精神健康状况的协作式慢性病管理模式：累积荟萃分析和元回归以指导未来的研究和实施。
Collaborative chronic care models for mental health conditions: cumulative meta-analysis and metaregression to guide future research and implementation.
机构信息
*Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System †Department of Psychiatry, Harvard Medical School, Boston, MA ‡School of Social Work, University of Michigan §VA Ann Arbor Center for Clinical Management Research ∥Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI ¶The Brown School, Washington University, St Louis, MO.
出版信息
Med Care. 2013 Oct;51(10):922-30. doi: 10.1097/MLR.0b013e3182a3e4c4.
OBJECTIVE
Prior meta-analysis indicates that collaborative chronic care models (CCMs) improve mental and physical health outcomes for individuals with mental disorders. This study aimed to investigate the stability of evidence over time and identify patient and intervention factors associated with CCM effects to facilitate implementation and sustainability of CCMs in clinical practice.
METHODS
We reviewed 53 CCM trials that analyzed depression, mental quality of life (QOL), or physical QOL outcomes. Cumulative meta-analysis and metaregression were supplemented by descriptive investigations across and within trials.
RESULTS
Most trials targeted depression in the primary care setting, and cumulative meta-analysis indicated that effect sizes favoring CCM quickly achieved significance for depression outcomes, and more recently achieved significance for mental and physical QOL. Four of 6 CCM elements (patient self-management support, clinical information systems, system redesign, and provider decision support) were common among reviewed trials, whereas 2 elements (health care organization support and linkages to community resources) were rare. No single CCM element was statistically associated with the success of the model. Similarly, metaregression did not identify specific factors associated with CCM effectiveness. Nonetheless, results within individual trials suggest that increased illness severity predicts CCM outcomes.
CONCLUSIONS
Significant CCM trials have been derived primarily from 4 original CCM elements. Nonetheless, implementing and sustaining this established model will require health care organization support. Although CCMs have typically been tested as population-based interventions, evidence supports stepped care application to more severely ill individuals. Future priorities include developing implementation strategies to support adoption and sustainability of the model in clinical settings while maximizing fit of this multicomponent framework to local contextual factors.
目的
先前的荟萃分析表明，协作式慢性病管理模式（CCM）可改善患有精神障碍的个体的身心健康结果。本研究旨在调查随着时间推移证据的稳定性，并确定与 CCM 效果相关的患者和干预因素，以促进 CCM 在临床实践中的实施和可持续性。
方法
我们回顾了 53 项分析抑郁、精神健康相关生活质量（QOL）或身体 QOL 结果的 CCM 试验。累积荟萃分析和元回归辅以试验内和试验间的描述性研究。
结果
大多数试验都将初级保健环境中的抑郁作为主要目标，累积荟萃分析表明，有利于 CCM 的效应大小很快在抑郁结果方面达到显著水平，而最近在精神和身体 QOL 方面也达到了显著水平。6 个 CCM 要素中的 4 个（患者自我管理支持、临床信息系统、系统重新设计和提供者决策支持）在被审查的试验中很常见，而另外 2 个要素（医疗保健组织支持和与社区资源的联系）则很少见。没有一个 CCM 要素与该模型的成功具有统计学上的关联。同样，元回归也未确定与 CCM 有效性相关的特定因素。尽管如此，个别试验中的结果表明，疾病严重程度的增加预示着 CCM 结果。
结论
重要的 CCM 试验主要来源于 4 个原始 CCM 要素。然而，实施和维持这一既定模式将需要医疗保健组织的支持。尽管 CCM 通常被作为基于人群的干预措施进行测试，但有证据支持将其应用于更严重的患者，采用分级护理的方式。未来的重点包括制定实施策略，以支持该模型在临床环境中的采用和可持续性，同时最大限度地使该多要素框架适应当地的背景因素。
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