实施初级保健中抑郁症治疗的协作式护理：一项质量改进实践再设计的群组随机评估。
Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign.
机构信息
Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, USA.
出版信息
Implement Sci. 2011 Oct 27;6:121. doi: 10.1186/1748-5908-6-121.
BACKGROUND
Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.
METHODS
The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.
RESULTS
Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).
CONCLUSIONS
Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.
TRIAL REGISTRATION
ClinicalTrials.gov: NCT00105820.
背景
荟萃分析表明，护士护理管理的协作式护理模式（CCM）对改善抑郁症的初级保健是有效的。本研究旨在开发可在退伍军人事务部（VA）内部维持和推广的 CCM 方法。循证质量改进（EBQI）使用 QI 方法在研究/临床合作关系内重新设计护理。该研究使用 EBQI 方法对 CCM 进行重新设计，测试了本地改编模型的实施效果，并评估了影响干预效果的背景因素。
方法
该研究的干预措施是将 EBQI 应用于 CCM 的实施。该研究采用集群随机设计作为一种形成性评估工具，以测试和改进重新设计过程的有效性，涉及五个州的七个干预和三个非干预 VA 初级保健实践。主要研究结果是患者抗抑郁药的使用情况。背景评估是描述性的，并使用亚组分析。主要的背景评估措施是自然主义初级保健临床医生（PCC）采用 CCM 的倾向。对于随机评估，经过培训的电话研究采访人员在评估中连续招募了患有重度抑郁症的 CCM 评估点患者，将接受评估的干预实践中的患者转诊至实施的 CCM，并在七个月后进行重新调查。
结果
采访人员共招募了 288 个 CCM 地点和 258 个非 CCM 地点的患者。接受干预地点治疗的患者更有可能接受适当的抗抑郁治疗（66%对 43%，p = 0.01），但与常规护理相比，症状改善没有显著差异。在背景方面，只有 40%的入组患者按照方案接受了完整的护理管理。PCC 采用 CCM 的倾向对患者的参与有很大的影响，属于早期采用者的患者完成了充分的护理经理随访，比采用 CCM 倾向较低的临床医生的患者要高得多（74%对 48%，p = 0.003）。
结论
使用 EBQI 设计和实施的初级保健实践中的抑郁症 CCM 提高了抗抑郁药的起始率。将质量改进方法与随机评估相结合具有挑战性，但使我们对将基于研究的 CCM 转化为实践的过程有了新的认识。需要进一步研究 PCC 态度和技能对 CCM 结果的影响，以及加强改善抗抑郁药使用与症状结果之间的联系。
试验注册
ClinicalTrials.gov：NCT00105820。
Zotero 插件