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IMPLEMENTATION EVIDENCE IN THE DETECTION AND TREATMENT OF POST-STROKE DEPRESSION
Project Number IMV 04-096 funded
by Medical Care.
July 1, 2003 -
December 31, 2009
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.1-5 Although effective treatments for PSD exist, 6-9 studies suggest that PSD is often underdiagnosed and undertreated.10-13 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.
The objectives for this planning grant are to: 1) Identify patient, provider, and system barriers to PSD detection and treatment, 2) Develop a multidisciplinary implementation strategy to adapt the existing primary care depression screening measures for systematic PSD screening, and 3) Plan an implementation project in VISN 8 and 11 evaluating the effect of implementing the existing depression screening tool on PSD detection and treatment.
We examined FY2001/2002 data from VISNs 8 and 11 to determine which VAMCs had the highest volume of ischemic stroke admissions. We also quantified where these patients had VA outpatient follow-up in the first 12 months post-stroke so that we could identify the clinical venues at each facility in which implementing the depression screening intervention would be most efficient. We will conduct focus groups of patients to identify barriers and facilitators to depression screening and treatment after stroke. We will conduct structured interviews of providers in the outpatient clinical settings in which most stroke survivors follow-up to identify provider-perceived barriers and facilitators for depression screening and treatment after stroke.
For FY2001/2002, 1061 veterans with ischemic stroke in VISN 8 and 398 in VISN 11 were identified. Considerable variation in outpatient follow-up was observed, with the largest proportion of patients having either a primary care or neurology follow-up within the first 6 months post-stroke. Patients and caregivers idenified the following barriers to depression detection and treatment: lack of knowledge about depression symptoms, not knowing what to expect after stroke, too little time with their doctors, social isolation after stroke, and medication side effects. Things that improved depression detection and treatment included: early information and education about post-stroke symptoms, contact with another stroke survivor or support group, and getting a phone call from a health professional.
Objective 1 of this planning grant has been met. This status report refers to Objectives 2 and 3. We have successfully began a funded implementation project in VISNs 8 and 11 to evaluate the effect of implementing the existing depression screening tool on PSD detection and treatment. This project is ongoing.
Aim 1 of Objectives 2&3; Study and clinic teams have been meeting regularly and have identified implementation strategies and barriers to implementing the depression reminder. The depression screening reminder is active is Indianapolis Neurology clinics and in Gainesville Primary Care Clinics (Aim 1). We are currently working toward activating the depression reminder in Indianapolis Primary Care Clinics and the Gainesville Neurology clinic and expect this to happen within the month.
For Aim 2 of Objectives 2&3; patient recruitment is underway at both sites to test a stroke patient self management program. Both sites have patients enrolled and actively participating in the self management program.
Indianapolis and Gainesville research teams continue to meet bi-weekly via phone to discuss patient recruitment and the ongoing depression screening reminder. Case Managers meet weekly via phone with the Co-PI to discuss patient self managment strategies.
We will supply providers with quarterly feedback reports on the depression screener reminder this summer. We plan to hold our first local DSMB meeting early fall.
This project will provide important insight into the patterns of care post-stroke so that the best sites for intervening to improve depression detection and treatment can be identified. The project will also provide key insight into patient and provider-perceived barriers to depression detection and treatment after stroke, including provider assessment of the feasibility of using the existing primary care depression performance measure to facilitate post-stroke depression screening. This project will also allow us to test the added impact and value of a stroke patient self management program within the VA.
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