20世纪90年代双相I型障碍的护理质量变化。
Changes in the quality of care for bipolar I disorder during the 1990s.
作者信息
Busch Alisa B, Ling Davina, Frank Richard G, Greenfield Shelly F
机构信息
Alcohol and Drug Abuse Treatment Program, McLean Hospital, Proctor Building, 115 Mill St., Belmont, MA 02478, USA.
出版信息
Psychiatr Serv. 2007 Jan;58(1):27-33. doi: 10.1176/ps.2007.58.1.27.
OBJECTIVE
This study estimated changes during the 1990s in the quality of usual-care treatment among persons diagnosed as having bipolar I disorder in a privately insured population.
METHODS
Retrospective private insurance administrative data were analyzed for enrollees aged 18 to 64 who were diagnosed as having bipolar I disorder during 1991 (431 person-years), 1994 (598 person-years), and 1999 (600 person-years). Medication and psychotherapy quality indicators were derived from bipolar disorder expert guidelines published in 1994, which were consistent with guidelines published until year 2002.
RESULTS
The unadjusted prevalence of receiving any lithium, valproate, or carbamazepine improved over the study period (68 percent in 1991, 64 percent in 1994, and 77 percent in 1999), whereas, compared with 1991, receiving any antidepressant in the absence of lithium, valproate, or carbamazepine increased in 1994 and then declined in 1999 (13 percent in 1991, 23 percent in 1994, and 14 percent in 1999). The unadjusted prevalence of receiving any psychotherapy declined steadily and sharply (94 percent in 1991, 89 percent in 1994, and 69 percent in 1999). The unadjusted prevalence of receiving any lithium, valproate, or carbamazepine and therapy together declined over time (65 percent in 1991, 58 percent in 1994, and 54 percent in 1999). After the analyses adjusted for patient characteristics, these changes were significant from p<.01 to p<.001.
CONCLUSIONS
The prevalence of receiving the pharmacotherapy recommended in the guidelines improved after guideline publication in 1994, whereas other quality measures that included receiving psychotherapy declined throughout the study period. These results suggest different psychotherapeutic modalities are under differing constraints under managed care, constraints that overpower consensus in the literature of quality practice. Policy makers should measure a variety of key therapeutic modalities when measuring quality in order to capture these differences.
目的
本研究评估了20世纪90年代在一个有私人保险的人群中，被诊断为双相I型障碍的患者接受常规治疗的质量变化。
方法
对1991年（431人年）、1994年（598人年）和1999年（600人年）被诊断为双相I型障碍的18至64岁参保人的私人保险行政数据进行回顾性分析。药物治疗和心理治疗质量指标源自1994年发布的双相情感障碍专家指南，该指南与直至2002年发布的指南一致。
结果
在研究期间，接受任何锂盐、丙戊酸盐或卡马西平治疗的未调整患病率有所改善（1991年为68%，1994年为64%，1999年为77%），而与1991年相比，在未使用锂盐、丙戊酸盐或卡马西平的情况下接受任何抗抑郁药治疗的比例在1994年上升，然后在1999年下降（1991年为13%，1994年为23%，1999年为14%）。接受任何心理治疗的未调整患病率稳步且大幅下降（1991年为94%，1994年为89%，1999年为69%）。同时接受任何锂盐、丙戊酸盐或卡马西平治疗和心理治疗的未调整患病率随时间下降（1991年为65%，1994年为58%，1999年为54%）。在对患者特征进行分析调整后，这些变化从p<0.01到p<0.001均具有统计学意义。
结论
1994年指南发布后，接受指南中推荐的药物治疗的患病率有所提高，而包括接受心理治疗在内的其他质量指标在整个研究期间均有所下降。这些结果表明，在管理式医疗下，不同的心理治疗方式受到不同的限制，这些限制超过了质量实践文献中的共识。政策制定者在衡量质量时应衡量各种关键治疗方式，以捕捉这些差异。
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