Aligning priorities: Treating depression in primary care. Paul J.

Transcription

1 Aligning priorities: Treating depression in primary care Paul J. Grand Rounds Psychiatry February 2 th 2016

2 Team Rachel Forcino Manish Mishra Michelle Dannenberg Lisa Marsch Yaara Zisman-Ilani Jim Matthews Steve Bartels Glyn Elwyn Erick Turner Paul Holzheimer Rachel Blitzer Neil Korsen Michelle Hinn Magenta Simmons

3 Disclosures Funding o Moore Foundation NIH BUPA Co-Developer o CollaboRATE (3 item measure of shared decision making, freely available CC License)

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8 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

9 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

10 Naoki Fuku Cloud Art Coffee Exhibition, 2014 Amsterdam, NL.

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14 Poor Care

15 Too much treatment Too little treatment

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19 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

20 National survey What matters most to consumers and clinicians in choosing depression treatments Barr, Forcino, Mishra et al. Competing priorities in treatment decision making: a US national survey of individuals with depression and clinicians who treat depression. BMJ Open. 2016

21 National survey Elicit consumer and clinician information priorities for the treatment of depression Identify areas of overlap and divergence between consumers and clinicians Assess the level of shared decision making experienced by individuals with depression

22 National survey - Eligibility National surveys (online) Individuals with (or resolved) depression o >18 years Read & write in English USA Clinicians who treat depression (last 12 months) o Read & write in English USA

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25 National Survey clinician rankings Clinicians asked to take 2 perspectives o What they feel the consumer needs to know o What they feel the consumer wants to know

26 National survey recruitment Recruitment Convenience sample o Quotas for consumers based on epidemiological data of US adults with depression representativeness o Paid for ads & internet panels for low quotas Collaborated with >15 healthcare orgs, advocacy groups

27 Results

28 Consumer survey n=972 Female 69% Mean age Treatment status In treatment Past treatment Awaiting treatment Most recent depression consultation <7days 7days 1 month 1 month 6 months > 6months Treatment ever used Medication Talk therapy Lifestyle change Alternative therapy Clinician visited Therapist Psychiatrist PCP 43 (SD13) 78% 17% 5% 23% 28% 27% 22% 93% 72% 42% 15% 35% 34% 24%

29 Clinician survey n=244 Female 52% Mean age 47 (SD 13) Specialty Therapist (Social Worker, Psychologist, LPC) Primary care /Internal Medicine Physician Psychiatrist Psychiatric/Mental Health Nurse Other Proportion of previous years clients with depression Majority Substantial portion Few Treatment you most commonly request Antidepressant medication Talk therapy Combination therapy 45% 33% 10% 3% 9% 28% 62% 10% 27% 31% 31%

30 Rankings Rank Consumer Clinician * Tie What consumers need to know 1 Will the treatment work? Will the treatment work? What are the side effects of How long before the patient 2 this treatment? feels better? Is the treatment covered by What are the side effects of 3 insurance? this treatment? 4 How long before I feel better? How does the treatment work? 5 How much does this treatment cost? What is involved in using the treatment?

31 Rankings Rank Consumer Clinician * Tie What consumers need to know What consumers want to know 1 Will the treatment work? Will the treatment work? Will the treatment work? What are the side effects of How long before the patient How long before the patient 2 this treatment? feels better? feels better? Is the treatment covered by What are the side effects of How much does the 3 insurance? this treatment? treatment cost? 4 How long before I feel better? How does the treatment work? Is the treatment covered by insurance?* How much does this What is involved in using the What are the side effects of 5 treatment cost? treatment? this treatment?*

32 Please think back to the last time you had a visit with a health care provider where a decision was made about how to treat your depression. 1. How much effort was made to help you understand your health issues? No effort was made Every effort was made 2. How much effort was made to listen to the things that matter most to you about your health issues? No effort was made Every effort was made 3. How much effort was made to include what matters most to you in choosing what to do next? No effort was made Every effort was made

33 SDM Consumer survey n=972 CollaboRATE score 18% (95% CI 16, 21) By clinician most commonly visited Therapist Psychiatrist PCP 18% (95% CI 14, 24) 23% (95% CI 18, 28) 14% (95% CI 9, 20)

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35 Competing priorities SDM is lacking

36 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

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38 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

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40 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing How does this work? Will this work? What are the side-effects? How much does this cost? Is there anything else I can do?

41 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Cited literature Whiteford et al (2013) Hegel et al (2006) Meredith et al (2007) Dwight Johnson, Meredith et al (2006) Cuijpers et al (2009) Cuijpers et al (2009) Guidelines Existing decision aids NICE (UK) Beyond Blue (Aus) AHRQ guidelines Cuijpers et al (2013) Richards et al (2012) Hoffman et al (2012) Whiteford et al (2013) Turner et al (2008) Warmerdam et al (2010) Mayo Clinic depression medication issue card

42 Initial version of OGDA for depression (sample section)

43 Depression in the US Overview What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

44 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing

45 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Assess understandability, meaning, face validity and clarity of the Option Grid decision aid for depression with target end users (consumers, general public & clinicians)

46 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Cognitive interviews o Iterative validation technique o Overt & covert problems with interpretation o Semi-structured questions & probes o o o o o Purpose of Grid & for who? Layout Words used (confusing poorly worded?) Missing questions When should it be used

47 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing 3 phases: i. Consumers & general public ii. Consumers & general public iii. Primary care clinicians (including integrated behavioral healthcare) 6 participants per stakeholder group

48 Results So far

49 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing

50 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Visually appealing and easy to use I think that it`s organized in a way that makes sense, the columns make it easy to understand how it`s organized and I think that it has useful information but not so much information that it feels overwhelming.

51 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Comprehensive It really does cover all the areas of making the decision, where do you want to go, what do you want to do. Spelled out very clearly. Wouldn t add anything-it would muddle it up

52 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Pictograms confusing I don t understand what the little dot things are, I found myself counting them

53 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Employer as resource confusing As far as your employer I don t know how the unless they re responsible for providing insurance but most people don t want to talk to their employer about these types of things and there s still that stigmatism about mental illness

54 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Helpful I actually think it would be very helpful because its laid out in a way that s clear but not prescriptive like it doesn t say do this; it just it gives them options but it gives them options with enough information to feel like they know what they re doing a little more clearly than without it

55 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing Early clinician views promising Its fairly thorough in going over the three different modalities of therapy and I like the way it lays them out and compares them. It s got useful information. I may try to hit on all the points that are on here but um I m sure I don t in every conversation and so its nice that has something that gathers all this together and presents it in a pretty easy fashion

56 Developing the Depression Grid Select Options & FAQs Develop Grid and Evidence Document Format the Grid Conduct User Testing

57 Depression in the US Recap What matters most? A national survey o Consumers o Clinicians The Option Grid decision aid for depression o Development o Cognitive interviews o Pilot testing

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