Depression Screening For Stroke Patients: A Magnate Hospital's Essay Evaluated Using RE-AIM Framework.

Describe about the Population Health For the Cognitive Impairment.

Clinical Guidelines on Depression Screening for Stroke Patients

Evidence-based healthcare guidelines for the United States and other four countries have recommended that stroke patients should undergo screening for depressive disorder. Caregivers should also monitor and evaluate the symptoms of depression during the development of stroke and after hospital discharge. However, despite the clinical guidelines, caregivers cannot recognize, diagnose, and treat post-stroke depression. Recent research has shown that a third of stroke patients in the US have depressive disorders (Robinson, & Jorge, 2015). The US records more than 790000 stroke patients each year (Nyquist et al., 2014). 5% of Stroke patients start showing symptoms of depression after a few days of diagnosis. 15% of the patients begin exhibiting the signs after a month while 21% take three months to experience the symptoms of depressive disorders. Depression interferes with the rehabilitation potential of stroke patients (Mittal, Hurn, & Schallert, 2016). The mental disorder also disrupts the quality of the patient’s life and functional recovery.

Patients diagnosed with ischemic stroke more outpatient and inpatient health services than the other types of stroke (Kernan et al., 2014). The cost of caring for stroke patients without depression is 63% cheaper caring for depressed stroke patients (Burton, & Tyson, 2015). The stroke patients with depression have an elevated incidence of suicidal thoughts. Additional statistics indicate that depressed stroke patients within the first ten years after diagnosis than their counterparts who lack the mental ailment. A magnate hospital in California implemented a quality improvement initiative to screen stroke clients for depression symptoms. The hospital intended to boost the healthcare of stroke clients and to meet the recommendations for clinical guidelines. The caregivers conducted Depression screening before discharging the stroke patients. The clients considered were diagnosed with a transient ischemic attack (TIA),   hemorrhagic stroke, and ischemic stroke. The initiative aimed to increase the number of stroke clients screened for depressive disorders before their discharge from the health facility. The caregivers then referred the patients with depression to special facilities for treatment.

This paper will use the RE-AIM framework to evaluate the depression screening initiative by the magnate hospital. RE-AIM is an acronym for Reach Effectiveness Adoption Implementation Maintenance.  The five steps of the framework will help to evaluate this initiative. After the evaluation, the framework will assist in the conclusion and assessment of the program’s effectiveness.

A magnet hospital in California began the initiative of screening stroke patients for depression, a project that is in line with the clinical guidelines. The evidence supporting the initiative indicates that stroke patients with depressive disorders are at high risk of dying than those lacking the mental complication (Jørgensen et al., 2016). However, there is little evidence about the financers of the project. The initiative intends to identify the depressed patients refer them to qualified psychiatrists to treat the mental complication. The key stakeholders started holding meetings eight months before implementing the project. The implementation committee consisted of four senior officials at the hospital. The members included the hospital’s stroke coordinator and medical director. The clinical leadership of the Behavioral Health Service (BHS) and the nursing manager of the stroke unit were also members of the team. The chair of the nursing research unit (NSU) completed the membership list. The medical director and the stroke coordinator formed a mandatory depression screening for stroke patients before their discharge from the hospital. The specialists formed the screening protocol six weeks before its implementation.

The Magnate Hospital's Depression Screening Initiative

The protocol consists of two simples steps. Firstly, is the initial and mandatory depressive disorder screening of all stroke patients using the Patient Health Questionnaire-2 (PHQ-2) Secondly, is the evaluation of stroke patients who are confident of depression if they should seek help due to their condition. The caregivers test the eligibility criteria for depression treatment using the Patient Health Questionnaire-9 (PHQ-9). The implementation team identified both foreseeable and unforeseeable challenges in conducting the screening. The predictable challenges include inadequate staffing to conduct the testing and convincing the physicians to embrace the program. The unforeseeable problems include the negligible compliance from the hospitalists and the lack of appreciation for the second step of the protocol. The project team took various actions to solve the impending challenges. The team engaged all the stakeholders through meetings and also maintained communication amongst one another through forms like phone calls and emails. The project group resolved the staffing issue by assigning the depression screening role to the registered nurses. The group also engaged with the hospitalists and the physicians to get their support. The use of PHQ-9 to evaluate the nature of the depressive disorder fills the current gap in research since most specialists only perform the first screening protocol. The target population of the initiative involves the stroke patients occupying the 28-bed capacity at the hospital.  The existing data that supports the initiative indicates that stroke patients with depressions are 3.4 times likely to die than those without depression (Davidson et al., 2015).

The RNs who are in charge of screening the stroke patients with depression expected to find a majority of them with the mental condition (Wei et al., 2015). The specialists expected a few stroke patients to test negative for depressive disorder after discharge from the hospital. The project for screening stroke patients is a new protocol for the health facility. Additionally, there are no available data on depression screening. Therefore, it is difficult to identify a benchmark for improvement or change. Nonetheless, the percentage of eligible stroke clients screened for depressive disorders did not meet the 100% target. The hospital describes the initiative as a fruitful exercise. The stakeholders joined forces to ensure that stroke patients are screened for depression before release from the health facility. There are no bodies currently reviewing the initiative; however, the NRC chair reviewed it before its implementation. Mechanisms that monitor the success of the initiative are the number of stroke patients who agree to undergo the depression screening. Large numbers of stroke patients turning up for the program indicates its success. Additionally, the reduction in the mortality rate of stroke patients after hospital discharge would also mean success.

Evaluation of the Initiative using the RE-AIM Framework

Researchers are beginning to recognize the essence of “public health impact and translatability” when analyzing the relevance of an investigation. Scientists have realized that the best way of rewarding the best research is to apply its contents to clinical use. The RE-AIM model was developed to enhance the likelihood of sustaining evidence-based interventions after their implementation (Harden et al., 2018). The framework has five steps which include Reach, Effectiveness, Adoption, Implementation, and Maintenance. All the steps are essential to gauge the translatability of a program into practice. Furthermore, the model assists scientists to understand the impact of a given program on the health of a targeted population.

The initial step of the RE-AIM framework is to gauge the exact number, representativeness, and proportion of people who took part in a specific initiative (Stoutenberg et al., 2018). Unfortunately, the hospital has no published data on the number of patients who participated in the depression screening. The only published information is that of the eligible stroke patients. The initiative targeted all stroke patients before their discharge; however, the researchers fail to avail the exact number of participants. An initiative that does not indicate the reach of the program shows its weakness. Despite the missing data on the number of participants, the researchers published the exclusion criteria used during the exercise. The stroke patients experiencing confusion, those with dementia, aphasia, and other cognitive impairment could not undergo the screening. Additionally, clients undergoing comfort care and those on hospice care did not qualify for the screening exercise. Therefore, it is easy to assume that all the eligible stroke patients underwent the depression screening before their discharge from the hospital.  

The screening protocol using the PHQ-2 and PHQ-9 is relatively new in the health sector not only in the USA but also all over the world. According to the pioneers, the protocol has numerous advantages over the other screening tools. Patients have admitted that the tools save time and are easy to manipulate. However, the lack of data on the number of participants overrides the advantages of the protocol.  All stroke patients should undergo depression screening to ascertain whether they have the mental complication or otherwise (Towfighi et al., 2017). The screening RNs should then refer the depressed patients to psychiatrists for treatment.

Effectiveness refers to the influence that an intervention has on essential outcomes (McGoey, Root, Bruner, & Law, 2015). The influence can impact the economic results and the quality of the patient’s life. However, the evaluators must also consider the negative impacts of the initiative. According to the RE-AIM framework, researchers should gauge the efficacy of a program by examining the thoughts of each participant. The determination of intervention effectiveness depends on the size of the outcome. However, the screening initiative has little data regarding the effectiveness of the program. The available data include 1) number of stroke patients referred to the depression specialists to address the mental complication, 2) number of stroke patients using anti-depressants before hospital discharge.  The initiative does not explain how the screening improved the quality of the participants’ lives. Additionally, the published initiative is silent on the negative impacts of depression screening for stroke patients.

Challenges and Solutions in Implementing Depression Screening Initiative for Stroke Patients

To understand how researchers should define the outcomes of various initiatives, the investigators reviewed a report of the health system by a specific college. The researchers assessed the College Breakthrough Series on Depression (CBS-D). The implementers of the model project specified the outcomes of their initiative as follows: 1) “number of students with five-point depreciation in their PHQ-9 after eight weeks from enrolment, 2) number of students having less than ten PHQ-9 scores after twelve weeks from enrolment, 3) number of students who find no difficulty and those that find difficulties in meeting their academic, occupational, and social responsibilities after twelve weeks from enrolment". This scenario presents an ideal example of how the researchers implemented and interpreted the outcome of the initiative. The definition of quantifiable and specific results enables researchers to implement the proposals of a given initiative.

The highlighted project succeeded in identifying its objectives at the beginning of the experiment as the researchers then proceeded to address each aim during the initiative development. The ability of the project to meet its goals allows the members of the public to adopt it in depression treatment. However, the model initiative and that of screening stroke patients do not explain the negative impact of the results.

Adoption refers to the representativeness, proportion, and the exact number of intervention agents and settings that will arrogate the intervention (Holtrop, Rabin, & Glasgow, 2018). Techniques like observations, surveys, and interviewing the intervention agents assist in ascertaining whether they are willing to adopt the interventions or otherwise. A lone study that concentrated on the healthcare professionals indicated that "only 50%" accepted to embrace the depression screening for stroke patients. However, there is no indication of the absolute number of professionals willing to affect the initiative. Furthermore, the published data fails to mention settings that are willing to espouse the project. The insufficient details on adoption weaken the strength of the project.

The published data indicate that only a few numbers of health professionals who are willing to embrace the initiative. The majority of the staff is reluctant to arrogate the initiative due to various valid reasons. Apart from the adoption at the staff level, an ideal initiative should attract interests from multiple health institutions. However, no information points towards hospitals that are ready to adopt the depression screening project for stroke patients after their discharge.

 Implementation refers to the similarity between the delivery of the initiative at the experimental level and reality platforms (Chan-Liston et al., 2018). Implementation is gauged at the organizational level. This step of RE-AIM framework concentrates at the costs of the initiative and the consistency of application. However, both the initiative for screening stroke patients and the ideal model discussed above fail to indicate the key areas of implementation. A majority of health facilities are eager to know the cost of an initiative before implementing it. Hospitals also seek for the consistency indices before embracing any project. Therefore, the pioneers of the project should research the two aspects of implementation before publishing the project.

Maintenance refers to the duration that an organization can take to institutionalize the initiative (Glasgow et al., 2010). In other words, maintenance focuses on the time that a firm can incorporate the initiative in its policies, organizational practices, and routine. The long-term impacts of the initiative on the participants are another element of maintenance. Therefore, this element of the RE-AIM framework involves both organization and individual level measures. The participants should explain the impacts of the project on them after six months. The initiative was developed in 2014 and has therefore existed for more than six months. However, there is insufficient data on the success of the initiative since its inception. Thus, the screening initiative fails the maintenance test.

According to the current situations, it is strenuous to conclude that this initiative should forge ahead based on the evaluated literature. Basing on the RE-AIM framework evaluation, an individual can conclude that the initiative should be discontinued to the glaring shortcomings. Nonetheless, it is evident that there is a shortfall in the amount of data accessed for this report. The researchers attempted to contact the initiative developers for additional discussion regarding the contents of the program. The investigators were curious to obtain additional information that can assist in evaluation using the RE-AIM framework. It was therefore impossible to develop a summary figure due to the availability of insufficient information. Preparing a final summary figure without adequate data is a futile exercise. The fact that this program gathers additional momentum each day is an indication that the missing details are available. However, at the point of submitting this report, adequate information was a limiting factor.

The reviewed initiative was developed due to the depressive disorder affecting the stroke patients.  The stroke patients develop depression as early as two days after diagnosis. The mental condition results in high death rates among the affected stroke patients than those lacking the complication. Specialists developed the initiative to enable the screening of stroke patients before their discharge from the various health facilities. The caregivers then refer the patients who are positive for the depressive disorder to the psychiatrist. As long as the program is a valuable asset in combating depression, there is a lack of adequate information to warrant a successful evaluation using the RE-AIM model. The initiative can assist in reducing the mortality rates due to depression if the developers avail sufficient information for evaluation.

Critical aspects of the initiative that are required for RE-AIM evaluation are not apparent. The insufficient information discourages various health facilities from embracing the program. A section of health practitioners also doubts its effectiveness due to the lack of information on cost and consistency.  Furthermore, it is difficult to implement the initiative due to lack of sufficient evidence. A look at the available literature indicates the possibility of numerous advantages of the initiative. However, at this juncture, additional data is required to constitute valid conclusions on the benefits of the program.  

References

Burton, L. J., & Tyson, S. (2015). Screening for mood disorders after stroke: a systematic review of psychometric properties and clinical utility. Psychological medicine, 45(1), 29-49.

Chan-Liston, M. L., Bourke, J. L., Sheehan, P., Niemcryk, S., Peng, M., Bwire, R., ... & Glasgow, R. (2018, August). The re-aim framework and REVLIMID REMS program: A methodology for REMS assessment using ISPE recommendations. In pharmacoepidemiology and drug safety (vol. 27, pp. 509-509). 111 river st, hoboken 07030-5774, NJ USA: Wiley.

Davidson, S. K., Harris, M. G., Dowrick, C. F., Wachtler, C. A., Pirkis, J., & Gunn, J. M. (2015). Mental health interventions and future major depression among primary care patients with subthreshold depression. Journal of affective disorders, 177, 65-73.

Glasgow, R.E., Dzewaltowski, D.A., Estabrooks, P.A., Gaglio, B.A., King, D., & Klesges, L. (2010) RE-AIM. Retrieved from https://www.re-aim.org.

Harden, S. M., Smith, M. L., Ory, M. G., Smith-Ray, R. L., Estabrooks, P. A., & Glasgow, R. E. (2018). RE-AIM in clinical, community, and corporate settings: Perspectives, strategies, and recommendations to enhance Public Health impact. Frontiers in public health, 6, 71.

Holtrop, J. S., Rabin, B. A., & Glasgow, R. E. (2018). Qualitative approaches to use of the RE-AIM framework: rationale and methods. BMC health services research, 18(1), 177.

Jørgensen, T. S., Wium-Andersen, I. K., Wium-Andersen, M. K., Jørgensen, M. B., Prescott, E., Maartensson, S., ... & Osler, M. (2016). The incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients. JAMA Psychiatry, 73(10), 1032-1040.

Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., ... & Johnston, S. C. C. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, STR-0000000000000024.

McGoey, T., Root, Z., Bruner, M. W., & Law, B. (2015). Evaluation of physical activity interventions in youth via the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework: A systematic review of randomized and non-randomised trials. Preventive medicine, 76, 58-67.

Mittal, N., Hurn, P. D., & Schallert, T. (2016). Exploring a need for improved preclinical models of post-stroke depression. Neural regeneration research, 11(4), 561.

Nyquist, P. A., Bilgel, M. S., Gottesman, R., Yanek, L. R., Moy, T. F., Becker, L. C., ... & Kral, B. G. (2014). Extreme deep white matter hyperintensity volumes are associated with African American race. Cerebrovascular Diseases, 37(4), 244-250.

Robinson, R. G., & Jorge, R. E. (2015). Post-stroke depression: a review. American Journal of Psychiatry, 173(3), 221-231.

Stoutenberg, M., Galaviz, K. I., Lobelo, F., Joy, E., Heath, G. W., Hutber, A., & Estabrooks, P. (2018). Peer Reviewed: A Pragmatic Application of the RE-AIM Framework for Evaluating the Implementation of Physical Activity as a Standard of Care in Health Systems. Preventing chronic disease, 15.

Towfighi, A., Ovbiagele, B., El Husseini, N., Hackett, M. L., Jorge, R. E., Kissela, B. M., ... & Williams, L. S. (2017). Poststroke depression: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 48(2), e30-e43.

Wei, N., Yong, W., Li, X., Zhou, Y., Deng, M., Zhu, H., & Jin, H. (2015). Post-stroke depression and lesion location: a systematic review. Journal of Neurology, 262(1), 81-90.