Børøsund Elin, Cvancarova Milada, Moore Shirley M, Ekstedt Mirjam, Ruland Cornelia M
Centre for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, Oslo, Norway.
J Med Internet Res. 2014 Dec 18;16(12):e295. doi: 10.2196/jmir.3348.
While Web-based interventions have been shown to assist a wide range of patients successfully in managing their illness, few studies have examined the relative contribution of different Web-based components to improve outcomes. Further efficacy trials are needed to test the effects of Web support when offered as a part of routine care.
Our aim was to compare in regular care the effects of (1) an Internet-based patient provider communication service (IPPC), (2) WebChoice, a Web-based illness management system for breast cancer patients (IPPC included), and (3) usual care on symptom distress, anxiety, depression, (primary outcomes), and self-efficacy (secondary outcome). This study reports preliminary findings from 6 months' follow-up data in a 12-month trial.
We recruited 167 patients recently diagnosed with breast cancer and undergoing treatment from three Norwegian hospitals. The nurse-administered IPPC allowed patients to send secure e-messages to and receive e-messages from health care personnel at the hospital where they were treated. In addition to the IPPC, WebChoice contains components for symptom monitoring, tailored information and self-management support, a diary, and communication with other patients. A total of 20 care providers (11 nurses, 6 physicians, and 3 social workers) were trained to answer questions from patients. Outcomes were measured with questionnaires at study entry and at study months 2, 4, and 6. Linear mixed models for repeated measures were fitted to compare effects on outcomes over time.
Patients were randomly assigned to the WebChoice group (n=64), the IPPC group (n=45), or the usual care group (n=58). Response rates to questionnaires were 73.7% (123/167) at 2 months, 65.9 (110/167) at 4 months, and 62.3% (104/167) at 6 months. Attrition was similar in all study groups. Among those with access to WebChoice, 64% (41/64) logged on more than once and 39% (25/64) sent e-messages to care providers. In the IPPC group, 40% (18/45) sent e-messages. Linear mixed models analyses revealed that the WebChoice group reported significantly lower symptom distress (mean difference 0.16, 95% CI 0.06-0.25, P=.001), anxiety (mean difference 0.79, 95% CI 0.09-1.49, P=.03), and depression (mean difference 0.79, 95% CI 0.09-1.49, P=.03) compared with the usual care group. The IPPC group reported significant lower depression scores compared with the usual care group (mean difference 0.69, 95% CI 0.05-1.32, P=.03), but no differences were observed for symptom distress or anxiety. No significant differences in self-efficacy were found among the study groups.
In spite of practice variations and moderate use of the interventions, our results suggest that offering Web support as part of regular care can be a powerful tool to help patients manage their illness. Our finding that a nurse-administered IPPC alone can significantly reduce depression is particularly promising. However, the multicomponent intervention WebChoice had additional positive effects.
Clinicaltrials.gov:NCT00971009; http://clinicaltrials.gov/show/NCT00971009 (Archived by WebCite at http://www.webcitation.org/6USKezP0Y).
虽然基于网络的干预措施已被证明能成功帮助各类患者管理自身疾病，但很少有研究探讨不同网络组件对改善治疗效果的相对贡献。需要进一步的疗效试验来检验将网络支持作为常规护理一部分时的效果。
我们的目的是在常规护理中比较以下三种情况的效果：（1）基于互联网的患者与医护人员沟通服务（IPPC）；（2）WebChoice，一种针对乳腺癌患者的基于网络的疾病管理系统（包括IPPC）；（3）常规护理对症状困扰、焦虑、抑郁（主要结局）和自我效能感（次要结局）的影响。本研究报告了一项为期12个月试验中6个月随访数据的初步结果。
我们从挪威的三家医院招募了167名最近被诊断为乳腺癌且正在接受治疗的患者。由护士管理的IPPC允许患者向其接受治疗的医院的医护人员发送和接收安全的电子邮件。除了IPPC，WebChoice还包含症状监测、个性化信息和自我管理支持、日记以及与其他患者沟通等组件。总共20名护理提供者（11名护士、6名医生和3名社会工作者）接受了培训，以回答患者的问题。在研究开始时以及研究的第2、4和6个月，通过问卷调查来测量结局。采用重复测量的线性混合模型来比较不同时间对结局的影响。
患者被随机分配到WebChoice组（n = 64）、IPPC组（n = 45）或常规护理组（n = 58）。问卷调查的回复率在2个月时为73.7%（123/167），4个月时为65.9%（110/167），6个月时为62.3%（104/167）。所有研究组的失访情况相似。在能够使用WebChoice的患者中，64%（41/64）登录不止一次，39%（25/64）向护理提供者发送了电子邮件。在IPPC组中，40%（18/45）发送了电子邮件。线性混合模型分析显示，与常规护理组相比，WebChoice组报告的症状困扰（平均差异0.16，95%可信区间0.06 - 0.25，P = 0.001）、焦虑（平均差异0.79，95%可信区间0.09 - 1.49，P = 0.03）和抑郁（平均差异0.79，95%可信区间0.09 - 1.49，P = 0.03）显著更低。与常规护理组相比，IPPC组报告的抑郁得分显著更低（平均差异0.69，95%可信区间0.05 - 1.32，P = 0.03），但在症状困扰或焦虑方面未观察到差异。各研究组在自我效能感方面未发现显著差异。
尽管存在实践差异且干预措施的使用程度一般，但我们的结果表明，将网络支持作为常规护理的一部分可以成为帮助患者管理疾病的有力工具。我们发现仅由护士管理的IPPC就能显著降低抑郁，这一发现尤其有前景。然而，多组件干预措施WebChoice有额外的积极效果。
Clinicaltrials.gov：NCT00971009；http://clinicaltrials.gov/show/NCT00971009（由WebCite存档于http://www.webcitation.org/6USKezP0Y）
