A process for developing an implementation intervention: QUERI Series

Abstract Background This article describes the process used by the authors in developing an implementation intervention to assist VA substance use disorder clinics in adopting guideline-based practices for treating depression. This article is one in a Series of articles documenting implementation science frameworks and tools developed by the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI). Methods The process involves two steps: 1) diagnosis of site-specific implementation needs, barriers, and facilitators (i.e., formative evaluation); and 2) the use of multi-disciplinary teams of local staff, implementation experts, and clinical experts to interpret diagnostic data and develop site-specific interventions. In the current project, data were collected via observations of program activities and key informant interviews with clinic staff and patients. The assessment investigated a wide range of macro- and micro-level determinants of organizational and provider behavior. Conclusion The implementation development process described here is presented as an optional method (or series of steps) to consider when designing a small scale, multi-site implementation study. The process grew from an evidence-based quality improvement strategy developed for – and proven efficacious in – primary care settings. The authors are currently studying the efficacy of the process across a spectrum of specialty care treatment settings.</p

The association of psychiatric comorbidity and use of the emergency department among persons with substance use disorders: an observational cohort study

<p>Abstract</p> <p>Background</p> <p>Psychiatric and substance use problems are commonly found to be contributing factors to frequent Emergency Department (ED) use, yet little research has focused on the association between substance use and psychiatric comorbidity. This study assesses the association of a psychiatric comorbidity on (ED) use among patients with substance use disorders (SUDs).</p> <p>Methods</p> <p>The study focuses on 6,865 patients who were diagnosed with SUDs in the ED of a large urban hospital in the southern United States from January 1994 – June 1998. Patients were grouped by type of substance use disorder. After examining frequency of visits by diagnosis, the sample was assigned to the following groups–alcohol dependence (ICD9 = 303), alcohol abuse (ICD9 = 305.0), cocaine dependence/abuse (ICD9 = 304.2, 305.6), and polysubstance/mixed use (ICD9 = 305.9). A patient was classified with psychiatric comorbidity if a psychiatric diagnosis appeared during any of the patient's visits. The following psychiatric diagnoses were included–schizophrenia/psychoses, bipolar disorder, depression, anxiety, and dementia (ICD-9 codes available upon request).</p> <p>Results</p> <p>Patients with SUDs and psychiatric comorbidity had significantly higher mean number of ER visits (mean = 5.2 SD = 8.7) than SUD patients without psychiatric comorbidity (mean = 2.5, SD = 3.7). In logistic regressions predicting several categorizations of heavier use of the ED (either 4+, 8+, 12+, 16+, or 20+ visits over the span of the study) SUD patients with psychiatric comorbidity had adjusted odds ratios of 3.0 to 5.6 (reference group = patients with SUDs but no psychiatric comorbidity). This association was found across all substance use diagnostic categories studied, with the strongest relationship observed among patients with cocaine disorders or alcohol dependence.</p> <p>Conclusion</p> <p>The results provide further support for the notion that the ED could and should serve as an important identification site for cost-effective intervention.</p