Gray Jodi, Haji Ali Afzali Hossein, Beilby Justin, Holton Christine, Banham David, Karnon Jonathan
Discipline of Public Health, The University of Adelaide, Adelaide, South Australia.
BMC Fam Pract. 2014 Jan 14;15:10. doi: 10.1186/1471-2296-15-10.
Most evidence on the effect of collaborative care for depression is derived in the selective environment of randomised controlled trials. In collaborative care, practice nurses may act as case managers. The Primary Care Services Improvement Project (PCSIP) aimed to assess the cost-effectiveness of alternative models of practice nurse involvement in a real world Australian setting. Previous analyses have demonstrated the value of high level practice nurse involvement in the management of diabetes and obesity. This paper reports on their value in the management of depression.
General practices were assigned to a low or high model of care based on observed levels of practice nurse involvement in clinical-based activities for the management of depression (i.e. percentage of depression patients seen, percentage of consultation time spent on clinical-based activities). Linked, routinely collected data was used to determine patient level depression outcomes (proportion of depression-free days) and health service usage costs. Standardised depression assessment tools were not routinely used, therefore a classification framework to determine the patient's depressive state was developed using proxy measures (e.g. symptoms, medications, referrals, hospitalisations and suicide attempts). Regression analyses of costs and depression outcomes were conducted, using propensity weighting to control for potential confounders.
Capacity to determine depressive state using the classification framework was dependent upon the level of detail provided in medical records. While antidepressant medication prescriptions were a strong indicator of depressive state, they could not be relied upon as the sole measure. Propensity score weighted analyses of total depression-related costs and depression outcomes, found that the high level model of care cost more (95% CI: -$314.76 to $584) and resulted in 5% less depression-free days (95% CI: -0.15 to 0.05), compared to the low level model. However, this result was highly uncertain, as shown by the confidence intervals.
Classification of patients' depressive state was feasible, but time consuming, using the classification framework proposed. Further validation of the framework is required. Unlike the analyses of diabetes and obesity management, no significant differences in the proportion of depression-free days or health service costs were found between the alternative levels of practice nurse involvement.
关于抑郁症协作护理效果的大多数证据来自随机对照试验这一选择性环境。在协作护理中，执业护士可担任病例管理员。初级保健服务改进项目（PCSIP）旨在评估在澳大利亚现实环境中执业护士参与的替代模式的成本效益。先前的分析已证明高水平执业护士参与糖尿病和肥胖症管理的价值。本文报告其在抑郁症管理中的价值。
根据观察到的执业护士参与抑郁症管理的临床活动水平（即抑郁症患者就诊百分比、用于临床活动的咨询时间百分比），将普通诊所分为低护理模式或高护理模式。使用关联的常规收集数据来确定患者层面的抑郁症结局（无抑郁天数比例）和卫生服务使用成本。未常规使用标准化抑郁症评估工具，因此使用替代指标（如症状、药物、转诊、住院和自杀未遂）开发了一个分类框架来确定患者的抑郁状态。进行了成本和抑郁症结局的回归分析，使用倾向加权来控制潜在混杂因素。
使用分类框架确定抑郁状态的能力取决于病历中提供的详细程度。虽然抗抑郁药物处方是抑郁状态的有力指标，但不能仅将其作为唯一衡量标准。对与抑郁症相关的总成本和抑郁症结局进行倾向得分加权分析发现，与低护理模式相比，高护理模式成本更高（95%置信区间：-$314.76至$584），无抑郁天数减少5%（95%置信区间：-0.15至0.05）。然而，如置信区间所示，该结果高度不确定。
使用所提出的分类框架对患者的抑郁状态进行分类是可行的，但耗时。需要对该框架进行进一步验证。与糖尿病和肥胖症管理的分析不同，在执业护士参与的不同水平之间，无抑郁天数比例或卫生服务成本未发现显著差异。
