Solberg L I, Fischer L R, Wei F, Rush W A, Conboy K S, Davis T F, Heinrich R L
HealthPartners Research Foundation and Medical Group, Minneapolis, MN 55440, USA.
Eff Clin Pract. 2001 Nov-Dec;4(6):239-49.
Although new strategies for managing depression in primary care (e.g., nurse telephone calls, collaborative care) have been shown to be effective, no models are available for their systematic implementation in the "real world."
To test whether a continuous quality improvement (CQI) intervention could be used to implement systems in primary care clinics to improve the care and outcomes for patients diagnosed with depression.
Before-after study with concurrent controls.
A multidisciplinary team from the three intervention clinics developed and implemented a graded set of five care management options, ranging from watchful waiting (nurse telephone call in 4 to 6 weeks) to mental health management, which clinicians could order for their patients with depression.
9 primary care clinics in greater Minneapolis-St. Paul, Minnesota.
Outpatients 18 years of age and older whose primary care clinic visit included an International Classification of Diseases, 9th revision, code for depression and who completed baseline and 3-month follow-up surveys before and after the intervention.
Measures of process of care (follow-up depression visits to physician, mental health visits, follow-up telephone calls) and outcomes of care (improved depression symptoms over 3 months, satisfaction with care).
Although the CQI team appeared to function well, only 30 of the 257 patients identified from depression-coded visits for this study were referred to the new system during the 3-month evaluation period. In both the intervention and control clinics, follow-up visits, mental health referrals, and follow-up telephone calls did not improve significantly from the preintervention levels of about 0.5 for a primary care visit, 0.4 for a mental health visit, or 0.1 for a follow-up phone call per person. The same was true of patient outcomes: The proportion of patients in the intervention and control clinics who had improved depression symptoms and those who were very satisfied with their depression care did not change significantly from the preintervention levels of 43% and 26%, respectively.
Our attempt to improve the primary care management of depression failed because physicians used the new order system so infrequently. Whether a greater leadership commitment to change or a different improvement process would alter our findings is an open question.
虽然初级保健中管理抑郁症的新策略（如护士电话随访、协作护理）已被证明是有效的，但尚无在“现实世界”中系统实施这些策略的模式。
测试持续质量改进（CQI）干预措施是否可用于在初级保健诊所实施相关系统，以改善被诊断为抑郁症患者的护理及治疗效果。
前后对照研究。
来自三家干预诊所的多学科团队制定并实施了一套分级的五项护理管理方案，从观察等待（4至6周内护士电话随访）到心理健康管理，临床医生可为其抑郁症患者选择这些方案。
明尼阿波利斯 - 圣保罗市及周边地区的9家初级保健诊所。
年龄在18岁及以上的门诊患者，其初级保健诊所就诊记录中包含国际疾病分类第九版的抑郁症编码，且在干预前后完成了基线调查和3个月的随访调查。
护理过程指标（对医生的抑郁症随访就诊、心理健康就诊、随访电话）和护理结果指标（3个月内抑郁症症状改善情况、对护理的满意度）。
尽管CQI团队似乎运作良好，但在3个月的评估期内，从本次研究中因抑郁症编码就诊而确定的257名患者中，只有30名被转介到新系统。在干预诊所和对照诊所，随访就诊、心理健康转诊和随访电话均未比干预前水平有显著改善，干预前每人每次初级保健就诊约为0.5次、心理健康就诊约为0.4次、随访电话约为0.1次。患者治疗效果也是如此：干预诊所和对照诊所中抑郁症症状有所改善的患者比例以及对抑郁症护理非常满意的患者比例，与干预前水平（分别为43%和26%）相比，均未显著变化。
我们改善抑郁症初级保健管理的尝试失败了，因为医生很少使用新的医嘱系统。对变革给予更大的领导支持或采用不同的改进流程是否会改变我们的研究结果，这仍是一个悬而未决的问题。
