Tailoring interventions to implement recommendations for the treatment of elderly patients with depression: a qualitative study

Background To improve adherence to evidence-based recommendations, it is logical to identify determinants of practice and tailor interventions to address these. We have previously prioritised six recommendations to improve treatment of elderly patients with depression, and identified determinants of adherence to these recommendations. The aim of this article is to describe how we tailored interventions to address the determinants for the implementation of the recommendations. Methods We drafted an intervention plan, based on the determinants we had identified in a previous study. We conducted six group interviews with representatives of health professionals (GPs and nurses), implementation researchers, quality improvement officers, professional and voluntary organisations and relatives of elderly patients with depression. We informed about the gap between evidence and practice for elderly patients with depression and presented the prioritised determinants that applied to each recommendation. Participants brainstormed individually and then in groups, suggesting interventions to address the determinants. We then presented evidence on the effectiveness of strategies for implementing depression guidelines. We asked the groups to prioritise the suggested interventions considering the perceived impact of determinants and of interventions, the research evidence underlying the interventions, feasibility and cost. We audiotaped and transcribed the interviews and applied a five step framework for our analysis. We created a logic model with links between the determinants, the interventions, and the targeted improvements in adherence. Results Six groups with 29 individuals provided 379 suggestions for interventions. Most suggestions could be fit within the drafted plan, but the groups provided important amendments or additions. We sorted the interventions into six categories: resources for municipalities to develop a collaborative care plan, resources for health professionals, resources for patients and their relatives, outreach visits, educational and web-based tools. Some interventions addressed one determinant, while other interventions addressed several determinants. Conclusions It was feasible and helpful to use group interviews and combine open and structured approaches to identify interventions that addressed prioritised determinants to adherence to the recommendations. This approach generated a large number of suggested interventions. We had to prioritise to tailor the interventions strategies.


Background
Only 50 % of patients with depression receive care in accordance with guidelines [1,2]. Many factors may impede or facilitate adherence and determine whether a patient receives appropriate care. These factors are referred to as determinants of practice [3]. Knowledge about determinants of practice can guide efforts to develop and choose interventions that are tailored to address those determinants and more effectively implement guidelines. Applying and increasing knowledge Open Access *Correspondence: eivind.aakhus@gmail.com 1 Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, 2312 Ottestad, Norway Full list of author information is available at the end of the article about effective strategies for implementing guidelines can potentially reduce the gap between scientific evidence and clinical practice.
The aim of the Tailored Implementation for Chronic Diseases (TICD) project was to directly compare alternative approaches in the tailoring process and subsequently assess the effectiveness of tailored implementation interventions [3]. The Norwegian part of TICD addressed elderly patients with depression [4]. Elderly patients with depression have an increased risk of a chronic course, and the prognosis is worse as compared with younger adults [5,6]. Evidence indicates that healthcare professionals use longer time to diagnose depression and initiate adequate treatment in elderly patients [7].
Adherence to guidelines for depression improves patient outcomes [8,9]. A logical step to improve adherence to guidelines is to identify significant determinants of practice and tailor implementation interventions to address these factors. Tailored interventions are more likely to improve professional practice than no intervention or dissemination of guidelines alone [10]. However, it is uncertain how best to tailor interventions. Thus, there is a need to compare different ways of identifying determinants and developing implementation strategies to address those determinants.
We conducted a systematic review of 13 clinical practice guidelines for the management of depression [11]. With the help of a reference group (see "Acknowledgments"), we prioritised six recommendations that we wanted to implement (Table 1). Depression in the elderly is frequent, affecting 10-16 % of people over 65 years, and complex, triggered by social, psychological, and biological factors [12,13]. Acknowledging this Table 1 Six prioritised recommendations for managing depression in the elderly in primary care a Municipalities are the atomic unit of local government in Norway and are responsible for outpatient health care services, senior citizen services, and other social services. There are 429 municipalities

Prioritised recommendations
Full recommendation to be discussed in the groups and interviews 1. Social contact Primary care physicians and other health care professionals should discuss social contact with elderly patients with depression, and recommend actions (e.g. group activities) for those who have limited social contact When needed, regular social contact with trained volunteers, recruited from centres for voluntary organisations, the red cross, mental health or community day care centres When possible, the patient's relatives should be involved in the plan to improve social contact 2. Collaborative care plan All municipalities a should develop a plan for collaborative care for patients with moderate to severe depression. The plan should describe the responsibilities and communication between professionals who have contact with the patient, within primary care and between primary and specialist care.
In addition, the plan should appoint depression case managers who have a responsibility for following the patient. The plan should describe routines for referral to specialist care 3. Depression case manager Primary care physicians should offer patients with moderate to severe depression regular contact with a depression case manager 4. Counselling Primary care physicians or qualified health care professionals should offer advice to elderly patients with depression regarding: Self-assisted programs, such as literature or web-based programs based on cognitive behavioural therapy principles Structured physical activity programmes, individually or group-based Healthy sleeping habits Anxiety coping strategies Problem solving therapy

Mild depression
Primary care physicians should usually not prescribe antidepressants to patients with mild depression. Primary care physicians may consider prescribing antidepressant medication to patients who suffer from a mild episode of depression and have previously responded to antidepressant medication when moderately or severely depressed 6. Severe depression, recurrent and chronic depression and dysthymia Primary care physicians should offer these patients a combination of antidepressant medication and psychotherapy. If the physician is not trained to provide the patient with psychotherapy, patients should be referred to trained health care professionals complexity, the recommendations addressed the need for a coordinated combination of interventions, including pharmacotherapy, psychotherapy, self-help strategies, social strategies, and coordination of care. As a result of the prioritising process in a previous part of this project only treatment issues, and not diagnostic, were chosen [14]. Although the evidence for the effectiveness of antidepressants in depression has been questioned [15], there are systematic reviews that indicate that antidepressants are beneficial in combination with psychotherapy in elderly patients with severe depression [16,17]. We identified 352 determinants of practice for the six recommendations using a multi-methods approach, and prioritised 99 determinants that we wanted to address by tailoring interventions to facilitate adherence to the recommendations [14]. The aim of this article is to describe how we developed implementation interventions based on these determinants of practice. We will evaluate the effectiveness of these interventions in a randomised trial [4], and conduct a process evaluation to examine the validity of the tailoring methods that were used [18]. Partners in the TICD project are conducting parallel studies addressing the implementation of guidelines for different chronic conditions in four other European countries. The sequential steps in the TICD project, the Norwegian publications focused on improving treatment of elderly patients with depression, and the cross-country TICD publications are summarised in Table 2.

Methods
The TICD group developed a common protocol for the study. Each of the five countries in the TICD project selected between eight and 30 determinants for discussion in focus groups. The methods, setting, study sample and group interviews are presented in detail elsewhere [19,20]. Here we briefly describe how we conducted our study in Norway.
We (EA, SF and AO) selected 22 of the 99 prioritised determinants of that we had identified in a previous study [14]. We used the tools provided by Flottorp and colleagues (TICD Worksheet 3: development of an implementation strategy) [21]. We independently assessed each of the 99 determinants by evaluating its likely impact (3 = major impact, 2 = moderate impact, 1 = minor impact) and the effect of the likely impact on adherence using a 7 point scale (−3 = major reduction in adherence, 0 = no effect in adherence and +3 = major increase in adherence) [21,22]. This process yielded a product of the likely impact of the determinant and the likely effect on adherence (range −9 to +9). We then discussed potential implementation strategies, the likely impact of the implementation strategy, the feasibility of the implementation strategy and whether the strategy should be targeted (only implemented for selected GPs, practices or communities where the determinant could be identified) or adjusted. In addition, we assessed each determinant in light of what we could accomplish within the resources and the timeframe of the project. We also assessed what might be realistic based on our knowledge of the Norwegian primary healthcare system. Thus, the prioritised determinants were not a result of the scoring process alone. We resolved disagreement by discussion.
We developed a draft of a plan with 55 interventions that addressed all the 22 prioritised determinants and the six recommendations. We grouped the 55 interventions in the plan in six different categories (Box 1). We grouped all interventions that the participants suggested into the six categories in the drafted plan. As described above, the intervention plan by the research team included 55 interventions that addressed all the prioritised determinants and could be fit within the six intervention categories [14]. This is presented in the logic model ( Fig. 1; "Appendix").
The logic model is a construct that connects the planned interventions to the determinants and the assumed effects of the interventions. One or more interventions may address one or more determinants.
We presented the selected 22 determinants to the groups (Table 3). We did not present our draft plan to the participants, to avoid influencing their thinking.

Setting and sample
We conducted six group interviews, one for each of the following stakeholder groups: general practitioners (GPs), primary health care nurses, implementation researchers, quality improvement officers, professional and voluntary organisations, and relatives of elderly patients with a present or past history of depression. In an earlier part of the project we experienced that elderly patients with present or past depression found the interview questions difficult and we terminated recruitment of patients earlier than planned [14]. Based on this experience, for this study we invited relatives of patients rather than patients. We contacted 17 individuals, 12 research or health care organisations, and eight stakeholder organisations by phone and subsequently email if they asked for further information. We invited people to participate or to suggest a colleague or a representative. After the groups sessions we asked each participant to rate whether they found their participation meaningful, useful and satisfactory.

Group interviews
We sent written material with the recommendations and information about how the groups would be organised to the participants in advance, and asked them to prepare for the group interviews. The group interviews followed a standardised procedure according to the common TICD protocol, although the content of the questions and responses differed across countries [19]. The interviews lasted 120 min and consisted of a brainstorming session followed by a structured interview phase. EA facilitated the groups. SF or IG were co-leaders, recorded all items, made field notes and asked questions as prompts when needed. First, EA introduced the project, the recommendations and information on the performance gap between clinical practice and the recommendations. Then each participant received a sheet with the six recommendations and the prioritised determinants. The participants brainstormed individually for 10 min and wrote down ideas for interventions to address each determinant for each recommendation. The group members then presented their suggested interventions to the group. EA recorded the suggestions for each determinant on a whiteboard. Following the principles of brainstorming we tried to avoid criticism, while we encouraged combining and extending previously suggested items [23]. There was no limit to the number or type of the items. After a short  break, EA briefly presented current knowledge regarding effectiveness of strategies to implement depression guidelines. We then conducted the structured part of the focus group. EA instructed the participants to discuss the interventions that they had suggested through the brainstorming session, to add others, and to prioritise the suggested interventions.
We based the prioritisation process on the following considerations: 1. Perceived importance of the targeted determinant 2. Perceived impact of the implementation intervention 3. Research evidence underlying the effect of the intervention 4. Feasibility and cost of the intervention 5. Other considerations

Deviation from the common TICD protocol
We tried to conduct the first group interview in accordance with the common protocol for the five national TICD projects. Following the first group interview, we realised that in our project it was not feasible to address each of the suggested interventions in the systematic way stated in the protocol due to the large number of suggested determinants and interventions, and a limited amount of time. We chose a more pragmatic approach for the remaining group interviews. We asked the groups to prioritise the interventions that we had recorded on the whiteboard, bearing in mind the considerations mentioned above throughout the procedure. The first four groups (implementation researchers, nurses, quality improvement officers, and representatives of organisations) followed the same sequence, starting with the first recommendation (social contact) and the first determinant (finding volunteers) ( Table 1).
We observed that the number of suggested interventions decreased as the session moved on. The groups produced fewer ideas for mild and severe depression (recommendations number five and six) as compared with social contact (the first recommendation). Thus, we asked the fifth group (relatives) to focus mainly on the first three recommendations (social contact, collaborative care plan, depression case manager) because we believed that these recommendations were most relevant to this group. We asked the last group (GPs) to focus on the last three recommendations (counselling, mild

Analysis
We applied a five-step framework for our analysis [24]: 1. Familiarisation We audiotaped all group sessions, photographed the results from the whiteboard, and made short notes from the discussions. We used the whiteboard results as the primary source of information for the analysis. We used the audio-recordings and the notes to include additional material that we had not recorded on the board. EA put all quotes containing suggested interventions in tables, one column for each group and one table for each recommendation. SF and EA reviewed these Tables 2. Identifying a thematic framework We used the drafted plan for an intervention package (Table 4, left column) as a comparator. 3. Indexing SF and EA independently analysed these data, assessing whether the interventions that we identified during each session were similar or different from each other or the intervention plan drafted by the research team. We categorised the interventions using the format of the drafted plan. 4. Charting We discussed our assessments and revised the final list of interventions for each determinant based on a consensus. EA linked the suggested interventions to the drafted plan, either as modifications of interventions already described or as new suggestions.

Mapping and interpretation
We all reviewed the revised intervention plan and grouped the interventions across recommendations and the TICD checklist items in order to identify any topics of related suggestions in the data-set [21]. We used a standardised procedure to rank the interventions according to the following criteria: 1. Is it feasible? (Score 1 = Yes, 2 = Maybe, This yielded a score for each intervention (range 2-6). A lower score indicated that a suggested intervention was both feasible and helpful. Finally, we assessed the score for each intervention and asked whether we should prioritise the intervention for the planned trial (Yes/No) and, if so, if we should adjust it to each municipality or practice (Yes/No)? We resolved disagreement by discussion.

Results
Thirty-one people consented to participate. Two did not show up (one sick, the other gave no reason). Thus, 29 people participated in the various group sessions (five GPs, four implementation researchers, six primary care nurses, six representatives from professional and voluntary organisations, five quality improvement officers and three relatives of elderly patients). Making personal calls was a practical and effective strategy to recruit participants. Three people living in other parts of Norway participated in the group interviews using Skype. The group sessions took place from October to December 2013. The groups were enthusiastic, relaxed and creative. Written feedback from 23 (80 %) of the participants indicated that they experienced the group sessions as meaningful. The limited time was a challenge and several claimed that they should have prepared better prior to the meeting. One Skype participant found it difficult to contribute to the structured part of the session for technical reasons. A majority (70 %) said that their participation was useful and 68 % said it was satisfactory. None indicated that their participation was unsatisfactory or not useful.
The six groups yielded approximately 450 suggested interventions, of which many were related to each other and to suggested interventions in the drafted plan. We found that approximately 70 suggestions contained statements or attitudes rather than interventions (such as "Lack of available services is more important than GPs' time constraints".). This left 379 suggestions of interventions for further analysis. In the first four group interviews, we presented the recommendations in the following order: social contact, collaborative care plan, depression case manager, counselling, mild depression and severe depression. There were 127 suggestions for interventions to improve adherence to the recommendation on social contact, 68 for collaborative care plan, 54 for depression case manager, 40 for counselling, 47 for mild depression, and 43 for severe depression. The groups with representatives of professional and voluntary organisations and quality improvement officers generated the most suggestions, (106 and 96 respectively). The group with nurses generated 67 suggestions and the implementation researchers 36. The groups with GPs and relatives focused mainly on three selected recommendations. They generated 41 and 33 suggestions respectively.
We reduced the number of interventions from 379 to 65 based on our assessments of their likely effectiveness and feasibility. Of these, 28 were added or modified after the group sessions (18 modifications and 10 new interventions). We determined that 18 of the interventions should be adapted to municipalities or practices (Table 4). In Table 4, we present the following for each recommendation: the research group's suggestions for interventions prior to the group interviews (first column), modifications of these suggestions and new suggestions from the group interviews (second column),

Recommendation: social contact
Draft plan from the research team

Modifications or new interventions from the group sessions Adaptation to municipalities or practices
Targeted determinant (see Table 3)    Table 3) Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees   Table 3) Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees   Table 3) Outreach visits to GPs. Discuss this with GPs. Suggest strategies to avoid prescribing antidepressants GP wants to "do something", drugs are simple actions

Recommendation: Antidepressants and psychotherapy in severe and recurrent depression
Draft plan from the research team

Modifications or new interventions from the group sessions Adaptation to municipalities or practices
Targeted determinant (see Table 3) In this table we use the terms "tailoring", "targeting" and "adjustment". We define these terms in the following way: Tailoring: planning interventions/strategies that are designed to achieve desired changes in healthcare practice based on an assessment of determinants of healthcare practice. Targeting: implementation of the tailored intervention for selected GPs, practices or communities (where the determinant could be identified) and

Resources for general practitioners and other
not for others (where the determinant could not be identified). Adjustment: modification of the tailored intervention to address determinants that are identified as the tailored intervention is implemented whether the intervention should be adapted to each municipality or practice and, if so, how (third column), and the determinant at which each intervention was targeted (last column). We removed suggestions that could not be tested in the planned randomised controlled design [4], such as "dissemination in the Norwegian Electronic Medical Handbook" and "using newspapers to inform patients". Some suggestions were related, although addressing different recommendations and determinants. We were able to group several interventions together. We reduced the number of interventions presented in the logic model from 65 (the sum of interventions suggested by the research team and the groups) to 52 by combining all similar or related interventions that addressed different determinants or recommendations as presented in the logic model ("Appendix"). Each intervention is numbered in the order it appears the first time. When a closely related intervention is noted later in relation to a different recommendation or determinant, it is given the same number and a sequential lowercase letter. Thus intervention 1a is closely related to 1b, 1c and 1d, although they may not appear in numerical order. An intervention could address a single determinant, such as this suggestion: "Discuss GPs' urge to do something and the view that prescribing antidepressants is a simple action in outreach visits", which addressed this determinant: "GPs want to do something, and prescribing drugs is easy". An intervention could also address several determinants, such as: "Provide structured referral forms for psychotherapy", which addressed these two determinants: "GPs do not have the expertise to provide psychotherapy" and "There is a lack of health professionals who can provide this type of service".
Several interventions could also address the same determinant. For example, this determinant: "There is a lack of other types of services that makes it difficult not to prescribe antidepressants in mild depression" was addressed by these three interventions: "Provide training in counselling to health professionals", "Provide CME approved courses in counselling to GPs", and "Provide courses as e-learning courses".

Discussion
We have conducted group interviews with several stakeholder groups to inform our decisions about how to tailor implementation interventions to improve adherence to clinical practice guidelines for elderly patients with depression. We developed a draft plan consisting of 55 interventions that addressed determinants of practice for the six recommendations, organised in six domains: resources for the development of a collaborative care plan, resources for GPs and other healthcare professionals, resources for patients and their relatives, outreach visits to GPs, educational resources for GPs and webbased services. The plan covered many of the interventions that the groups suggested. However, the groups added many new ideas, and they modified approximately half of the interventions suggested in the draft plan.

Strengths and limitations
We included several stakeholder groups, to achieve a purposeful sample of healthcare professionals, relatives of elderly patients with depression, implementation researchers and others that might be able to suggest effective interventions to address the identified determinants of practice. This approach to tailoring an intervention to prioritised determinants was standardised across five countries and disease groups in the TICD project [4,[25][26][27][28]. We are not aware of any other project that has addressed tailoring of implementation interventions in this comprehensive manner, using a check-list systematically to identify and prioritise determinants of practice and to identify interventions that could address them [21]. However, due to the complexity of our recommendations, the large number of prioritised determinants and the limited time available for the interviews, it was not feasible for us to address each of the suggested interventions in the systematic way stated in the common TICD protocol.
The recommendations that we prioritised addressed several levels of the healthcare system, from the patients and their relatives to the healthcare professionals and the healthcare administration in the municipalities. The use of the TICD checklist to prioritise determinants and interventions made it possible to analyse the results in a systematic way [21]. Nonetheless, the results from this part of the analysis were assessments based on our considerations and judgments. An alternative strategy would be for representatives from the stakeholder groups to do this assessment. The wide range and the large number of interventions that the groups discussed within a limited time may have compromised more detailed and structured discussions, and may have resulted in superficial assessments for some determinants or interventions.
The number of suggested interventions for each determinant and recommendation varied. Recommendations presented early in the session appeared to yield the most suggestions. These recommendations addressed mainly the community and municipalities, while the last recommendations addressed clinicians. It is possible that the nature of the first guidelines generated more suggestions. It is also possible that there were fewer suggestions for the recommendations presented later in the interview because of exhaustion in the groups. One solution to this could have been to present the recommendations in a different order for each of the groups.
The large number of suggested interventions addressed only six recommendations, whereas clinical practice guidelines frequently contain many more recommendations. There is a risk that guideline developers will experience information overload, if they try to use this approach for a full guideline.
We excluded suggested interventions that could not be evaluated in our planned cluster randomised controlled trial. Thus, we omitted potentially useful dissemination channels suggested by the groups, such as media and e-resources that are popular among healthcare professionals (The Norwegian electronic health library, the Norwegian Directorate of Health's web site and the Norwegian Electronic Medical Handbook).

Comparison with existing literature
Determinants of practice related to depression guidelines are numerous and apply to all levels of the healthcare system [14,29,30]. Relatively few studies on improving the care of patients with depression have described the development of a systematically planned intervention tailored to address identified determinants. Shirazi and colleagues [31] demonstrated that tailoring an educational intervention, based on GPs' readiness-to-change (high-low), improved GPs' performances in hypothetical (role-playing) consultations as compared with controls. Verhaak and colleagues [32] found that disability (particularly disability that affects participation, self-care and social activities) had a major impact on depression in the elderly. One might argue that the interventions that we planned considered this aspect to a limited degree only. Nevertheless, we addressed social withdrawal and frailty in our planned interventions. Furthermore, their findings indicated that the effect of disability on depression was largest among the younger elderly (those between 60 and 70 years). We included patients 65 years or older in our study. In a randomised controlled trial based on a psychological theoretical framework, Baker and colleagues [33], identified obstacles to adherence among 34 GPs, and tailored their intervention to each practitioner. They found that this strategy improved assessment of suicide risk and depression, assessed with Beck's Depression Inventory. They found no difference for anti-depressant therapy or utilisation of psychotherapeutic services. Addressing clinicians individually to identify determinants of practice is an attractive approach, but rarely realistic in large-scale efforts to implement clinical practice guidelines. We deemed this approach unfeasible.
In a joint analysis of the studies to tailor interventions in the TICD project, Huntink and colleagues [20] found no relationship between the total number of suggested interventions and the number of unique suggestions (interventions only suggested by one group).

Implications for research and practice
The extent to which there are similar determinants of practice in other settings and the extent to which similar interventions would be appropriate in other settings is uncertain. However, many of the same determinants are likely to be similar in other settings. The approach that we used to develop a package of tailored implementation interventions was both feasible and efficient. Those interested in tailoring interventions to implement guidelines can use the TICD checklist [21] and the interview methods that we used in this study.
We are evaluating the effectiveness of the tailored interventions that we have developed in a randomised trial [4]. We will assess whether we identified the most important determinants and selected appropriate interventions to address those in a process evaluation [18].
There is a paucity of research comparing different methods of identifying determinants of practice and tailoring implementation interventions to address those. To our knowledge, the TICD project is one of the first projects that have done this [19,20,34]. We need more research to improve the methods used to tailor interventions and to understand how best to do this. This includes evaluation of strategies to prioritise suggested interventions, given the abundance of suggestions that is possible, as illustrated by this study.    Explanation Each intervention is numbered in the order it appears the first time. When a closely related intervention is noted later in relation to a different recommendation or determinant, it is given the same number and a sequential lowercase letter. Thus intervention 1a is closely related to 1b, 1c and 1d. The interventions are described in more detail in part C. CCP-C collaborative care plan-content, CCP-D collaborative care