title: Delivering stepped care: an analysis of implementation in routine practice.
abstract: BACKGROUND
  In the United Kingdom, clinical guidelines recommend that services for depression and anxiety should be structured around a stepped care model, where patients receive treatment at different 'steps,' with the intensity of treatment (i.e., the amount and type) increasing at each step if they fail to benefit at previous steps. There are very limited data available on the implementation of this model, particularly on the intensity of psychological treatment at each step. Our objective was to describe patient pathways through stepped care services and the impact of this on patient flow and management.
  
  
  METHODS
  We recorded service design features of four National Health Service sites implementing stepped care (e.g., the types of treatments available and their links with other treatments), together with the actual treatments received by individual patients and their transitions between different treatment steps. We computed the proportions of patients accessing, receiving, and transiting between the various steps and mapped these proportions visually to illustrate patient movement.
  
  
  RESULTS
  We collected throughput data on 7,698 patients referred. Patient pathways were highly complex and very variable within and between sites. The ratio of low (e.g., self-help) to high-intensity (e.g., cognitive behaviour therapy) treatments delivered varied between sites from 22:1, through 2.1:1, 1.4:1 to 0.5:1. The numbers of patients allocated directly to high-intensity treatment varied from 3% to 45%. Rates of stepping up from low-intensity treatment to high-intensity treatment were less than 10%.
  
  
  CONCLUSIONS
  When services attempt to implement the recommendation for stepped care in the National Institute for Health and Clinical Excellence guidelines, there were significant differences in implementation and consequent high levels of variation in patient pathways. Evaluations driven by the principles of implementation science (such as targeted planning, defined implementation strategies, and clear activity specification around service organisation) are required to improve evidence on the most effective, efficient, and acceptable stepped care systems.
authors.affiliation: Mood Disorders Centre, University of Exeter, Exeter, EX4 4QG, UK. D.a.richards@exeter.ac.uk
authors.forename: David A
authors.initials: DA
authors.lastname: Richards
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
authors.forename: Christina
authors.initials: C
authors.lastname: Pagel
authors.forename: Alice
authors.initials: A
authors.lastname: Weaver
authors.forename: Martin
authors.initials: M
authors.lastname: Utley
authors.forename: John
authors.initials: J
authors.lastname: Cape
authors.forename: Steve
authors.initials: S
authors.lastname: Pilling
authors.forename: Karina
authors.initials: K
authors.lastname: Lovell
authors.forename: Simon
authors.initials: S
authors.lastname: Gilbody
authors.forename: Judy
authors.initials: J
authors.lastname: Leibowitz
authors.forename: Lilian
authors.initials: L
authors.lastname: Owens
authors.forename: Roger
authors.initials: R
authors.lastname: Paxton
authors.forename: Sue
authors.initials: S
authors.lastname: Hennessy
authors.forename: Angela
authors.initials: A
authors.lastname: Simpson
authors.forename: Steve
authors.initials: S
authors.lastname: Gallivan
authors.forename: David
authors.initials: D
authors.lastname: Tomson
authors.forename: Christos
authors.initials: C
authors.lastname: Vasilakis
mesh_terms: D001007:Anxiety / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D015331:Cohort Studies; D019091:Critical Pathways; D003695:Delivery of Health Care; D003863:Depression / Q000628:therapy*; D003865:Major Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000379:methods*; D011340:Problem Solving; D011614:Psychotherapy, Brief; D012107:Research Design; D012648:Self Care; D006113:United Kingdom