This thesis is divided into two main parts. The theoretical part defines the concept of self-assessment and focuses on the significance and forms of self-assessment, as well as the factors arising during implementation of self-assessment in education. This part also contains findings from specialized publications analysing the relationship between assessment and self-assessment directed towards individualisation (personalisation). The practical part of this thesis takes the form of pro-active research, the aim of which is to observe implementation of self- assessment by a specific pupil with a specific learning disability. It describes how to teach an integrated pupil to self-assess, confirms that the pupil is able to self-assess his work and describes the steps involved in the implementation. Key words evaluation, self-assessment, pupil with special needs, integrated pupil, descriptive language, evaluation criteria, quality indicator, forms of self-assessment, action research

Au cours de cette thèse, nous nous sommes d'abord intéressés à l'optimisation des ressources et à la modulation adaptative dans les systèmes SC-FDMA (Single Carrier Frequency Division Multiple Access). Ce problème d'optimisation est combinatoire à complexité de calcul exponentielle. Afin de pallier à cette difficulté, nous avons utilisé la théorie de la dualité canonique, grâce à laquelle, la complexité du problème d'optimisation devient polynômiale et cela en constitue une amélioration remarquable. L'approche proposée est très proche de la solution optimale. Nous avons ensuite étudié la problématique complexe de l'allocation de ressources pour le "Streaming Vidéo" dans les réseaux sans fil, où il est nécessaire d'assurer une transmission vidéo de haute qualité en présence de canaux et de brouillages variables au cours du temps. Dans ce contexte, nous avons proposé une nouvelle méthode d'allocation de puissance conjointement à l'adaptation du débit vidéo. Pour ce faire, nous avons adopté une approche de la théorie de contrôle, intitulée "Risk-Sensitive Control". Nous avons dédié la troisième partie de la thèse à la conception d'une nouvelle stratégie "best-M" pour le renvoi du CQI (Channel Quality Indicator) pour les systèmes multi-utilisateurs et multi-porteuses. En générale, l'erreur d'estimation du CQI ainsi que son délai de renvoi sont gérés au niveau de la station de base. Notre nouvelle stratégie "best-M" suppose que la gestion de ces problèmes est confiée aux utilisateurs. De ce fait, la performance du système se trouve améliorée sans que son débit de signalisation ne soit augmenté en voix montante. / Adaptive resource allocation in wireless communication systems is crucial in order to support the diverse QoS needs of the services and optimize resource utilization. The design of resource allocation schemes should consider the service type for which it is intended. Moreover, due to feedback delay and channel estimation error, the Channel Quality Indicator (CQI) reported to the transmitter may not be a perfect measure of the channel quality and its use for resource allocation may severely degrade the systems performance. In this thesis, we study resource allocation and CQI reporting for wireless networks while taking the aforementioned factors into consideration. First, we consider resource allocation and adaptive modulation in uplink SC-FDMA systems. This is a combinatorial problem whose optimal solution is exponentially complex. We use canonical duality theory to derive a polynomial complexity resource allocation algorithm that provides a nearly optimal solution to the problem. Then, we focus on resource allocation for video streaming in wireless networks with time-varying interference. To this end, by using risk-sensitive control approach, we develop a cross-layer optimization framework that performs power control at the PHY/MAC layer and rate adaptation at the APPLICATION layer jointly and provides fairness among nodes. Finally, by using stochastic control and game theory, we design a robust best-M CQI reporting scheme for multi-carrier and multi-user systems which takes into account the impact of feedback delay and error in CQI computation. Performing resource allocation on the basis of the proposed CQI reporting can significantly improve the system performance.

No description available.

The quality of nursing care is becoming an increasingly important concept in contemporary nursing. The most effective means of achieving quality of nursing care and the means of proof is the accreditation of medical facilities. It is a significant appreciation of professionalism, the work of health professionals and an important signal for the patients. Quality of care, security of supply and preventing potential risks for health care priority. The main aim of the thesis "The influence of accreditation on quality of care in selected health facilities" was to map the set of quality management and impact monitoring and evaluation of quality indicators in hospitals accredited by the Czech Republic. To determine whether accreditation has become an instrument to ensure comparable quality, and time has changed from an unpopular instrument into an instrument for continuous quality improvement. The survey took place from November 2010 to March 2011 in the form of quantitative data collection using an anonymous questionnaire survey in selected hospitals accredited by the Czech Republic. In the research study were asked managers of nursing care, main, upper station and sisters. The thesis has been established 6 goals. The first objective was to determine what indicators of quality nursing care in accredited hospitals pursue. Interested in us as quality indicators that were studied before accreditation, and quality indicators to setting up medical facilities in preparation for accreditation. The second objective was determine how frequently watched indicator of quality is monitored in hospital. The third objective was to determine whether there was in accredited hospitals to reduce adverse events - falls. The fourth objective was to determine whether there was in accredited hospitals to reduce the incidence of nosocomial infections in complying with barrier nursing regime. The fifth objective was to identify the biggest problems arose during the implementation of audits, completeness and comprehensiveness of nursing documentation management into practice. " The sixth objective was to determine whether there was during the preparation of an increase in hospital nursing staff. The thesis then was examined six hypotheses. First hypothesis Accredited hospitals monitor the quality of care provided by at least ten quality indicators - were confirmed. Hypothesis 2 The most frequently monitored indicator of the quality of nursing care, the prevalence of pressure ulcers - was confirmed. All respondents said they monitor the prevalence of pressure ulcers as an indicator of quality nursing care. Hypothesis 3 gaining accreditation to reduce the incidence of falls - was confirmed. Hypothesis 4 obtaining accreditation decreased nosocomial infections - was confirmed. Hypothesis 5 The biggest problem in implementing the audit, management complexity and completeness of nursing documentation in practice "has been an increase in paperwork for nursing staff - were confirmed. Hypothesis 6 During the preparation for accreditation has been an increase in nursing staff - has not been confirmed. Accreditation is perceived by respondents as beneficial for the hospital. Due to accreditation standards and developing quality indicators were identified risk areas in the provision of hospital care and detail can be paid to the prevention of adverse events, nosocomial infections and other risks. The results of work will be to provide medical facilities where the research was conducted investigation, the presentation of the research will be presented at a conference, the South Bohemian nursing days "and also gives the United Accreditation Commission of the Czech Republic as a presentation at the conference to be held early next year (spring ) 2012th Nursing standards were created.

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2018-03-09T19:02:10Z No. of bitstreams: 1 Beatrice de Barros Lima.pdf: 4437029 bytes, checksum: 617cb7a6bd81b32d6b8a4d04d656a2ab (MD5) / Made available in DSpace on 2018-03-09T19:02:11Z (GMT). No. of bitstreams: 1 Beatrice de Barros Lima.pdf: 4437029 bytes, checksum: 617cb7a6bd81b32d6b8a4d04d656a2ab (MD5) Previous issue date: 2016-11 / Mestrado Profissional em Enfermagem Assistencial / A pesquisa trata da gestão do risco de queda como estratégia para segurança do paciente. Tem por objeto de estudo a gestão do risco quedas do paciente idoso hospitalizado em uma instituição certificada. O objetivo geral traçado é elaborar uma tecnologia da informação e comunicação a partir da perspectiva dos enfermeiros para gerenciar o risco de queda no contexto da segurança do paciente, e os objetivos específicos são: identificar os motivos das não conformidades relacionadas as evidenciadas no instrumento de auditoria e as possíveis estratégias facilitadoras nas perspectivas dos enfermeiros e discutir os resultados diante das recomendações do programa nacional de segurança do paciente na prevenção de queda por meio da auditoria interna. Utilizou-se como metodologia um estudo de natureza qualiquantitativa, de caráter descritivo e exploratório com abordagem no método de estudo de caso, cujo cenário foi um hospital privado, terciário na zona sul do Rio de Janeiro. Como referencial teórico, utilizaram-se estudos sobre segurança do paciente, gestão de riscos, acidentes por quedas e idoso. A coleta de dados foi realizada por meio de entrevista semiestrutura, no período de novembro de 2015 a junho de 2016, com 23 enfermeiros que exercem suas atividades nas referidas unidades: clínica, semi-intensiva e coronária. As respostas foram analisadas por meio de análise descritiva simples, emergindo quatro categorias temáticas: segurança do paciente, segurança do paciente com relação à meta 6, aspectos relacionados às não conformidades, perfil do cliente com maior risco de queda e relação com o envelhecimento. Resultado pesquisa: as respostas da auditoria interna com os motivos das não conformidades e estratégias para torna-las em conformidades, nos mostrou a necessidade de uma tecnologia de informação e comunicação no intuito de atender às ações de segurança do paciente com risco de queda. Com isto, almejo somar conhecimento científico à instituição que preconiza a qualidade do cuidado e da segurança nos processos assistenciais / The research comes from the decline of risk management as a strategy for patient safety. Its object of study risk management of elderly patients hospitalized falls in a certified institution. The general objective set is to develop an information and communication technology from the perspective of nurses to manage the risk of falling in the context of patient safety and the specific objectives are to identify the reasons for non-conformities evidenced in the audit tool and possible strategies enabling the perspectives of nurses and discuss the results on the recommendations of the national patient safety program in fall prevention through internal audit. It was used as a study methodology of qualitative-quantitative, descriptive, exploratory approach to the case study method, whose setting was a private tertiary hospital in the south of Rio de Janeiro. As a theoretical framework, we used studies of patient safety, risk management, accidents from falls, elderly. Data collection was conducted through semi-structured interviews, from November 2015 to June 2016, with twenty-three nurses who pursue their activities in these units: clinical, semiintensiva and coronary. The responses were analyzed by simple descriptive analysis, emerging four thematic categories: patient safety, patient safety with respect to target 6, aspects of the non-conformities, and customer profile with higher risk of falling and related to aging. Preliminary results showed us identify the knowledge of nurses before the patient safety issue, patient safety with respect to target 6 and reporting the reasons and suggesting strategies for non-compliance audit tool interna.Com analysis of speeches revealed the need for information and communication technology in order to meet patient safety actions with risk of falling. With the result of this research, we aim to add scientific knowledge institution that advocates the quality of care and safety in care processes

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction. Drug-related problems are frequent in clinical practice and are related to increased morbidity and mortality as well as health care costs. In this context, Medication Review (MR) services may be key elements in improving the use of medicines. However, there are few studies on implementation, monitoring, evaluation and improvement of the quality of such services. Therefore, there is a need for further research with focus on the subject with the aim of defining scientific models for these services. Aim. To develop quality indicators for Medication Review services. Methods. Initially, an overview of systematic reviews was performed in the databases Embase, LILACS, PubMed, Scopus, The Cochrane Library and Web of Science using the key words "medication review", "pharmacist" and "systematic review". Subsequently, a methodological development study was realized in two subsequent steps. In the first step, variables used to describe MR practices with potential to constitute indicators were identified through the reviews included in the overview. In the second step, a panel of experts categorized the variables in structure, processes and outcomes; choosen variables that could give support to the development; and, developed quality indicators for MR services. The quality indicators were reviewed and ranked by a senior-evaluator as the approach, source and pre-specification. Results. In the overview, 11 systematic reviews met the inclusion criteria. It was observed that MR is approached as both clinical service and pharmaceutical intervention adopting ten different terminologies. Regardless of terminologies, the main objective of MR practice is to identify and solve drug-retated problems. Most of the reviews presented methodological quality below ideal. In addition, none of the reviews focused on quality assessment of the MR practice. In the methodological development study, 272 variables were extracted from the reviews; 253 variables were chosen for the development of indicators; and, 71 quality indicators for MR services were developed. Of these, four were of structure, 45 of processes and 22 of outcomes. In addition, most indicators were classified as explicit (n = 55), empirical (n = 7) and quantitative (n = 61). Conclusion. Heterogeneity of terminologies, definitions and approach of MR as well as the low methodological rigor of the studies limit the comparison of this practice. Thus, it is necessary an international agreement on the MR process and to stablish minimum quality standards for the MR practice, which can be done through quality indicators. In this scenario, the combination of scientific evidence and a panel of experts may assist in the development of indicators for MR services. Given the above, the results obtained in conjunction with indicators developed from other sources could support the construction of scientific models to implement, assess, optimize and compare quality of MR practices. / Introdução. Problemas farmacoterapêuticos são frequentes na prática clínica e estão relacionados ao aumento da morbimortalidade e os custos com serviços de saúde. Nesse contexto, serviços de Revisão da Farmacoterapia (RF) podem ser elementos-chave na melhora do processo de uso dos medicamentos. Entretanto, são escassos estudos sobre implantação, monitorização, avaliação e aprimoramento da qualidade destes serviços. Logo, são necessárias mais pesquisas sobre o tema a fim de definir modelos científicos para estes serviços. Objetivo. Desenvolver indicadores de qualidade para serviços de Revisão da Farmacoterapia. Metodologia. Inicialmente, foi realizada uma overview de revisões sistemáticas nas bases de dados Embase, LILACS, PubMed, Scopus, The Cochrane Library e Web of Science utilizando os descritores “medication review” “pharmacist” e “systematic review”. Posteriormente, foi realizado um estudo de desenvolvimento metodológico em duas etapas subsequentes. Na primeira etapa, variáveis utilizadas para descrever a prática da RF com potencial de constituir indicadores foram identificadas a partir das revisões incluídas na overview. Posteriormente, um painel de especialistas categorizou as variáveis em estrutura, processos e resultados; elegeu as variáveis que poderiam dar subsídio ao desenvolvimento; e, desenvolveu indicadores de qualidade para serviços de RF. Os indicadores foram revisados e classificados por uma avaliadora-sênior quanto à abordagem, fonte e pré-especificação. Resultados. Na overview, 11 revisões sistemáticas preencheram os critérios de inclusão. Observou-se que, a RF é abordada tanto como serviço clínico quanto intervenção farmacêutica adotando dez diferentes terminologias. Independente das terminologias, o principal objetivo da prática da RF é identificar e resolver problemas farmacoterapêuticos. A maioria das revisões apresentaram qualidade metodológica abaixo do ideal. Ademais, nenhuma das revisões tinha foco em avaliação da qualidade da prática da RF. No estudo de desenvolvimento metodológico, 272 variáveis foram extraídas a partir das revisões; 253 variávies foram eleitas para o desenvolvimento dos indicadores; e, 71 indicadores de qualidade para serviços de RF foram desenvolvidos. Destes, quatro foram de estrutura, 45 de processos e 22 de resultados. Além disso, a maioria dos indicadores foi classificada como explícito (n=55), empírico (n=7) e quantitativo (n=61). Conclusões. A heterogeneidade das terminologias, definições e abordagem da RF bem como o baixo rigor metodológico dos estudos limitam a comparação desta prática. Assim, é necessário consensuar internacionalmente o processo da RF e padrões mínimos de qualidade para a prática, o que pode ser feito por meio de indicadores de qualidade. Neste cenário, a combinação entre evidência científica e consenso de especialistas pode auxiliar no desenvolvimento de indicadores para RF. Frente ao exposto, os resultados obtidos em conjunto com indicadores desenvolvidos a partir de outras fontes poderão embasar a construção de modelos científicos para implantar, avaliar, otimizar e comparar a qualidade da RF. / São Cristóvão, SE

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / In the state of Rio Grande do Sul the expansion of forestry has been one of the major agents of landscape change, occupying land previously intended for livestock farming and agriculture with low technical level, in areas under the influence of the Pampa biome and the transition of this biome for the Atlantic Forest. There is a widespread belief about the negative impacts caused by forest plantations on natural resources. Thus, it is necessary to evaluate the impacts caused by the introduction of forest plantations on the landscape components, especially on the soil and organic matter. This study was performed to characterize the components of the landscape topography, vegetation cover and their relations with soil, as well as temporal variation in soillandscape Forestry Experiment Station, located in the central region of Rio Grande do Sul were also found, changes in inventory levels and nitrogen (N and SN) and organic carbon (CO and SCO) in profiles Typic Umbrian and the labile and stable organic matter in surface horizon of the soil under native forest at the intermediate stage regeneration and field man-made with over 35 years, mixed forest of Eucalyptus and Eucalyptus robusta 35, forest of Eucalyptus grandis with 4 and 21 years, forest of Acacia mearnsii at age 7, forest of Eucalyptus saligna and 6 years mixed forest with Pinus 10 years. The results indicated that there is a transitory components of the landscape between the edge of the Southern Rio Grande Plateau and the Central Depression of Rio Grande do Sul, as well, there is a characterization of the natural vegetation types and conflicts of land use. It was also found that the relief and the genesis of the soils were vegetational conditions for development and that in 22 years there have been expanding cultivation of Eucalyptus and Pinus and the native forest on the anthropic field, especially in lands with Argissolos Bruno-Acinzentados and Argissolos Vermelhos. The organic matter of Argissolo Vermelho distrófico úmbrico, the results suggest that the levels and stocks of nitrogen and organic carbon of their surface horizon, altered by the introduction of man-made forest and field areas of deciduous forest, with a decrease especially in land occupied by forest of Acacia mearnsii and field of human activity. In relation to the stocks of organic carbon and nitrogen in the soil profile had a greater influence of other factors and processes of soil formation than the occupation of land in the last four decades. We also observed changes in the distribution of particulate organic carbon (POC g.kg-1) in the surface horizon of the soil, and this organic matter fraction of a sensitive indicator of changes in land use and soil. / No estado do Rio Grande do Sul a expansão da silvicultura tem atuado como um dos principais agentes de alteração da paisagem, ocupando terras anteriormente destinadas à pecuária extensiva e à agricultura com baixa tecnificação, em áreas sob a influência do bioma Pampa e na transição desse bioma para o de Mata Atlântica. Existe uma crença generalizada acerca dos impactos negativos ocasionados pelas plantações florestais sobre os recursos naturais. Assim, faz-se necessária a avaliação dos impactos causados pela introdução dos plantios florestais sobre os componentes da paisagem, principalmente sobre o solo e sua matéria orgânica. Neste estudo foi realizada a caracterização dos componentes da paisagem relevo, cobertura vegetal e suas relações com os solos, além da variação temporal da relação solo-paisagem numa Estação Experimental de Silvicultura, localizada na região central do Rio Grande do Sul. Foram verificadas também, as alterações nos teores e estoques de nitrogênio (N e SN) e de carbono orgânico (CO e SCO) em perfis de Argissolo Vermelho distrófico úmbrico e as frações lábeis e estáveis da matéria orgânica do horizonte superficial desse solo sob a Floresta nativa em estágio médio de regeneração e campo antrópico com mais de 35 anos, floresta mista do gênero Eucalyptus e de Eucalyptus robusta com 35 anos, floresta de Eucalyptus grandis com 4 e 21 anos , floresta de Acacia Mearnsii com 7 anos, floresta de Eucalyptus saligna com 6 anos e floresta mista do gênero Pinus com 10 anos. Os resultados indicaram que há um caráter transitório nos componentes da paisagem, entre o Rebordo do Planalto Sul-Riograndense e a Depressão Central do Rio Grande do Sul, como também, existe uma descaracterização das fitofisionomias naturais e a existência de conflitos de uso do solo. Constatou-se também, que o relevo e a gênese dos solos foram condicionantes para o desenvolvimento fitofisionômico e que em 22 anos houve expansão dos cultivos de Eucalyptus e Pinus, e da floresta nativa sobre o campo antrópico, principalmente nas terras com Argissolos Bruno-Acinzentados e Argissolos Vermelhos. Quanto à matéria orgânica do Argissolo Vermelho distrófico úmbrico, os resultados sugerem que os teores e estoques de nitrogênio e carbono orgânico do seu horizonte superficial, apresentam alterações frente à introdução de florestamentos e do campo antrópico sobre áreas de Floresta Estacional Decidual, havendo decréscimo principalmente em terras ocupadas pela floresta de Acacia Mearnsii e campo antrópico. Já em relação aos estoques de nitrogênio e carbono orgânico no perfil do solo, houve maior influência dos demais fatores e processos de formação do solo do que a ocupação das terras nas últimas quatro décadas. Foram constatadas também alterações na distribuição do carbono orgânico particulado (POC g.kg-1) no horizonte superficial do solo, sendo esta fração da matéria orgânica um indicador sensível às alterações no uso e ocupação do solo.

The diploma thesis deals with the issue of falls among the elderly placed in residential social care facilities. The author mainly focuses on the issue whether the falls can be viewed as a quality indicator of the offered care. The author deals with the issue of falls both on the general level (legislation, standards of quality) and also on the level of a specific residential social care provider represented by home for the elderly Sue Ryder in Prague. Further, the author deals with the issue of falls in inpatient healthcare facilities, as this issue is viewed as an important indicator in terms of comparing quality of care between social care and health care facilities. The key issue of the thesis are the ways to prevent falls of the elderly, so that their basic rights (especially the right to have their own choice), independence and self- sufficiency can be maintained, and also the intervention procedures in these cases. The aim of the thesis is to provide its readers with suggestions on how to improve quality of healthcare in terms of dealing with falls. These suggestions are based on the author's thorough examination of the relevant theoretical and legislative materials. The suggestions are further based on analyzing the fall records, covering a period of 18 months, provided by Sue Ryder...

Contexte De nombreuses études, utilisant des indicateurs de qualité variés, ont démontré que la qualité des soins pour la dépression n’est pas optimale en première ligne. Peu de ces études ont examiné les facteurs associés à la réception d’un traitement adéquat, en particulier en tenant compte simultanément des caractéristiques individuelles et organisationnelles. L'association entre un traitement adéquat pour un épisode dépressif majeur (EDM) et une amélioration des symptômes dépressifs n'est pas bien établie dans des conditions non-expérimentales. Les objectifs de cette étude étaient de : 1) réaliser une revue systématique des indicateurs mesurant la qualité du traitement de la dépression en première ligne ; 2) estimer la proportion de patients souffrant d’EDM qui reçoivent un traitement adéquat (selon les guides de pratique clinique) en première ligne ; 3) examiner les caractéristiques individuelles et organisationnelles associées à l’adéquation du traitement pour la dépression ; 4) examiner l'association entre un traitement minimalement adéquat au cours des 12 mois précédents et l'évolution des symptômes dépressifs à 6 et 12 mois. Méthodes La littérature sur la qualité du traitement de la dépression a été examinée en utilisant un ensemble de mots-clés (« depression », « depressive disorder », « quality », « treatment », « indicator », « adequacy », « adherence », « concordance », « clinical guideline » et « guideline ») et « 360search », un moteur de recherche fédérée. Les données proviennent d'une étude de cohorte incluant 915 adultes consultant un médecin généraliste, quel que soit le motif de consultation, répondant aux critères du DSM-IV pour l’EDM dans la dernière année, nichés dans 65 cliniques de première ligne au Québec, Canada. Des analyses multiniveaux ont été réalisées. Résultats Bien que majoritairement développés à partir de guides de pratique clinique, une grande variété d'indicateurs a été observée dans la revue systématique de littérature. La plupart des études retenues ont utilisé des indicateurs de qualité rudimentaires, surtout pour la psychothérapie. Les méthodes utilisées étaient très variées, limitant la comparabilité des résultats. Toutefois, quelque soit la méthode choisie, la plupart des études ont révélé qu’une grande proportion des personnes souffrant de dépression n’ont pas reçu de traitement minimalement adéquat en première ligne. Dans notre échantillon, l’adéquation était élevée (> 75 %) pour un tiers des indicateurs de qualité mesurés, mais était faible (< 60 %) pour près de la moitié des mesures. Un peu plus de la moitié de l'échantillon (52,2 %) a reçu au moins un traitement minimalement adéquat pour la dépression. Au niveau individuel, les jeunes adultes (18-24 ans) et les personnes de plus de 65 ans avaient une probabilité moins élevée de recevoir un traitement minimalement adéquat. Cette probabilité était plus élevée pour ceux qui ont un médecin de famille, une assurance complémentaire, un trouble anxieux comorbide et une dépression plus sévère. Au niveau des cliniques, la disponibilité de la psychothérapie sur place, l'utilisation d'algorithmes de traitement, et le mode de rémunération perçu comme adéquat étaient associés à plus de traitement adéquat. Les résultats ont également montré que 1) la réception d'au moins un traitement minimalement adéquat pour la dépression était associée à une plus grande amélioration des symptômes dépressifs à 6 et à 12 mois; 2) la pharmacothérapie adéquate et la psychothérapie adéquate étaient toutes deux associées à de plus grandes améliorations dans les symptômes dépressifs, et 3) l'association entre un traitement adéquat et l'amélioration des symptômes dépressifs varie en fonction de la sévérité des symptômes au moment de l'inclusion dans la cohorte, un niveau de symptômes plus élevé étant associé à une amélioration plus importante à 6 et à 12 mois. Conclusions Nos résultats suggèrent que des interventions sont nécessaires pour améliorer la qualité du traitement de la dépression en première ligne. Ces interventions devraient cibler des populations spécifiques (les jeunes adultes et les personnes âgées), améliorer l'accessibilité à la psychothérapie et à un médecin de famille, et soutenir les médecins de première ligne dans leur pratique clinique avec des patients souffrant de dépression de différentes façons, telles que le développement des connaissances pour traiter la dépression et l'adaptation du mode de rémunération. Cette étude montre également que le traitement adéquat de la dépression en première ligne est associé à une amélioration des symptômes dépressifs dans des conditions non-expérimentales. / Background Numerous studies, using a variety of quality indicators, highlight an important gap in the quality of care for depression in primary care. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The objectives of this study were to i) systematically review indicators used to measure the quality of depression treatment in primary care, ii) estimate the proportion of primary care patients with a MDE who receive adequate treatment, iii) examine the individual and organizational characteristics associated with the receipt of minimally adequate treatment for depression, iv) examine the association between receiving minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6 and 12 months. Methods The literature on the quality of depression treatment was reviewed using a set of keywords (depression, depressive disorder, quality, treatment, indicator, adequacy, adherence, concordance, clinical guideline and guideline) and « 360search », a federated search engine. Data were obtained from a cohort study including 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for previous-year MDE, and nested within 65 primary care clinics in Quebec, Canada. Multilevel analyses were conducted. Results Though mostly based on recommendations from clinical practice guidelines, a great variety of indicators were observed. Most studies used rudimentary indicators to measure the quality of depression treatment, especially for psychotherapy. Studies also differed greatly with respect to the methods used, thus limiting the comparability of results. However, whatever the chosen method, most studies reveal that a large proportion of people with depression do not receive minimally adequate treatment in primary care settings. In our sample, adherence to guidelines was high (> 75 %) for one third of the quality indicators that were measured but was low (< 60 %) for nearly half of the measures. Just over half of the sample (52.2 %) received at least one minimally adequate treatment for depression. At the individual level, young adults (18-24) et older people (>65) had a lower probability of receiving at least one minimally adequate treatment. This probability was higher for people with a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and a more severe depression. At the clinic level, the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration perceived as adequate were associated with more adequate treatment. Results also showed that i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. Conclusions Our findings suggest that interventions are needed to increase the quality of depression treatment in primary care. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration. This study also shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions.

Contexte De nombreuses études, utilisant des indicateurs de qualité variés, ont démontré que la qualité des soins pour la dépression n’est pas optimale en première ligne. Peu de ces études ont examiné les facteurs associés à la réception d’un traitement adéquat, en particulier en tenant compte simultanément des caractéristiques individuelles et organisationnelles. L'association entre un traitement adéquat pour un épisode dépressif majeur (EDM) et une amélioration des symptômes dépressifs n'est pas bien établie dans des conditions non-expérimentales. Les objectifs de cette étude étaient de : 1) réaliser une revue systématique des indicateurs mesurant la qualité du traitement de la dépression en première ligne ; 2) estimer la proportion de patients souffrant d’EDM qui reçoivent un traitement adéquat (selon les guides de pratique clinique) en première ligne ; 3) examiner les caractéristiques individuelles et organisationnelles associées à l’adéquation du traitement pour la dépression ; 4) examiner l'association entre un traitement minimalement adéquat au cours des 12 mois précédents et l'évolution des symptômes dépressifs à 6 et 12 mois. Méthodes La littérature sur la qualité du traitement de la dépression a été examinée en utilisant un ensemble de mots-clés (« depression », « depressive disorder », « quality », « treatment », « indicator », « adequacy », « adherence », « concordance », « clinical guideline » et « guideline ») et « 360search », un moteur de recherche fédérée. Les données proviennent d'une étude de cohorte incluant 915 adultes consultant un médecin généraliste, quel que soit le motif de consultation, répondant aux critères du DSM-IV pour l’EDM dans la dernière année, nichés dans 65 cliniques de première ligne au Québec, Canada. Des analyses multiniveaux ont été réalisées. Résultats Bien que majoritairement développés à partir de guides de pratique clinique, une grande variété d'indicateurs a été observée dans la revue systématique de littérature. La plupart des études retenues ont utilisé des indicateurs de qualité rudimentaires, surtout pour la psychothérapie. Les méthodes utilisées étaient très variées, limitant la comparabilité des résultats. Toutefois, quelque soit la méthode choisie, la plupart des études ont révélé qu’une grande proportion des personnes souffrant de dépression n’ont pas reçu de traitement minimalement adéquat en première ligne. Dans notre échantillon, l’adéquation était élevée (> 75 %) pour un tiers des indicateurs de qualité mesurés, mais était faible (< 60 %) pour près de la moitié des mesures. Un peu plus de la moitié de l'échantillon (52,2 %) a reçu au moins un traitement minimalement adéquat pour la dépression. Au niveau individuel, les jeunes adultes (18-24 ans) et les personnes de plus de 65 ans avaient une probabilité moins élevée de recevoir un traitement minimalement adéquat. Cette probabilité était plus élevée pour ceux qui ont un médecin de famille, une assurance complémentaire, un trouble anxieux comorbide et une dépression plus sévère. Au niveau des cliniques, la disponibilité de la psychothérapie sur place, l'utilisation d'algorithmes de traitement, et le mode de rémunération perçu comme adéquat étaient associés à plus de traitement adéquat. Les résultats ont également montré que 1) la réception d'au moins un traitement minimalement adéquat pour la dépression était associée à une plus grande amélioration des symptômes dépressifs à 6 et à 12 mois; 2) la pharmacothérapie adéquate et la psychothérapie adéquate étaient toutes deux associées à de plus grandes améliorations dans les symptômes dépressifs, et 3) l'association entre un traitement adéquat et l'amélioration des symptômes dépressifs varie en fonction de la sévérité des symptômes au moment de l'inclusion dans la cohorte, un niveau de symptômes plus élevé étant associé à une amélioration plus importante à 6 et à 12 mois. Conclusions Nos résultats suggèrent que des interventions sont nécessaires pour améliorer la qualité du traitement de la dépression en première ligne. Ces interventions devraient cibler des populations spécifiques (les jeunes adultes et les personnes âgées), améliorer l'accessibilité à la psychothérapie et à un médecin de famille, et soutenir les médecins de première ligne dans leur pratique clinique avec des patients souffrant de dépression de différentes façons, telles que le développement des connaissances pour traiter la dépression et l'adaptation du mode de rémunération. Cette étude montre également que le traitement adéquat de la dépression en première ligne est associé à une amélioration des symptômes dépressifs dans des conditions non-expérimentales. / Background Numerous studies, using a variety of quality indicators, highlight an important gap in the quality of care for depression in primary care. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The objectives of this study were to i) systematically review indicators used to measure the quality of depression treatment in primary care, ii) estimate the proportion of primary care patients with a MDE who receive adequate treatment, iii) examine the individual and organizational characteristics associated with the receipt of minimally adequate treatment for depression, iv) examine the association between receiving minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6 and 12 months. Methods The literature on the quality of depression treatment was reviewed using a set of keywords (depression, depressive disorder, quality, treatment, indicator, adequacy, adherence, concordance, clinical guideline and guideline) and « 360search », a federated search engine. Data were obtained from a cohort study including 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for previous-year MDE, and nested within 65 primary care clinics in Quebec, Canada. Multilevel analyses were conducted. Results Though mostly based on recommendations from clinical practice guidelines, a great variety of indicators were observed. Most studies used rudimentary indicators to measure the quality of depression treatment, especially for psychotherapy. Studies also differed greatly with respect to the methods used, thus limiting the comparability of results. However, whatever the chosen method, most studies reveal that a large proportion of people with depression do not receive minimally adequate treatment in primary care settings. In our sample, adherence to guidelines was high (> 75 %) for one third of the quality indicators that were measured but was low (< 60 %) for nearly half of the measures. Just over half of the sample (52.2 %) received at least one minimally adequate treatment for depression. At the individual level, young adults (18-24) et older people (>65) had a lower probability of receiving at least one minimally adequate treatment. This probability was higher for people with a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and a more severe depression. At the clinic level, the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration perceived as adequate were associated with more adequate treatment. Results also showed that i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. Conclusions Our findings suggest that interventions are needed to increase the quality of depression treatment in primary care. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration. This study also shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions.