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Articles   |    
Enhanced Fidelity to Treatment for Bipolar Disorder: Results From a Randomized Controlled Implementation Trial
Jeanette Waxmonsky, Ph.D.; Amy M. Kilbourne, Ph.D., M.P.H.; David E. Goodrich, Ed.D.; Kristina M. Nord, L.M.S.W.; Zongshan Lai, M.P.H.; Christina Laird, Ph.D., L.C.S.W.; Julia Clogston, L.M.S.W.; Hyungjin Myra Kim, Sc.D.; Christopher Miller, Ph.D.; Mark S. Bauer, M.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300039
View Author and Article Information

Dr. Waxmonsky is with the Department of Psychiatry, University of Colorado School of Medicine, Denver. Dr. Kilbourne, Dr. Goodrich, Ms. Nord, Mr. Lai, Ms. Clogston, and Dr. Kim are with the Center for Clinical Management Research, Veterans Affairs (VA) Ann Arbor Healthcare System, and with the exception of Dr. Kim, are also with the Department of Psychiatry, University of Michigan Medical School, both in Ann Arbor, Michigan. Dr. Kim is also with the Center for Statistical Consultation and Research, University of Michigan, Ann Arbor. Dr. Laird is with the VA Eastern Colorado Healthcare System, Denver. Dr. Miller and Dr. Bauer are with Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston. Send correspondence to Dr. Kilbourne at amykilbo@umich.edu.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  The authors compared fidelity to bipolar disorder treatment at community practices that received a standard or enhanced version of a novel implementation intervention called Replicating Effective Programs (REP).

Methods  Five community practices in Michigan and Colorado were assigned at random to receive enhanced (N=3) or standard (N=2) REP to help implement Life Goals Collaborative Care (LGCC), a psychosocial intervention consisting of four self-management support group sessions, ongoing care management contacts by phone, and dissemination of guidelines to providers. Standard REP includes an intervention package consisting of an outline, a treatment manual and implementation guide, a standard training program, and as-needed technical assistance. Enhanced REP added customization of the treatment manual and ongoing, proactive technical assistance from internal and external facilitators. Multiple and logistic regression analyses determined the impact of enhanced versus standard REP on patient-level fidelity.

Results  The participants (N=384) had a mean age of 42 years; 67% were women, and 30% were nonwhite. Participants attended an average of three group sessions and had an average of four care management contacts. After adjustment for patient factors, enhanced REP was associated with 2.6 (p<.001) times more total sessions and contacts than standard REP, which was driven by 2.5 (p<.01) times more care management contacts. Women and participants with a history of homelessness had fewer total sessions and contacts.

Conclusions  Enhanced REP was associated with improved LGCC fidelity, primarily for care management contacts. Additional customization of interventions such as LGCC may be needed to ensure adequate treatment fidelity for vulnerable populations.

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Table 1Core components and fidelity measures for assessment of Life Goals Collaborative Care (LGCC)
Table Footer Note

a The Session Fidelity Checklist (28,30) is used by an independent rater who performs direct observations of all four self-management sessions randomly selected from each health specialist’s cohorts of participants.

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Table 2Components of standard and enhanced Replicating Effective Programs (REP) to support implementation of Life Goals Collaborative Care (LGCC)
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Table 3Treatment fidelity at practices that received enhanced or standard Replicating Effective Programs (REP) to support implementation of Life Goals Collaborative Care (LGCC)
Table Footer Note

a Chi square tests compared distributions across categories.

Table Footer Note

b Minimum fidelity to LGCC was defined as ≥3 group sessions and ≥4 care management sessions.

Table Footer Note

c Optimal fidelity to LGCC was defined as 4 group sessions and ≥6 care management sessions.

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Table 4Relationship of patient characteristics and treatment fidelity at practices that received enhanced or standard Replicating Effective Programs (REP) to support implementation of Life Goals Collaborative Carea
Table Footer Note

a The estimates were obtained from multiple regressions analyses that adjusted for all covariates except standard or enhanced REP (df=1).

Table Footer Note

b Minimum fidelity to LGCC was defined as ≥3 group sessions and ≥4 care management sessions.

Table Footer Note

c Optimal fidelity to LGCC was defined as 4 group sessions and ≥6 care management sessions.

Table Footer Note

*p<.05, **p<.001

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Table 5Relationship of patient characteristics and treatment fidelity, by multivariable regression analysis that included REP site as fixed effectsa
Table Footer Note

a Enhanced or standard Replicating Effective Programs (REP) was provided at five sites to support implementation of Life Goals Collaborative Care (LGCC). The estimates were adjusted for all covariates (df=1).

Table Footer Note

b Minimum fidelity to LGCC was defined as ≥3 group sessions and ≥4 care management sessions.

Table Footer Note

c Optimal fidelity to LGCC was defined as 4 group sessions and ≥6 care management sessions.

Table Footer Note

*p<.05, **p<.001

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