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BACKGROUND/RATIONALE:
At least 11,000 veterans have a stroke each year. Post-stroke depression (PSD) occurs in 25-40% of ischemic stroke survivors and is associated with worse functional outcomes and increased post-stroke mortality. Although effective treatments for PSD exist, studies suggest that PSD is often underdiagnosed and undertreated. The VA has successfully implemented interventions to improve depression detection in primary care, but to date no efforts have been specifically targeted toward improving the detection and treatment of PSD.
OBJECTIVE(S):
Our immediate objective is to test the planned system intervention to evaluate which aspects of the intervention are critical to improving the quality of care for veterans with PSD, and to refine it to prepare for our long-term objective: a multi-site study across multiple sites and VISNs. To address our immediate objective, we will evaluate two specific study aims using a quasi-experimental design comparing improvement in depression screening and treatment in veteran stroke survivors receiving care at two facilities receiving the intervention.
The primary aim of the study is to evaluate the effectiveness of a system intervention to improve the proportion of veterans screened and treated for PSD. The system intervention is based on extending the use of the current depression performance measure that mandates yearly depression screening in VA primary care clinics to target veteran stroke survivors a) following-up in Primary Care within six months of stroke, and b) following-up in VA Neurology clinics. The secondary aim of the study is to evaluate whether a patient-based self-management intervention provides additional benefit beyond the system intervention alone in improving guideline-adherent treatment of depression and improves patient depression symptoms, quality of life, and self-efficacy compared to usual post-stroke care. Subjects for the secondary aim will be recruited from the two intervention sites and will be randomized, stratified by site, to the patient intervention or usual care.
METHODS:
Aim 1: All data will be obtained from the VA administrative databases. These data include ICD-9 codes extracted from Patient Treatment File main as well as basic demographics (i.e., age, gender, race, ethnicity, depression screening results, antidepressants prescribed, and number and type of outpatient follow-up appointments in the six months after stroke). All outcome data for this aim will be collected from electronic medical records (EMR) that are part of the usual clinic care of the patients (VISTA and PBM data). Aim 2: Intervention patients receive a self-management program over the first six months post-stroke. The program consists of six sessions delivered either in person or by phone and four additional follow-up calls to assess goal setting, behaviors, and study outcomes. Control patients will get baseline, three, and six-month interviews with the same outcome assessments. They will be provided American Stroke Association printed literature about stroke risk factors, warning signs, and community resources and will receive one individual session prior to discharge or within two weeks of discharge focusing on stroke symptoms and risk factor education. They will receive the same number of calls at similar frequency to the intervention patients but the calls will generically cover how they are doing since their stroke and will not address goal setting, post-stroke behaviors, or self-management strategies. Data for the self-management program will be collected via patient interviews during the course of the study. The baseline interview will take place prior to hospital discharge or within two weeks of discharge. Two other interviews for outcome assessment will be done by phone at three and six months post-stroke. The primary outcome for the patient self-management intervention is depression symptoms as assessed by the PHQ-9. Secondary outcomes include depression treatment, quality of life (measured by the Stroke-specific Quality of Life scale), self efficacy, fear of injury, and stroke outcomes (patient-reported modified Rankin scale).
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FINDINGS/RESULTS:
Study in progress. The depression reminder has been activated in Neurology and Primary Care clinics at the two sites. EMR data for the pre-study period has been obtained and is being analyzed. As of May 2008, 51 patients have been enrolled in Aim 2 of the study.
IMPACT:
This project will evaluate a CPRS-based depression screening reminder to improve detection and treatment of post-stroke depression. Additionally, the project will evaluate the potential additional benefit of self-management intervention post-stroke in the prevention and/or reduction of depression symptoms in the first 6 months post-stroke. Since CPRS-baesd depression screening in Primary Care is a part of routine care, this project has the potential, if successful, to provide a mechanism to rapidly expand and improve evidence-based depression care to veterans with stroke.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems
DRE:
Quality of Care
Keywords:
Depression, PTSD, Stroke
MeSH Terms:
Epidemiology
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