Suicide
Conditions
Keywords
prevention, implementation science
Brief summary
The overall objective of this national quality improvement project is to develop an adaptive implementation strategy to improve the implementation of suicide risk screening and evaluation in Veterans Health Administration ambulatory care settings (i.e., VA Risk ID).
Detailed description
VA Risk ID is the largest implementation of population-based suicide risk screening and evaluation in any United States healthcare system to date. Given the considerable scope of this initiative, several strategies have been employed to support national implementation. To facilitate continuous quality improvement, ongoing evaluation of VA Risk ID and interventions to improve implementation of the three-stage screening and evaluation process are needed. This project is intended to help VHA facilities address challenges to implementing VA Risk ID to fidelity using a sequence of evidence-based implementation strategies (audit and feedback followed by audit and feedback plus external facilitation). By doing so, it will ensure that more Veterans are screened and evaluated for suicide risk, which is the basis of effective, patient-centered suicide risk management. By adapting the implementation intervention dose based on facility performance and monitoring implementation over time, this project will allow the program office to focus resources where and when needed the most.
Interventions
BEHAVIORALAudit and Feedback
The following components will be incorporated into the audit and feedback intervention: i) individualized facility performance data (site level), ii) frequent delivery intervals (monthly), iii) comparisons with other sites, iv) graphical and text form displays of information, v) constructive, non-punitive tone, vi) target performance or benchmark provided, and vii) specific actions or recommendations for meeting the target.
BEHAVIORALExternal Facilitation
Facilitation will be conducted by a team of facilitators who will employ the facilitation process to improve uptake of VA Risk ID. Trained external facilitators will flexibly deliver the facilitation process utilizing an integrated set of implementation strategies (e.g., stakeholder engagement, identification of barriers and facilitators, education, problem solving, the use of formative data, communication, and ongoing support).
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
Sequential Multiple Assignment Randomized Trial
Eligibility
Sex/Gender
ALL
Healthy volunteers
Yes
Inclusion criteria
* Intervention occurs at the site/facility level. Up to 140 VHA facilities across the country will participate in the project. Sites will be allocated to various interventions based on performance (i.e., pre-determined benchmarks for adequate implementation).
Exclusion criteria
* This is a national quality improvement project. Sites that are randomized to different intervention arms based on performance may refuse to participate in the implementation interventions.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 1 | Change from baseline and intervention Phase 1 month 8 | C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from baseline to month 8 of intervention Phase 1. Higher numbers reflect greater change in adherence from baseline to month 8 of intervention Phase 1. |
| Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake- Phase 1 | Change from baseline and intervention Phase 1 month 8 | CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from baseline to month 8 of intervention Phase 1. Higher numbers reflect greater change in adherence from baseline to month 8 of intervention Phase 1. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2a | Change from month 9 of intervention phase 1 and month 9 of intervention phase 2 | C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. |
| Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2a | Change from month 9 of intervention phase 1 and month 9 of intervention phase 2 | CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. |
| Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2b | Change from month 9 of intervention phase 1 and month 9 of intervention phase 2 | C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. |
| Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2b | Change from month 9 of intervention phase 1 and month 9 of intervention phase 2 | CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. |
Countries
United States
Participant flow
Recruitment details
138 VHA facilities were recruited and enrolled. Sites were allocated to different implementation strategies based on performance.
Pre-assignment details
All sites started with implementation as usual during run-in phase.
Participants by arm
| Arm | Count |
|---|---|
| Implementation As Usual This group included sites that responded to implementation as usual during run-in and continued with implementation as usual throughout the trial period. There were no sites in Arm 1 as none of the facilities implemented adequately after the run-in phase. | 0 |
| Implementation As Usual This group included sites that responded to implementation as usual during run-in and continued with implementation as usual throughout the trial period. There were no sites in Arm 1 as none of the facilities implemented adequately after the run-in phase. | 0 |
| Audit & Feedback Responders Continue This group included sites that did not implement adequately after the run-in phase, received audit & feedback (A&F) in Phase 1, responded to A&F, and continued A&F in Phase 2.
Phase 1: randomized to A&F arm
Phase 2: randomized A&F arm again | 0 |
| Audit & Feedback Responders Continue This group included sites that did not implement adequately after the run-in phase, received audit & feedback (A&F) in Phase 1, responded to A&F, and continued A&F in Phase 2.
Phase 1: randomized to A&F arm
Phase 2: randomized A&F arm again | 6 |
| Audit & Feedback Responders Switch This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, responded to A&F and switched to A&F Light in Phase 2. (Note. IAU became A&F Light during Phase 2).
Phase 1: randomized to A&F arm
Phase 2: randomized A&F Light arm | 0 |
| Audit & Feedback Responders Switch This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, responded to A&F and switched to A&F Light in Phase 2. (Note. IAU became A&F Light during Phase 2).
Phase 1: randomized to A&F arm
Phase 2: randomized A&F Light arm | 6 |
| Audit & Feedback Non-Responders Continue This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, did not respond to A&F, and continued A&F in Phase 2.
Phase 1: randomized to A&F arm
Phase 2: randomized A&F arm again | 0 |
| Audit & Feedback Non-Responders Continue This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, did not respond to A&F, and continued A&F in Phase 2.
Phase 1: randomized to A&F arm
Phase 2: randomized A&F arm again | 38 |
| Audit & Feedback Non-Responders Add Facilitation This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, did not respond to A&F, and accepted and received A&F + External Facilitation in Phase 2. (Note. Only included sites that accepted EF).
Phase 1: randomized to A&F arm
Phase 2: randomized to A&F plus External Facilitation arm | 0 |
| Audit & Feedback Non-Responders Add Facilitation This group included sites that did not implement adequately after the run-in phase, received A&F in Phase 1, did not respond to A&F, and accepted and received A&F + External Facilitation in Phase 2. (Note. Only included sites that accepted EF).
Phase 1: randomized to A&F arm
Phase 2: randomized to A&F plus External Facilitation arm | 17 |
| Implementation As Usual to Audit & Feedback Light This group included sites that did not implement adequately after the run-in phase, continued with IAU in Phase 1, and received A&F Light in Phase 2. (Note. IAU became A&F Light during Phase 2)
Phase 1: randomized to Implementation as Usual arm
Phase 2: received implementation as usual which became A&F Light | 0 |
| Implementation As Usual to Audit & Feedback Light This group included sites that did not implement adequately after the run-in phase, continued with IAU in Phase 1, and received A&F Light in Phase 2. (Note. IAU became A&F Light during Phase 2)
Phase 1: randomized to Implementation as Usual arm
Phase 2: received implementation as usual which became A&F Light | 66 |
| Total | 133 |
Baseline characteristics
| Characteristic | Total | Implementation As Usual to Audit & Feedback Light | Audit & Feedback Non-Responders Add Facilitation | Audit & Feedback Responders Switch | Audit & Feedback Responders Continue | Audit & Feedback Non-Responders Continue |
|---|---|---|---|---|---|---|
| Age, Continuous | NA years | NA years | NA years | NA years | NA years | NA years |
| Facility Complexity Facility Complexity Level 1a-1c | 83 Site/Facilities | 41 Site/Facilities | 13 Site/Facilities | 1 Site/Facilities | 2 Site/Facilities | 26 Site/Facilities |
| Facility Complexity Facility Complexity Level 2 | 22 Site/Facilities | 12 Site/Facilities | 4 Site/Facilities | 1 Site/Facilities | 1 Site/Facilities | 4 Site/Facilities |
| Facility Complexity Facility Complexity Level 3 | 28 Site/Facilities | 13 Site/Facilities | 0 Site/Facilities | 4 Site/Facilities | 3 Site/Facilities | 8 Site/Facilities |
| Race (NIH/OMB) American Indian or Alaska Native | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) Asian | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) Black or African American | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) More than one race | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) Unknown or Not Reported | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Race (NIH/OMB) White | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Region of Enrollment United States | 133 Site/Facilities | 66 Site/Facilities | 17 Site/Facilities | 6 Site/Facilities | 6 Site/Facilities | 38 Site/Facilities |
| Sex: Female, Male Female | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
| Sex: Female, Male Male | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities | NA Site/Facilities |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk | EG004 affected / at risk | EG005 affected / at risk |
|---|---|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
| other Total, other adverse events | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 | 0 / 0 |
Outcome results
Primary
Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 1
C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from baseline to month 8 of intervention Phase 1. Higher numbers reflect greater change in adherence from baseline to month 8 of intervention Phase 1.
Time frame: Change from baseline and intervention Phase 1 month 8
Population: All sites that completed Phase 1 are included in the analysis. Sites that received Audit \& Feedback in addition to Implementation as Usual during Phase 1 are compared to sites that only received Implementation as Usual during Phase 1.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 1 | 13.0 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 1 | 11.9 change in percent adherence |
p-value: 0.1895% CI: [-0.46, 2.48]Mixed Models Analysis
Primary
Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake- Phase 1
CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from baseline to month 8 of intervention Phase 1. Higher numbers reflect greater change in adherence from baseline to month 8 of intervention Phase 1.
Time frame: Change from baseline and intervention Phase 1 month 8
Population: All sites that completed Phase 1 are included in the analysis. Sites that received Audit \& Feedback in addition to Implementation as Usual during Phase 1 are compared to sites that only received Implementation as Usual during Phase 1.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake- Phase 1 | 11.0 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake- Phase 1 | 7.45 change in percent adherence |
p-value: 0.0695% CI: [-0.11, 7.28]Mixed Models Analysis
Secondary
Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2a
C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2.
Time frame: Change from month 9 of intervention phase 1 and month 9 of intervention phase 2
Population: Responding sites that continued to received audit \& feedback during Phase 2 are compared to responding sites that switched to audit \& feedback light during Phase 2. For Phase 2, it was pre-specified to compare only Audit \& Feedback Light to Audit and Feedback for the group of sites that responded to Audit \& Feedback during Phase 1.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2a | 13.3 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2a | 11.7 change in percent adherence |
p-value: 0.695% CI: [-4.5, 7.9]Mixed Models Analysis
Secondary
Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2b
C-SSRS uptake is a site level adherence measure of the percentage of patients in ambulatory care who received a timely annual suicide risk screen (i.e., during the first encounter/visit after the annual suicide risk screen reminder was due). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2.
Time frame: Change from month 9 of intervention phase 1 and month 9 of intervention phase 2
Population: Nonresponding sites that received audit and feedback in Phase 2 are compared to nonresponding sites that received audit \& feedback plus external facilitation during Phase 2.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2b | 18.9 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Columbia Suicide Severity Rating Scale Screener (C-SSRS) Uptake- Phase 2b | 23.4 change in percent adherence |
p-value: 0.0295% CI: [-8.3, -0.67]Mixed Models Analysis
Secondary
Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2a
CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2.
Time frame: Change from month 9 of intervention phase 1 and month 9 of intervention phase 2
Population: Responding sites that continued to received audit \& feedback during Phase 2 are compared to responding sites that switched to audit \& feedback light during Phase 2. For Phase 2, it was pre-specified to compare only Audit \& Feedback Light to Audit and Feedback for the group of sites that responded to Audit \& Feedback during Phase 1.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2a | 6.2 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2a | 10.2 change in percent adherence |
p-value: 0.3695% CI: [-12.8, 4.7]Mixed Models Analysis
Secondary
Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2b
CSRE uptake is a site level adherence measure of the percentage of patients in ambulatory care who had a positive C-SSRS screener and received the CSRE as intended (same day and by the appropriate provider). The score is a facility adherence score. Adherence ranges from 0 to 100, higher scores reflect higher adherence. The outcome measure is reported as the change in facility adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2. Higher numbers reflect greater change in adherence from month 9 of intervention phase 1 to month 9 of intervention phase 2.
Time frame: Change from month 9 of intervention phase 1 and month 9 of intervention phase 2
Population: Nonresponding sites that received audit and feedback in Phase 2 are compared to nonresponding sites that received audit \& feedback plus external facilitation during Phase 2.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Phase 1: Audit & Feedback | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2b | 13.0 change in percent adherence |
| Phase 1: Implementation As Usual | Change in Comprehensive Suicide Risk Evaluation (CSRE) Uptake-Phase 2b | 13.6 change in percent adherence |
p-value: 0.8295% CI: [-5.5, 4.4]Mixed Models Analysis