的理想测试案例 这些问题是因为VLWH是一个少数民族、低收入、性少数的退伍军人群体 不成比例的代表。 具体目标：1)通过在VHA艾滋病毒诊所中进行的整群随机对照试验，确定 为实施战略增加外部便利，该战略包括现场一级临床冠军和 协作性学习。2)确定Hitides对抑郁症和自杀意念变化的影响 在接受干预的艾滋病毒阳性退伍军人中。3)估计HITIDES对预算的影响 通过计算每项战略的成本来实施战略。 方法：使用混合型3型有效性-实施试验来检查 实施和干预有效性是一种创新的方法，适用于缺乏 对有效性的有力证据与节约成本的干预措施相结合。此混合试验将使用集群 8个VHA HIV诊所的随机抽样。选择这些诊所是为了实现诊所的平衡和多样化。 特征，并随机分配到两个实施臂中的一个。对每个目标的评估将使用 主要(例如，QUERI开发的时间跟踪工具)和次要(例如，临床数据仓库)的混合 数据。我们希望临床冠军、学习协作和外部促进部门能够相互关联 具有更大的覆盖面和采用率；然而，临床冠军和协作学习的独家ARM 预计成本会更低。 下一步：对8家VHA艾滋病毒诊所实施HITIDES干预的结果将用于 告知未来广泛推广的实施战略的选择。调查结果将在 与我们的运营合作伙伴VA HIV、丙型肝炎和VACO相关条件计划合作 VISN领导层。

Project Summary / Abstract Background: HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) is a collaborative care intervention that adapts the primary care collaborative care model for depression treatment to HIV clinics. In a randomized controlled trial, HITIDES significantly improved depression symptoms for Veterans Living with HIV (VLWH) and delivered cost savings. However, no VHA HIV clinics have implemented HITIDES. The goal of this study is to support broad implementation of the HITIDES intervention by testing two appropriate implementation strategies: a clinical champion from each site who, with the help of a learning collaborative of peers, will work with local clinicians and leadership to implement the HITIDES intervention at their site with and without the assistance of external facilitation from an implementation expert. Significance/Impact: Preliminary work has been completed to identify implementation strategies acceptable to VLWH and HIV care providers; however, the relative effectiveness and cost of these implementation strategies is unknown. While the HITIDES depression care team (DCT) is housed off-site and can deliver services consistently with high quality and fidelity, the ability of the DCT to interface and engage with HIV care providers at sites is unknown. Additionally, the mediating effect of site-level implementation outcomes such as reach and adoption on effectiveness of the intervention is unknown. Because the DCT can provide services to multiple HIV clinics, a small-scale rollout of the intervention is needed before considering a national roll out. Innovation: This study employs an innovative hybrid study design to concurrently examine implementation and effectiveness outcomes. The use of implementation success as a mediating factor for intervention effectiveness is also novel. The relative ability of implementation activities to impact care for vulnerable populations is an area of research where little is known. VHA HIV clinics are an ideal test case for examining these questions because VLWH are a group where racial minority, low income, sexual minority Veterans are disproportionately represented. Specific Aims: 1) Determine, through a cluster-randomized controlled trial among VHA HIV clinics, the effect of adding external facilitation to an implementation strategy consisting of a site-level clinical champion and learning collaborative. 2) Determine the impact of HITIDES on changes in depression and suicidal ideation among HIV-positive Veterans receiving the intervention. 3) Estimate the budget impact of HITIDES implementation strategies by calculating the costs of each strategy. Methodology: The use of a hybrid type-3 effectiveness-implementation trial to examine the interaction of implementation and intervention effectiveness is an innovative methodology ideal for situations where the lack of robust evidence of effectiveness is coupled with a cost-saving intervention. This hybrid trial will use a cluster randomization of 8 VHA HIV clinics. These clinics will be chosen for balance and diversity of clinic characteristics and randomly assigned to one of the two implementation arms. Evaluation of each aim will use a mix of primary (e.g., QUERI-developed time-tracking tool) and secondary (e.g., clinical data warehouse) data. We expect the clinical champion, learning collaborative, and external facilitation arm to be associated with greater reach and adoption; however, the clinical champion and learning collaborative alone arm is expected to be less costly. Next steps: The findings from implementation of the HITIDES intervention to 8 VHA HIV clinics will be used to inform selection of implementation strategies for a broad roll out in the future. Findings will be presented in cooperation with our operational partner, VA HIV, Hepatitis C, and Related Condition Program to VACO and VISN leadership.