A. What evidence are you proposing to translate into practice?
There is evidence to suggest that suicide is a major public health concern with greatest risk in older adults, and that there are age disparities across the continuum of care for those experiencing depression and suicidal ideation. In the United States, adults age 65 and older are rapidly increasing and are disproportionately more likely to die by suicide. Late life depression (LLD) is a significant predictor of suicide and is associated with increased health care costs. Psychological autopsy studies identified LLD as the most common psychiatric diagnosis in adult suicide victims and attempters. Moreover, adults with LLD are more likely to be hospitalized for a medical complication and die earlier than non-depressed older adults. Access to mental health services is another predictor of suicide among older adults. Studies have shown that older adults experiencing mental disorders are significantly less likely than younger adults to receive specialty metal health care and rarely see mental health professionals. However, mental health care delivered in the primary care settings has been shown to significantly reduce access barriers, depression, disability, suicidal ideation and all-cause mortality in older adults. Despite the prevalence of age disparities, few studies have investigated age and treatment of depression and suicidal ideation. In addition, Medicare (i think you mean Medicaid?) expansion will likely put the burden of late life suicide detection and management squarely on the shoulders of primary care providers. In order to improve the quality of care that older suicidal patients receive in primary care, there is a need for provider training (this sounds like it is the "evidence" you are proposing to translate… i.e., increase its use in practice) that addresses both the recognition of suicidal ideation and the willingness to treat. Community physicians will feel the increased burden of Medicare Expansion, and therefore, efficient, accessible and flexible training models are needed to ensure busy primary care providers are kept current on the latest information about late life suicide risk and interventions. I am ultimately proposing to develop a technology based tool that will help assist primary care providers in the detection and referral process for depression and suicidal ideation in older adults. With the advent of distance learning technologies (e.g. web and pod casts), and health information technology (e.g. iPad based assessment and decision making tools), trainings for depression and suicide need not be limited to closed systems of care, but could easily reach many providers across the US.
- Justify that this evidence is “ready for translation.”
15 years ago it was documented that 75% of older adults who commit suicide visited a primary care physician within 4 weeks of their suicide, 39% visited within a week of their suicide and 20% visited within 24 hours of their act. Interestingly, one study found that the high rates of suicide after doctor’s visits was not due to poor recognition, but rather ageism—the tendency to view mental health problems as a normal part of aging, and not a serious condition. Although there has been a call for better physician education about geriatric mental health issues and an increase in successful programs raising awareness among service providers of geriatric suicide, suicide rates after doctor’s visits remain high. I am hoping to conduct this project in 3 phases. The first phase involves getting an update on the current situation in order to understand whether there has been improvement in this area. RG: you provide a compelling case to focus on the PCP and the office visit here, but it would help your case if you can find evidence that PCP training or education can lead to a change in suicidal intent or behavior.
- Identify a single, key behavior change target for your translational activity.
Suicidal ideation in older adults is commonly overlooked because providers (1) don’t often know which targeted questions to ask and (2) do not feel comfortable or supported by the setting in which they practice to make referrals. With this intervention, we would like to assist primary care providers in asking targeted questions and also provide an action plan for making referrals. RG: this is a good study question, but it will be a study to "build the evidence" rather than "translate" the evidence… so along the T3 spectrum, this would be T2 rather than T3 research.
- Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available.
Many healthcare systems are currently looking to get primary care providers to utilize the PHQ-9 in order to identify depression in their patient population. The acceptance of this short screening tool has been low. In order for providers to adopt a tool that would at best help in the area of depression and suicide management, they has to be incentives which may include partnership with the system in which providers practice. RG: you will want to show numbers if possible; but also, you will want to show evidence that PHQ-9 increases depression detection rates (i think this is true/you can find), and that PHQ-9 use decreases suicidality (this might be hard to find studies on).
B. What is the quality (performance) gap?
There is evidence to indicate that primary care physicians are willing to treat geriatric suicidal ideation, but not to the extent that they are willing to treat it in younger patients. Our findings are consistent with the findings of other studies. For example, Callahan, et.al showed that physician training in diagnosing geriatric depression did not increase the number of mental health referrals made by physicians (this doesn't help your case; you will need to address "why" your intervention will be more successful). This was largely due to a “lack of faith” that late-life depression could be successfully treated. A lack of knowledge about efficacy in the treatment of depression is a commonly cited reason for under-treatment in primary care. The literature suggests that providers believe treatments for depression have limited utility in older adults RG: performance gap question here might be "how often do PCPs screen (or identify) (or effectively treat) geriatric patients for suicidality?
C. What is the outcome gap?
Even with a program in place or a tool in place, providers will not adopt the new tool and use it.RG: here, the outcome might be suicidal attempt (or death).
D. Is there evidence that changing performance will improve health (clinical outcomes)?
There is substantial evidence to suggest that depression treatment in older decreases suicidal ideation and improves overall quality of life in this group and imp that shows that older improvement in quality of family planning. (this evidence might lead you to refine your question… it might be to screen/detect geriatric depression rather than suicidality) An RCT known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) showed an intervention’s effectiveness in community-based primary care with depressed older patients, however there were also challenges related to sustainability and dissemination. RG: Now you're talking!! This study sounds like it should be a major basis on which you propose your study. The intervention’s effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.
(Edited by Ralph Gonzales - original submission Sunday, April 6, 2014, 7:02 PM)