Dickinson L Miriam, Dickinson W Perry, Rost Kathryn, DeGruy Frank, Emsermann Caroline, Froshaug Desireé, Nutting Paul A, Meredith Lisa
Department of Family Medicine, University of Colorado Denver, Aurora, CO, USA.
J Gen Intern Med. 2008 Nov;23(11):1763-9. doi: 10.1007/s11606-008-0738-2. Epub 2008 Aug 5.
Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.
To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.
Secondary analysis from the Quality Improvement in Depression Study dataset.
The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.
Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.
Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).
Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.
为改善初级保健中抑郁症治疗所做的努力评估了不同患者群体的策略，但很少有研究考察临床医生层面因素对抑郁症治疗的影响。
使用多水平有序回归模型来区分患者层面和临床医生层面的影响，以研究影响初级保健环境中抑郁症治疗的临床医生特征。
对抑郁症研究数据集质量改进项目进行二次分析。
1023名患有抑郁症的初级保健患者，他们在6个月随访中报告了治疗情况，且其临床医生（n = 158）在该研究中至少有4名患者。
主要结局变量是抑郁症治疗强度，它基于患者报告的治疗数据，通过与AHCPR抑郁症治疗指南的一致性评估得出。主要自变量是治疗抑郁症的临床实践负担，它来自患者和临床医生报告的综合测量指标，并测试其与临床医生报告的实践负担是否存在显著关联。
治疗患有更多慢性合并症患者的临床医生在其临床实践中感知到的治疗抑郁症负担较小（斯皮尔曼相关系数ρ = -0.30，p < 0.05）。治疗患有更多慢性合并症患者的临床医生也提供更高强度的抑郁症治疗（调整后的比值比 = 1.44，p = 0.02），即使在调整了患者层面慢性合并症的影响后（调整后的比值比 = 0.95，p = 0.45）。
提供更多慢性护理的临床医生也提供更高强度的抑郁症治疗，这表明照顾复杂患者的临床医生可以将抑郁症护理纳入其临床实践。针对这些临床医生开展干预措施以提高他们提供符合指南的抑郁症护理的能力是一项有价值的工作，值得进一步研究。
