Implementing electronic health record-based anxiety and depression screening in an epilepsy clinic: Theory-based implementation strategy and pre-post quantitative outcomes using Reach, Effectiveness, Adoption, Implementation, and Maintenance

• DOI: 10.1017/cts.2025.74
• Publication Date: 2025-04-16T05:32:42Z
• Authors: Heidi M. Munger C...; Halley B. Alexander; Sabina Gesell; Mingyu Wan; Kelly R. Conner; Cormac O’Donovan; Jane Boggs; Christian Robles; Maria Sam; Jerryl Christopher; Christina Marini; Beverly M. Snively

Abstract

Introduction: Anxiety and depression in epilepsy are common and impactful. Screening with validated measures at every epilepsy visit is a quality measure, yet screening remains limited due to time constraints.

Methods: This study aimed to develop an implementation strategy for anxiety and depression screening at an epilepsy center and evaluate it in a pre-post design with RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Guided by the Capability, Opportunity, Motivation-Behavior behavior change wheel framework, the strategy incorporated electronic health record tools and support staff activation of electronic screeners during visit check-in. Outcomes were evaluated over five months post-implementation and compared with two 3-month pre-implementation timeframes.

Results: Post-implementation, 29.2% of 943 visits met the anxiety and depression screening quality measure, a significant increase from 12.6% immediately pre-implementation (p < 0.0001) and 6.28% before any screening interventions (p < 0.0001). Patients who completed electronic screeners post-implementation were younger than non-completers (mean 39.3 vs. 43.4 years, p = 0.001) and more likely to be white than other race/ethnicity categories (p = 0.002). There was substantial variability in screening rates among clinic staff (0–80% for support staff, 10.1–55.3% for providers), with higher screening among neurology support staff than temporary staff. Only 0.23% of post-implementation visits had screeners initiated but left incomplete. A shift to virtual visits during COVID-19 complicated Maintenance.

Conclusions: This framework-based implementation strategy effectively increased screening rates by epilepsy specialists, though challenges remain, including variability across clinic team members and lower reach among older and non-white patients. This study describes a feasible strategy for epilepsy centers to use for improved performance on an American Academy of Neurology quality measure (depression and anxiety screening for patients with epilepsy).