Implementation of Electronic Health Record-based Anxiety and Depression Screening in an Epilepsy Clinic: Description of Theory-based Implementation Strategy and Quantitative Outcomes Using RE-AIM
Paneeni Lohana1, Beverly Snively2, Jerryl Christopher 3, Sabina Gesell2, Heidi Munger Clary4
1Neurology, Atrium Wake Forest Baptist Medical Center, 2Atrium Wake Forest Baptist Medical Center, 3Biostatistics, University of North Carolina, 4Wake Forest University School of Medicine
Objective:
To describe an implementation strategy for anxiety and depression screening at epilepsy clinic visits and perform an outcome assessment using components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.
Background:
Anxiety and depression in epilepsy are common, yet under-detected and undertreated. The American Academy of Neurology quality measures include screening for them at every visit. However, a survey of epilepsy specialists indicated a top barrier is limited time to conduct screening.
Design/Methods:
A strategy for anxiety and depression screening was developed using the Capability, Opportunity, Motivation (COM-B) behavior change framework. The strategy was implemented, incorporating electronic health record (EHR)-based tools and certified medical assistant (CMA) initiation of electronic screeners at the end of check-in. Outcomes were evaluated over a five-month period using components of the RE-AIM framework. Due to COVID-19 and the subsequent transition to virtual visits near the implementation period, evaluation of Maintenance was complicated.
Results:
During the five-month timeframe there were 1097 visits scheduled and 876 visits completed. Among the completed visits, quality measure for anxiety and depression screening was met in 30.9% of visits, compared to 6.2% of consecutive visits in a three-month timeframe prior to any screening implementation interventions. Patients who completed screening were younger than those who did not (mean age 39.4 years (SD 16.0) vs. 43.6 (SD 18.1), p=0.002). Differences by gender or race/ethnicity were not statistically significant. There was substantial provider and CMA-level variability in screening (0-80% for CMAs and 11.5-55.9% for providers), though CMAs and clinic team members who attended education sessions had higher visit screening than temporary staff. Only 0.5% of electronic screeners initiated were not fully completed.
Conclusions:
This framework-based anxiety and depression screening strategy increased quality measure attainment by epilepsy specialists, but with considerable variability across clinic team members and lower reach among older patients.