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| FIDELITY TO MODEL IMPROVES TREATMENT OUTCOMES |
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With greater adherence or fidelity to the Three Component Model (3CM), better depression outcomes are obtained. The Initiative investigators have developed and tested a measure of fidelity to 3CM that is derived from routine telephone logs kept by the care manager. The article abstract (Medical Care, November 2006, Volume 44, Issue 11, pages 1030-1037), can be found at http://journals.lww.com/lww-medicalcare/Abstract/2006/11000/A_Fidelity_Measure_for_Integrated_Management_of.10.aspx
Below are the abstract and a care manager telephone log showing where the raw data for fidelity assessment comes from as reported in the article.
A Fidelity Measure for Integrated Management
of Depression in Primary Care
Thomas E. Oxman, MD,* Herbert C. Schulberg, PhD,† Rebecca L. Greenberg, MS,†
Allen J. Dietrich, MD,* John W. Williams, Jr., MD, MHS,‡ Paul A. Nutting, MD, MPH,§
and Martha L. Bruce, PhD, MPH†
Background: Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and
their evaluation need a fidelity measure.
Objectives: We sought to develop and validate a fidelity measure
using data gathered during routine clinical application of the clinical
model.
Methods: Longitudinal outcome data on depression severity were
obtained from 224 subjects experiencing major depression or dysthymia
and assigned to a 3-component model (3CM) intervention.
Data on 10 essential 3CM process-of-care components were obtained
from telephone logs maintained by care managers administering
3CM care. Stakeholders (n 23), including researchers,
health care administrators, and care managers, independently rated
the importance of the 10 elements distributing 100 points among the
elements. Mean ratings were used as weights to construct a fidelity
score. Predictive validity was assessed using logistic regression for
patient response and remission at 3 and 6 months.
Results: 3CM fidelity was high, with a mean of 74.1 at 3 months
and 75.9 at 6 months. Given a large gap in the scores’ distribution,
subjects were classified into zero, low-, and high-fidelity groups.
Logistic regressions adjusting for baseline depression found a distinct
continuum. Patients that were provided high fidelity 3CM were
significantly more likely to achieve treatment response and remission
at 3 months. At 6 months, high-fidelity care was again significantly
more likely to produce a response, but remission rate did not
differ from patients provided low fidelity.
Conclusions: Most patients received a substantially implemented
“3CM dose.” Even within this high implementation, however, a
higher fidelity score was associated with better outcomes. The easily
applied measure is a promising tool for monitoring the quality of implementation of integrated care.
Medical Care • Volume 44, Number 11, November 2006
Key Words: primary care, depressive disorders, program
evaluation
(Med Care 2006;44: 000–000)
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