Collaboration Overcomes Resistance To Use of Practice Guidelines

Despite resistance and skepticism, practice guidelines can be implemented into routine clinical care in large organized systems of care. Moreover, they can be used to inform and facilitate staff and resident education and training, raise standards of care, stimulate research in areas where guidelines are deficient, and reduce public and professional stigma surrounding mental illness.

So said leaders of Unity Health Systems in Rochester, N.Y., and other psychiatric educators at a workshop at APA's 2005 annual meeting in Atlanta in May.

John McIntyre, M.D., and colleagues at Unity described a systematic effort to implement APA practice guidelines in a community behavioral health system that provides mental health and substance use services in urban, suburban, and rural areas.

McIntyre, a former APA president, is chair of the APA Steering Committee on Practice Guidelines and director of the Department of Psychiatry and Behavioral Health at Unity Health. He described seven benefits to organized systems of care associated with the adoption of practice guidelines in routine care (see box).

Psychiatrist Rory Houghtalen, M.D., medical director for education at Unity, described an ongoing process of culture change including marketing of guidelines throughout the organization, creation of toolkits to train staff in application of guidelines, use of documentation aids to encourage best practices, and a quality-improvement process to monitor and provide feedback about progress.

As an example of the process, Houghtalen described Unity's effort to implement the APA practice guideline on major depression. A multidisciplinary work group composed largely of supervisory staff was formed to read and digest the guideline, and a group of “trainers” was identified at each of Unity's four outpatient clinics.

The trainers' job is to act as champions for their guideline, helping to educate staff and monitor implementation, Houghtalen explained. The work group is responsible for distilling the guideline into “bite-size chunks” that clinicians and staff can easily incorporate into everyday practice. In the case of major depression, these take the form of nine evaluation-performance items and 10 treatment-performance items.

These are the 10 evaluation-performance items: defining the syndrome, identifying and documenting target symptoms, assessing risk, rating severity, identifying subtype, identifying history of hypomania/mania, counting prior episodes, defining treatment history, and identifying and accounting for comorbidity.

These are the 10 treatment-performance items: education for all patients; frequent acute visits to advance alliance, adherence, and remission; psychotherapy as a monotherapy delivered weekly during acute phase; use of a depression-specific psychotherapy when possible; adherence to Texas Medication Algorithm Project decisions; achievement of remission and recovery before stopping acute-phase treatment; continuation treatment for four to 12 months at the same medication dose for all patients showing remission with medication; tapered psychotherapy visits over four to 12 months for remitting patients receiving psychotherapy; consideration of maintenance antidepressants and/or psychotherapy for some patients with two past episodes and all patients with three or more past episodes; and consideration of peer support group for all patients.

Houghtalen underscored the importance of counting past episodes as an example of how a discrete clinical behavior can be crucial to overall care and outcome.

“If you look at the science, you know that a patient with two or more episodes of major depression is a candidate for maintenance antidepressant treatment,” he said. “If you don't know how many episodes the patient has had, you can't early on start educating the patient and keeping in your own mind the importance that maintenance therapy is going to have in the ultimate outcome.”

Other resources were then created to help clinicians and staff incorporate the performance items into routine practice.

Finally, Unity staff and clinicians have been trained in the use of the Quick Inventory of Depression Symptomatology (QIDS). “We are trying to get everyone to do a baseline QIDS at the time of diagnosis so we can measure severity, make decisions about treatment selection, follow the treatment progress, and determine whether we have achieved remission,” Houghtalen said.

Houghtalen said Unity was fortunate in having McIntyre, the leader of APA's practice-guideline effort, as an administrative champion. Having such a champion is a critical factor for organized systems struggling with how to make use of practice guidelines a day-to-day reality in treatment of patients.

Joel Yager, M.D., vice chair for education at the University of New Mexico School of Medicine, told workshop participants that literature on information dissemination—in medicine and other fields—confirms that local opinion leaders are the most important factor in ensuring that a new technology or practice is widely adopted.

“One of the ways for guidelines to be implemented is to have discussions with opinion leaders and hope to get buy-in,” he said.“ If you don't get buy-in from people whose opinions you respect and value, your product isn't going to make it.”

Yager also cited resources available from APA, including online CME courses focused on the guidelines, which can help in training and educating staff. He noted that questions about the guidelines are now appearing on certification and recertification exams by the American Board of Psychiatry and Neurology and other examining bodies, providing a compelling reason to incorporate guidelines into residency training and continuing medical education.

“We have heard from residencies that have been incorporating practice guidelines systematically in a variety of ways in didactics, mostly around case conferences or in psychopathology courses,” Yager said.“ Residents will come into case conferences with a scenario and then go back and ask, `What does this guideline have to say to my particular patient problem?'”

More information about how Unity Health Systems is incorporating APA's practice guidelines into routine care is available from Houghtalen at [email protected].▪