Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• Dissemination and implementation
• e.g., of health system strategies

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of strategies to disseminate and implement research findings and new discoveries into community practice to foster evidence-based, state-of-the-art treatment.
• Compare the effectiveness of strategies to advance evidence-based practices using dissemination and demonstration projects.
• Compare the effectiveness of various strategies to approach communities for the dissemination of evidence-based treatment approaches and the impact on outcomes.
• Compare the effectiveness of strategies designed to increase communication across sectors relevant to coordination of evidence-based care for SMI patients with comorbid psychiatric disorders, with a specific focus on substance abuse and psychotic disorders and symptoms.
• Compare the effectiveness of strategies for appropriate hospital and ED discharge planning and care coordination in preventing homelessness and incarceration of SMI patients.
• Compare the effectiveness of alternative approaches for dissemination of evidence-based guidelines, including different formats, media, incentives, technologies, and decision support resources/systems vs. usual care.
• Compare the effects of different patient demographic characteristics, preferences, and resources as predictors of practitioner adherence to evidence-based guidelines? Is there sufficient evidence for use of any of these factors in implementation/dissemination to direct/inform treatment decision-making and treatment recommendations, especially when there are alternative evidence-based treatment approaches to consider? Is there evidence of an interaction between any patient variables noted above and the dissemination approach? What are the implications with regard to development evidence-based clinical practice guidelines and patient-treatment matching?
• (Similar to above) Compare the effects of different practitioner demographic characteristics and treatment preferences/beliefs, as well as health care system and/or treatment settin

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

• Patients with Serious Mental Illness (SMI)
• Patients with specific mental illnesses

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• SMI patients treated in the public sector, who may be at high risk for homelessness and incarceration
• Any sub-groups, including different patient demographic characteristics, primary SMI diagnosis, medical/psychological co-morbidities, and attitudes, preferences, and resources that may influence practitioner decision making or practitioner-patient interaction in practice.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Understanding and implementation of evidence-based, state-of-the-art treatment
• Culturally relevant dissemination of evidence-based guidelines
• Greater use of (adherence to) evidence-based guidelines by practitioners in “real world” practice.
• Improved practitioner beliefs and attitudes towards evidence-based practice/guidelines, including those related to trust/belief in value of guidelines (for their patients) and the importance of routine use of guidelines.
• Better patient treatment adherence – due to improved matching of patients (e.g., in terms of characteristics, preference, and resources) to treatment recommendations and services.
• Coordination of evidence-based care across the mental health, social welfare, and criminal justice systems to prevent SMI patients in the public sector from falling through the cracks can potentially prevent homeless or incarceration for these vulnerable patients.

Describe any health-related risks, side effects, or harms that you are concerned about.

• There is emerging evidence that disruptions in continuity of access to clinically indicated medications can negatively affect the course of disease in seriously ill psychiatric patients and potentially precipitate adverse clinical and life events. For example, clinically stable Medicaid psychiatric patients who were required to switch or discontinue medications because of prescription drug management plans were more likely to become homeless, be seen in emergency departments, or be incarcerated.
• Exacerbation of patient symptomatology and/or functioning – Practitioner adherence to guideline may interfere with practitioner provision of treatment and/or damage the therapeutic alliance, resulting in poorer patient response/outcomes and perhaps even deterioration.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

• There is a need for more work on implementation science. More work on science in mental health is also needed because so much remains unknown.
• Few theoretical models have been developed and tested as frameworks for improving adherence to evidence-based guidelines for patients with SMI.
• Evidence-based practice (evidence-based guidelines) will not improve patient care unless they are accepted and utilized by practitioners; however, many studies show very low adherence to evidence-based guidelines and recommendations.
• Most, but not all, research suggests that adherence to evidence-based guidelines is associated with improved patient outcomes/response to treatment; it is important to understand the factors accounting for this variation.
• Patient care/treatment outcomes may be improved through research on approaches to using evidence-based clinical practice guidelines in patient-practitioner shared decision making and informed consent. In other words, achieving a better understanding of how to incorporate guidelines into patient care such that, at a minimum, they do not have a negative impact of quality of care.
• Because there is considerable variation in treatment for serious mental illness (SMI), dissemination and implementation research is needed. Recent studies have shown that many patients with SMI do not receive treatments that are consistent with evidence-based guidelines. The Schizophrenia Patient Outcomes Research Team (PORT) client survey reported that the rates at which patients’ treatment conformed to the recommendations were modest at best, generally below 50%. In addition, conformance rates were higher for pharmacological than for psychosocial treatments. There is very little comparative evidence on the use of combinations of treatments.
• Research is needed to determine best practices for approaching communities and whether or not this affects outcomes.
• There is a continuing gap between development and testing of evidence-based treatme

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

• I have been involved in studies of the potentially negative consequences of prescription drug management plans on the course of disease in seriously ill psychiatric patients, especially those in the public sector. I have also been involved in developing self-assessment tools for psychiatrists that are geared toward applying evidence-based approaches in clinical practice, and in efforts to disseminate measurement-based care for PTSD.
• Current/prior models (e.g., Diffusion of innovation, stages of change) have provided a better understanding of some of the critical determinants of evidence-based practitioner behavior; however, these models only account for a small portion of the variance. There is a need for research focused on the development and evaluation of new and more comprehensive/integrative models to inform guideline implementation practices.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

• It is likely that optimal strategies for dissemination are not “one size fits all” but will differ depending on community-specific circumstances.
• Uncertainty regarding evidence-based approaches and strategies to improve use of evidence-based guidelines in real word mental health care (e.g., private practice).

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

• Rapid and sustained dissemination of evidence-based practices is highly relevant to psychiatrists and their patients. The American Board of Psychiatry and Neurology will make self-assessment mandatory for maintenance of certification by 2014; self-assessments must represent the state of the art in evidence-based practices.

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

There appear to be vulnerable subgroups of patients receiving care in the public sector who may be at high risk for homelessness, incarceration, or both, and represent a substantial burden for states.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

• Rapid and sustained dissemination of evidence-based practices is highly relevant to psychiatrists and their patients. The American Board of Psychiatry and Neurology will make self-assessment mandatory for maintenance of certification by 2014; self-assessments must represent the state of the art in evidence-based practices.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

1- Through AHRQ and CTSA activities. Our organization was invited to send a participant to the Issues Exploration Forum on Mental Health; 2- Through AHRQ and CTSA activities; 3- I was invited to participate in the Issues Exploration Forum on Mental Health as a representative of the American Psychiatric Institute on Research and Education.