Clever Sarah L, Ford Daniel E, Rubenstein Lisa V, Rost Kathryn M, Meredith Lisa S, Sherbourne Cathy D, Wang Nae-Yuh, Arbelaez Jose J, Cooper Lisa A
Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Med Care. 2006 May;44(5):398-405. doi: 10.1097/01.mlr.0000208117.15531.da.
Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes.
The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms.
Prospective cohort study.
Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care.
Primary care patients with current symptoms and probable depressive disorder.
Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors.
For each 1-point increase in IDM ratings, the probability of patients' report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004).
Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.
在基层医疗环境中，抑郁症的治疗不足。很少有研究调查患者参与决策对符合指南治疗及抑郁症治疗效果的影响。
本研究的目的是确定患者参与决策是否与符合指南的治疗及抑郁症状改善相关。
前瞻性队列研究。
一项针对基层医疗中抑郁症质量改善策略的多地点、全国性随机临床试验。
有当前症状且可能患有抑郁症的基层医疗患者。
患者在进入研究6个月后，用从差到优的5分制量表对其参与自身护理决策的程度进行评分。使用改良版的流行病学研究中心抑郁量表（CES-D），每6个月测量一次抑郁症状，持续2年。我们使用多变量逻辑回归模型，在控制患者和医疗服务提供者因素的情况下，研究不同决策参与度组接受符合指南治疗及抑郁症症状缓解的概率（Pr）。
决策参与度评分每增加1分，患者报告接受符合指南治疗的概率增加4%至5%（最低和最高决策参与度评分的调整后Pr分别为0.31和0.50，P<0.001）。同样，决策参与度评分每增加1分，抑郁症状缓解的概率增加2%至3%（最低和最高决策参与度评分的调整后Pr分别为0.10和0.19，P = 0.004）。
在医疗决策中参与度评分较高的抑郁症患者，在18个月内接受符合指南治疗并改善症状的可能性更高。增加患者参与决策的干预措施可能是改善抑郁症治疗及治疗效果的重要手段。
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