Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Implementation Science
Published in: Implementation Science 1/2015

Open Access 01-12-2015 | Research

A tailored intervention to implement guideline recommendations for elderly patients with depression in primary care: a pragmatic cluster randomised trial

Authors: Eivind Aakhus, Ingeborg Granlund, Jan Odgaard-Jensen, Andrew D. Oxman, Signe A. Flottorp

Published in: Implementation Science | Issue 1/2015

Login to get access

Abstract

Background

Elderly patients with depression are underdiagnosed, undertreated and run a high risk of a chronic course. General practitioners adhere to clinical practice guidelines to a limited degree. In the international research project Tailored Implementation for Chronic Diseases, we tested the effectiveness of tailored interventions to improve care for patients with chronic diseases. In Norway, we examined this approach to improve adherence to six guideline recommendations for elderly patients with depression targeting healthcare professionals, patients and administrators.

Methods

We conducted a cluster randomised trial in 80 Norwegian municipalities. We identified determinants of practice for six recommendations and subsequently tailored interventions to address these determinants. The interventions targeted healthcare professionals, administrators and patients and consisted of outreach visits, a website presenting the recommendations and the underlying evidence, tools to manage depression in the elderly and other web-based resources, including a continuous medical education course for general practitioners. The primary outcome was mean adherence to the recommendations. Secondary outcomes were improvement in depression symptoms as measured by patients and general practitioners. We offered outreach visits to all general practitioners and practice staff in the intervention municipalities. We used electronic software that extracted eligible patients from the general practitioners’ lists. We collected data by interviewing general practitioners or sending them a questionnaire about their practice for four patients on their list and by sending a questionnaire to the patients.

Results

One hundred twenty-four of the 900 general practitioners (14 %) participated in the data collection, 51 in the intervention group and 73 in the control group. We interviewed 77 general practitioners, 47 general practitioners completed the questionnaire, and 134 patients responded to the questionnaire. Amongst the general practitioners who provided data, adherence to the recommendations was 1.6 percentage points higher in the intervention group than in the control group (95 % CI −6 to 9).

Conclusions

The effectiveness of our tailored intervention to implement recommendations for elderly patients with depression in primary care is uncertain, due to the low response rate in the data collection. However, it is unlikely that the effect was large. It remains uncertain how best to improve adherence to evidence-based recommendations and thereby improve the quality of care for these patients.

Trial registration

ClinicalTrials.gov: NCT01913236.
Appendix
Available only for authorised users
Literature
1.
Skoog I. Psychiatric epidemiology of old age: the H70 study—the NAPE lecture 2003. Acta Psychiatr Scand. 2004;109(1):4–18.CrossRefPubMed
2.
Solhaug HI, Romuld EB, Romild U, Stordal E. Increased prevalence of depression in cohorts of the elderly: an 11-year follow-up in the general population—the HUNT study. Int Psychogeriatr. 2012;24:151–8.CrossRefPubMed
3.
Licht-Strunk E, van der Windt DA, van Marwijk HW, de Haan M, Beekman AT. The prognosis of depression in older patients in general practice and the community. A systematic review. Fam Pract. 2007;24:168–80.CrossRefPubMed
4.
Denihan A, Kirby M, Bruce I, Cunningham C, Coakley D, Lawlor BA. Three-year prognosis of depression in the community-dwelling elderly. Br J Psychiatry. 2000;176:453–7.CrossRefPubMed
5.
6.
Chang-Quan H, Bi-Rong D, Zhen-Chan L, Yuan Z, Yu-Sheng P, Qing-Xiu L. Collaborative care interventions for depression in the elderly: a systematic review of randomized controlled trials. J Investig Med. 2009;57:446–55.PubMed
7.
Williams JW, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A. Systematic review of multifaceted interventions to improve depression care. Gen Hosp Psychiatry. 2007;29:91–116.CrossRefPubMed
8.
Hepner KA, Rowe M, Rost K, Hickey SC, Sherbourne CD, Ford DE, et al. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007;147:320–9.CrossRefPubMed
9.
Smolders M, Laurant M, Verhaak P, Prins M, van Marwijk H, Penninx B, et al. Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis. Gen Hosp Psychiatry. 2009;31:460–9.CrossRefPubMed
10.
Lugtenberg M, Burgers JS, Besters CF, Han D, Westert GP. Perceived barriers to guideline adherence: a survey among general practitioners. BMC Fam Pract. 2011;12:98.CrossRefPubMedPubMedCentral
11.
Kjosavik SR, Hunskaar S, Aarsland D, Ruths S. Initial prescription of antipsychotics and antidepressants in general practice and specialist care in Norway. Acta Psych Scand. 2011;123:459–65.CrossRef
12.
13.
Wensing M, Oxman A, Baker R, Godycki-Cwirko M, Flottorp S, Szecsenyi J, et al. Tailored Implementation For Chronic Diseases (TICD): a project protocol. Implement Sci. 2011;6:103.CrossRefPubMedPubMedCentral
14.
Huntink E, van Lieshout J, Aakhus E, Baker R, Flottorp S, Godycki-Cwirko M, et al. Stakeholders contributions to tailored implementation programs: an observational study of group interview methods. Implement Sci. 2014;9:185.CrossRefPubMedPubMedCentral
15.
Wensing M, Huntink E, van Lieshout J, Godycki-Cwirko M, Kowalczyk A, Jager C et al. Tailored implementation of evidence-based practice for patients with chronic diseases. PloS One. 2014; doi:10.​1371/​journal.​pone.​0101981.
16.
Krause J, Van Lieshout J, Klomp R, Huntink E, Aakhus E, Flottorp S, et al. Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implement Sci. 2014;9:102.CrossRefPubMedPubMedCentral
17.
Norwegian Directorate of health. National guidelines for diagnosing and treatment of adults with depression in primary and specialist health care. Norwegian; 2009; Report IS1561.
18.
19.
Aakhus E, Granlund I, Odgaard-Jensen J, Wensing M, Oxman AD, Flottorp SA. Tailored interventions to implement recommendations for elderly patients with depression in primary care: a study protocol for a pragmatic cluster randomised controlled trial. Trials. 2014; doi:10.​1186/​1745-6215-15-16.
20.
Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008; doi:10.​1136/​bmj.​a2390.
21.
Schwartz D, Lellouch J. Explanatory and pragmatic attitudes in therapeutical trials. J Chron Dis. 1967;20:637–48.CrossRefPubMed
22.
WHO. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
23.
Aakhus E, Granlund I, Oxman AD, Flottorp SA. Tailoring interventions to implement recommendations for the treatment of elderly patients with depression: a qualitative study. Int J Ment Health Syst. 2015; doi:10.​1186/​s13033-015-0027-5.
24.
25.
Guy W. ECDEU assessment manual for psychopharmacology—revised. Rockville: DHEW Publication; 1976.
26.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–70.CrossRefPubMed
27.
Steinert T, Eisele F, Langle G, Albani C, Flammer E, Borbe R. PGI-I (patient’s global impression) as an outcome and quality indicator of psychiatric in-patient treatment: results and concordance with doctor’s assessments. Psychiatr Prax. 2010;37:343–9.CrossRefPubMed
28.
Dunlop BW, Li T, Kornstein SG, Friedman ES, Rothschild AJ, Pedersen R, et al. Concordance between clinician and patient ratings as predictors of response, remission, and recurrence in major depressive disorder. J Psychiatr Res. 2011;45:96–103.CrossRefPubMedPubMedCentral
29.
Cohen-Mansfield J, Shmotkin D, Goldberg S. Loneliness in old age: longitudinal changes and their determinants in an Israeli sample. Int Psychoger. 2009;21:1160–70.CrossRef
30.
Holmen K, Furukawa H. Loneliness, health and social network among elderly people—a follow-up study. Arch Gerontol Geriatr. 2002;35:261–74.CrossRefPubMed
31.
George CF, Peveler RC, Heiliger S, Thompson C. Compliance with tricyclic antidepressants: the value of four different methods of assessment. Br J Clin Pharmacol. 2000;50:166–71.CrossRefPubMedPubMedCentral
32.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74.CrossRefPubMed
33.
Fretheim A, Oxman AD, Havelsrud K, Treweek S, Kristoffersen DT, Bjorndal A. Rational prescribing in primary care (RaPP): a cluster randomized trial of a tailored intervention. PLoS Med. 2006; doi:10.​1371/​journal.​pmed.​0030134.
34.
Flottorp S, Oxman AD, Havelsrud K, Treweek S, Herrin J. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. BMJ. 2002;325:367.CrossRefPubMedPubMedCentral
35.
36.
Aakhus E, Oxman AD, Flottorp SA. Determinants of adherence to recommendations for depressed elderly patients in primary care: a multi-methods study. Scand J Prim Health Care. 2014;32:170–9.CrossRefPubMedPubMedCentral
37.
Thorpe KE, Zwarenstein M, Oxman AD, Treweek S, Furberg CD, Altman DG, et al. A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers. J Clin Epidemiol. 2009;62:464–75.CrossRefPubMed
38.
Bauer MS. A review of quantitative studies of adherence to mental health clinical practice guidelines. Harvard Rev Psychiat. 2002;10:138–53.CrossRef
39.
Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha T, Bryson H, et al. Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand. 2004;109:8–20.CrossRef
40.
Duhoux A, Fournier L, Nguyen CT, Roberge P, Beveridge R. Guideline concordance of treatment for depressive disorders in Canada. Soc Psych Psych Epid. 2009; doi:10.​1007/​s00127-008-0444-8.
41.
Baker R, Reddish S, Robertson N, Hearnshaw H, Jones B. Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice. Br J Gen Pract. 2001;51:737–41.PubMedPubMedCentral
42.
Callahan CM, Hendrie HC, Dittus RS, Brater DC, Hui SL, Tierney WM. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42:839–46.CrossRefPubMed
43.
Sinnema H, Majo M, Volker D, Hoogendoorn A, Terluin B, Wensing M, et al. Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: a cluster randomised controlled trial. Implement Sci. 2015;10:33.CrossRefPubMedPubMedCentral
44.
Sinnema H, Terluin B, Wensing M, Volker D, Franx G, van Balkom A, et al. Systematic tailoring for the implementation of guideline recommendations for anxiety and depressive disorders in general practice: perceived usefulness of tailored interventions. BMC Fam Pract. 2013;14:94.CrossRefPubMedPubMedCentral
45.
Richter-Sundberg L, Nyström ME, Krakau I, Sandahl C. Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines. Prim Health Care Res Dev. 2015; doi:10.​1017/​S146342361400024​3.
46.
Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180 Suppl 6:57–60.
47.
48.
Foy R, Parry J, McAvoy B. Clinical trials in primary care. BMJ. 1998;317:1168.
49.
Eccles M, Grimshaw J, Campbell M, Ramsay C. Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care. 2003;12:47–52.CrossRefPubMedPubMedCentral
50.
Fretheim A, Zhang F, Ross-Degnan D, Oxman AD, Cheyne H, Foy R et al. A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation. J Clin Epidemiol. 2015; doi:10.​1016/​j.​jclinepi.​2014.​10.​003.
51.
Jager C, Freund T, Steinhauser J, Aakhus E, Flottorp S, Godycki-Cwirko M, et al. Tailored intervention for chronic diseases (TICD): a protocol for process evaluation in cluster randomized controlled trials in five European countries. Trials. 2014;15:87.CrossRefPubMedPubMedCentral
52.
Olsen L, Aisner D, McGinnis JM, Institute of Medicine Roundtable on Evidence-Based M. The learning healthcare system: workshop summary. Washington, D.C: National Academies Press; 2007.
Metadata
Title
A tailored intervention to implement guideline recommendations for elderly patients with depression in primary care: a pragmatic cluster randomised trial
Authors
Eivind Aakhus
Ingeborg Granlund
Jan Odgaard-Jensen
Andrew D. Oxman
Signe A. Flottorp
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2015
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/s13012-016-0397-3

Other articles of this Issue 1/2015

Implementation Science 1/2015 Go to the issue

Research

Implementation of a post-arrest care team: understanding the nuances of a team-based intervention

Study protocol

A hybrid effectiveness-implementation cluster randomized trial of group CBT for anxiety in urban schools: rationale, design, and methods

Study protocol

An effectiveness-implementation hybrid trial study protocol targeting posttraumatic stress disorder and comorbidity

Research

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda

Research

Sustainability of knowledge translation interventions in healthcare decision-making: a scoping review

Study protocol

An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial