Outcomes Pre-intermediate Audio Vk

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FormanHoffman VL, Middleton JC, McKeeman JL, et al. Strategies To Improve Mental Health Care for Children and Adolescents [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Dec. (Comparative Effectiveness Reviews, No. 181.)

This section presents the findings of this systematic review, starting with the results of the literature searches and description of included studies. The findings for each Key Question (KQ) present an overview of the identified evidence, followed by key points and detailed results. Detailed results include a description of relevant studies, intermediate outcome findings, patient health and service utilization outcomes, risk of bias considerations (with rating presented in full in Appendix D), and strength of evidence grades for each study. KQ 1 studies are presented individually. We synthesized the results qualitatively rather than quantitatively because of high levels of heterogeneity in the number and types of strategy components, differences between the experimental and control arms (i.e., in some studies, a single component distinguished strategy and control arms, and in other studies, several components differed between arms), and outcomes assessed. We relied on author-reported measures of differences between groups and associated variances, but when these were not reported, we calculated differences and computed odds ratios (ORs) or mean differences, along with 95% confidence intervals (CIs) for between-arm comparisons.

Results of our searches appear in Figure 2. We reviewed 7,917 titles and abstracts dually and independently and identified 533 articles for full-text review. Because of the lack of standard terminology used to define the types of studies of interest to this review, we used a wide-ranging search strategy. As a result, many citations were not relevant, leading to a much smaller pool of included studies at the full-text review stage. We excluded 516 of these articles at the full-text review stage, leaving 17 articles representing 17 studies (one article reports on two different studies,66 and another two articles67,68 report outcomes for the same trial). Common reasons for exclusion included not meeting review criteria for population (i.e., not focusing on health care systems, organizations, or practitioners that provide mental health care for children and adolescents with mental health problems [n=242]), not meeting review criteria for comparator (i.e., not including a comparator [n=44]), not meeting review criteria for intervention (i.e., quality improvement [QI], implementation, and dissemination strategies [n=100]), not meeting review criteria for publication type (cross-sectional studies, nonsystematic reviews [n=57]), and not meeting review criteria for outcome (included only patient health outcomes or only intermediate outcomes for strategies not implementing an evidence-based practice [EBP] [n=40]).

In addition, we searched for related publications to extract contextual information on the reasons for success or failure of strategies. Our searches yielded 1,158 citations of which we reviewed 33 full-text studies. Six studies provided additional contextual information and were incorporated in the results pertaining to each intervention. Additionally, we found two articles that contributed to our evidence base. Specifically, one article68 contributed new outcomes to an already included study; we constructed an add-on search to capture its indexing terms. We included a second article in the review as a new study, arising from handsearches.91 PubMed indexed it as an adult rather than a child study; as a result, we did not capture it in our systematic searches.

We also reached out to principal investigators or their surrogates to elicit their views on the critical components of the strategies included in this review. Three investigators (lead investigators on two studies and one proxy for two studies with a deceased principal investigator) did not respond to our repeated outreach attempts. A fourth respondent refused because of lack of time, and a fifth responded to us but was unable to provide us with information because the principal investigator (lead on two studies) was deceased. Investigators for the remaining 10 studies listed critical components or contextual factors, which we present in the results below.

Table 4 exhibits study characteristics of included studies organized by primary component of strategy according to the EPOC taxonomy (i.e., professional training or financial or organizational change).

Seven studies had unclear risk of bias, 1 had low, 3 had medium, and 6 had high. Most studies were RCTs or CCTs. The majority were clustered at the practitioner, practice, or organizational level. The other two studies included an interrupted time-series study and a cohort study with a historical control. Seven of the studies focused on professional training (i.e., only included professional components), while the other 10 studies focused on financial or organizational changes (i.e., included at least one financial or organizational component). Settings included primary care, community health, and schools. Each included study is reported in detail by KQ below. Full evidence tables are available at

We categorized the strategies tested in 7 studies as spanning multiple categories of our original three classifications: QI, implementation, or dissemination. This overlap prompted us to use a different system, based on the EPOC taxonomy, to ultimately classify strategies as professional training (i.e., strategies that comprised only professional components) or financial or organizational change (i.e., strategies that comprised at least one financial or organizational component).

Seven studies did not report a patient health or service utilization outcome because the strategy employed an EBP. For these studies, positive intermediate outcomes were assumed to have positive effects on patient outcomes. Six studies reported on changes in mental health status (e.g., symptoms, recovery, remission), one on socialization skills and behaviors, one on functional status, and four on service utilization.

The model from qualitative comparative analysis (QCA) that best explained the data looked at the presence of several components. These included educational materials or meetings, educational outreach components, patient-mediated intervention components, audit and feedback, one or more reminders components, one or more financial components, use of a clinical multidisciplinary team, and changing of the scope of patient benefits. The model evaluated these components in relation to having a statistically significant improvement in a majority of the practitioner-, system-, and patient-level intermediate outcomes tested (and rated as having at least low strength of evidence for benefit) or having at least low strength of evidence for benefit for at least one patient health or service utilization outcome (and rated as having at least low strength of evidence for benefit).

Seven studies reported in six publications focused on professional training strategies.66,87,88,90,91,95 These studies each included various professional components according to the EPOC taxonomy and no financial or organizational components. Studies included a maximum of five professional components. Components included distribution of educational materials, educational meetings, local consensus processes, educational outreach visits, patient-mediated interventions, audit and feedback, reminders, marketing, individual support by phone or email, project coordinator assistance, and monthly ongoing training sessions.

One strategy targeted school counselors, five targeted community-based mental health providers, and one targeted general practitioners. One of these studies ultimately targeted general practitioners who treated children and adolescents with psychosis,90 two targeted community-based mental health practitioners,91,95 one targeted community therapists treating children with anxiety,87 one targeted school counselors attempting to prevent externalizing behaviors among children at high risk of aggressive behaviors,88 and two studies reported in one publication targeted nurses who encountered children and adolescents who were suspected victims of abuse.66 Details of each of these studies are described below.

One RCT87 (low risk of bias), conducted in 2009, focused on implementing cognitive behavioral therapy (CBT). Specifically, it evaluated the effectiveness of three 6-hour training modalities of CBT for anxiety in youth and the impact of ongoing consultation after training. Participants were 115 community therapists randomly assigned to one of three 1-day workshops to examine the effectiveness of the training modality: routine training (RT, training as usual, n=41), computer training (CT, computerized training as usual, n=34), and augmented training that emphasized active learning (AT, n=39). After the workshops, all participants received 3 months of ongoing consultation that included case consultation, didactics, and problem solving.

Therapists participated in an additional role-playing exercise at posttraining and 3-month followup (postconsultation) that involved simulated clinical situations where therapists encountered a research assistant acting as a child with anxiety seeking care. Independent assessors coded digital recordings of these sessions to determine the proportion of therapists in each training condition trained to adherence, skill, and knowledge criteria.

All three modalities resulted in limited gains in therapist adherence, skill, or knowledge (Table 6). All groups improved in adherence to CBT measured by an Adherence Skills Checklist, participant skill (level of competence shown by the therapist in delivering treatment), and knowledge of CBT for youth anxiety, but the study found no significant effect on training or interaction of time and training. In addition, the proportion of therapists trained to criterion did not differ across treatment groups for adherence, skill, or knowledge. The study found differences in satisfaction across training modalities (F=7.22, df=2 and 112, p

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