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      Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project)

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          Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice.


          Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care.

          Design: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system.

          Participants: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia).

          Intervention: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework.

          Measures: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact.


          This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society.

          Trial registration

 identifier: NCT03285659; Registered 12th September, 2017.

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          Most cited references 25

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          Development and validation of the Patient Assessment of Chronic Illness Care (PACIC).

          There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model-measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support. A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied. Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC. The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32-0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation. The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.
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            Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.

            Depression is common in primary care but is suboptimally managed. Collaborative care, that is, structured care involving a greater role of nonmedical specialists to augment primary care, has emerged as a potentially effective candidate intervention to improve quality of primary care and patient outcomes. To quantify the short-term and longer-term effectiveness of collaborative care compared with standard care and to understand mechanisms of action by exploring between-study heterogeneity, we conducted a systematic review of randomized controlled trials that compared collaborative care with usual primary care in patients with depression. We searched MEDLINE (from the beginning of 1966), EMBASE (from the beginning of 1980), CINAHL (from the beginning of 1980), PsycINFO (from the beginning of 1980), the Cochrane Library (from the beginning of 1966), and DARE (Database of Abstracts of Reviews of Effectiveness) (from the beginning of 1985) databases from study inception to February 6, 2006. We found 37 randomized studies including 12 355 patients with depression receiving primary care. Random effects meta-analysis showed that depression outcomes were improved at 6 months (standardized mean difference, 0.25; 95% confidence interval, 0.18-0.32), and evidence of longer-term benefit was found for up to 5 years (standardized mean difference, 0.15; 95% confidence interval, 0.001-0.31). When exploring determinants of effectiveness, effect size was directly related to medication compliance and to the professional background and method of supervision of case managers. The addition of brief psychotherapy did not substantially improve outcome, nor did increased numbers of sessions. Cumulative meta-analysis showed that sufficient evidence had emerged by 2000 to demonstrate the statistically significant benefit of collaborative care. Collaborative care is more effective than standard care in improving depression outcomes in the short and longer terms. Future research needs to address the implementation of collaborative care, particularly in settings other than the United States.
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              A Guide for applying a revised version of the PARIHS framework for implementation

              Background Based on a critical synthesis of literature on use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework, revisions and a companion Guide were developed by a group of researchers independent of the original PARIHS team. The purpose of the Guide is to enhance and optimize efforts of researchers using PARIHS in implementation trials and evaluations. Methods Authors used a planned, structured process to organize and synthesize critiques, discussions, and potential recommendations for refinements of the PARIHS framework arising from a systematic review. Using a templated form, each author independently recorded key components for each reviewed paper; that is, study definitions, perceived strengths/limitations of PARIHS, other observations regarding key issues and recommendations regarding needed refinements. After reaching consensus on these key components, the authors summarized the information and developed the Guide. Results A number of revisions, perceived as consistent with the PARIHS framework's general nature and intent, are proposed. The related Guide is composed of a set of reference tools, provided in Additional files. Its core content is built upon the basic elements of PARIHS and current implementation science. Conclusions We invite researchers using PARIHS for targeted evidence-based practice (EBP) implementations with a strong task-orientation to use this Guide as a companion and to apply the revised framework prospectively and comprehensively. Researchers also are encouraged to evaluate its use relative to perceived strengths and issues. Such evaluations and critical reflections regarding PARIHS and our Guide could thereby promote the framework's continued evolution.

                Author and article information

                00 34 977 524109 ,
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                13 December 2017
                13 December 2017
                : 17
                [1 ]Primary Care Area Camp de Tarragona, Catalan Health Institute, Tarragona, Spain
                [2 ]GRID grid.452479.9, Primary Care Research Institute IDIAP Jordi Gol, ; Barcelona, Spain
                [3 ]ISNI 0000 0000 9238 6887, GRID grid.428313.f, Mental Health Service, University Hospital Parc Taulí, ; Sabadell, Spain
                [4 ]GRID grid.7080.f, Department of Psychiatry and Legal Medicine, , Autonomous University of Barcelona, ; Barcelona, Spain
                [5 ]University Psychiatric Hospital Pere Mata Institute, Reus, Spain
                [6 ]ISNI 0000 0000 9635 9413, GRID grid.410458.c, Mental Health Centre Esquerra Eixample, Hospital Clínic, ; Barcelona, Spain
                [7 ]ISNI 0000 0004 1767 8811, GRID grid.411142.3, Institute of Neuropsychiatry and Addictions, Hospital del Mar, IMIM, ; Barcelona, Spain
                [8 ]ISNI 0000 0004 1762 4012, GRID grid.418264.d, CIBERSAM, ; Madrid, Spain
                [9 ]Healthcare Corporation Parc Taulí, Primary Care Area, Sabadell, Spain
                [10 ]ISNI 0000 0000 9127 6969, GRID grid.22061.37, Primary Care Service Vallès Occidental, Catalan Health Institute, ; Sabadell, Spain
                [11 ]ISNI 0000 0001 2284 9230, GRID grid.410367.7, Unit for the Study and Treatment of Pain – ALGOS, Universitat Rovira i Virgili, ; Tarragona, Spain
                [12 ]ISNI 0000 0001 2284 9230, GRID grid.410367.7, Department of Psychology, , Universitat Rovira i Virgili, ; Tarragona, Spain
                [13 ]Centre d’Atenció Primària de Constantí, Carrer dels Horts, 6, 43120 Constantí (Tarragona), Spain
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: FundRef, Generalitat de Catalunya;
                Award ID: SLT002/16/00106
                Award Recipient :
                Study Protocol
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                © The Author(s) 2017


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