Type III Hybrid Effectiveness-Implementation Trial of a Clinical Decision Support System for the Implementation of Problem Solving Treatment in Community Health Centers

摘要 以证据为基础的临床干预措施通常提供的保真度很低，很快就被从业者抛弃了 训练结束后。针对这些发现，我们与从业者和客户合作，共同设计了一个 支持抑郁症问题解决治疗(PST)的自动决策支持工具。PST-Aid是一个网络- 基于应用程序，在使用PST设定目标和制定行动计划时促进从业者与客户的协作， 我们将其概念化为教育和重组实施战略。 我们建议通过与合作伙伴OCHIN Health的利益相关者团体合作，进一步重新设计PST援助 信息学网络，包括45个州的300个独立社区卫生中心，为 &gt；每月有130,000个独立客户。我们将进行混合型III型有效性-随机实施 标准PST实施与PST-aid强化PST实施的临床试验比较 实施战略。我们将测试：1)PST援助是否会改善实施结果(初步 和持续的保真度、采用率、覆盖范围和减少反应性适应)；2)可用性、参与度、 适当性在PST援助对实施效果的影响中起中介作用；3)PST援助更多 有效减轻患者抑郁症状，改善功能。 我们将在PST培训来自20-30个OCHIN诊所的60名从业者，然后随机分配他们接受PST- 援助VS PST照常进行。我们将招募多达350名抑郁症状加重的客户(PHQ-9&>10)，或 平均每个接受过PST培训的从业者5-6人。 嵌入电子健康记录中的以客户和从业者为中心的决策支持工具，如PST助手 有可能提高循证干预措施的适当性、参与度和可用性。这个 这类工具能够支持PST等临床干预要素的保真度，同时降低 负担，将是在提供护理方面向前迈出的重要一步，并将对一系列 有效但很少使用的干预措施。

ABSTRACT Evidence-based clinical interventions are often delivered with poor fidelity and abandoned by practitioners soon after training. In response to these findings, we have worked with practitioners and clients to co-design an automated decision support tool supporting Problem Solving Treatment (PST) for depression. PST-Aid is a web- based app that promotes practitioner–client collaboration in the use of PST for goal setting and action planning, which we conceptualize as an educate and reorganize implementation strategy. We propose to further redesign PST Aid by working with stakeholder groups from our partnering OCHIN health informatics network, which includes >300 independent community health centers across 45 states serving >130,000 unique clients monthly. We will conduct a hybrid type III effectiveness-implementation randomized clinical trial comparing standard PST implementation with PST implementation augmented by the PST-Aid implementation strategy. We will test whether: 1) PST Aid results in improved implementation outcomes (initial and sustained fidelity, adoption, reach, and reduced reactive adaptations); 2) changes in usability, engagement, and appropriateness mediate the effect of PST Aid on implementation outcomes; and 3) PST Aid is more effective in reducing client depressive symptoms and improving functioning. We will train 60 practitioners from 20–30 OCHIN clinics in PST, and then randomly assign them training in PST- Aid vs PST as Usual. We will recruit up to 350 clients with elevated depressive symptoms (PHQ-9>10), or an average of 5–6 per each practitioner trained in PST. Client and practitioner-centered decision-support tools embedded in electronic health records such as PST Aid have the potential to enhance appropriateness, engagement, and usability of evidence-based interventions. The ability of such tools to support fidelity to elements of clinical interventions like PST, while at the same time reducing burden, would represent a major step forward for the delivery of care and would have implications for a range of effective but seldom used interventions.