Wissow Lawrence S, Zafar Waleed, Fothergill Kate, Ruble Anne, Slade Eric
Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 703 Hampton House, 624 N. Broadway, Baltimore, MD, USA.
Department of Emergency Medicine, World Health Organization Collaborating Center for Emergency Medicine and Trauma Care, Aga Khan University, Karachi, Pakistan.
BMC Health Serv Res. 2016 Jan 22;15:584. doi: 10.1186/s12913-015-1237-x.
To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers.
Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77% female, 58% at their site 10 or more years; 44% in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level.
The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50%) increase in work (95% CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff.
Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.
为进一步推动精神卫生与初级保健的整合，本研究开发了一种新方法，用于量化将常见精神卫生问题的护理工作转移至儿科初级保健提供者时所涉及的工作量及来源。
通过电子邮件/基于网络的方式，对马里兰州儿科医生的便利样本（n = 58）进行调查（77%为女性，58%在其工作地点工作10年或更长时间；44%为私人执业，52%在城市工作，48%与驻点精神卫生提供者合作执业）。参与者被要求审阅11个病例 vignettes，这些病例描述了儿童/青少年精神卫生问题的初级保健管理，并与第12个描述单纯多动症病例的参考 vignette 相比，根据基于整数的顺序量表对所涉及的总体工作量进行评分。受访者还被要求指出影响其评分的因素（时间、精力、压力）。vignettes 呈现了三种诊断（多动症、焦虑症和抑郁症）与三种据报道会使精神卫生护理复杂化的因素（躯体共病、精神共病和难相处的家庭）的组合。参考病例预先设定的工作量值为2。使用线性回归并在受访者层面采用随机效应，得出诊断和复杂化因素与工作量之间关系的估计值。
58名儿科医生给出了593个 vignette 回复。抑郁症与工作量增加1.09个单位（约50%）相关（95%置信区间0.94，1.25），而焦虑症与单纯多动症参考病例相比无显著差异（p = 0.28）。尽管与参考病例相比，所有三种复杂化因素都提高了工作量评分，但家庭复杂性和精神共病提高得最多（分别为0.87和1.07个单位，P < 0.001），而躯体共病提高得最少（0.44个单位，p < 0.001）。与总体工作量增加最密切相关的因素是医生时间、医生脑力精力和压力；最不密切相关的是工作人员时间、医生体力精力和医疗事故风险。与驻点精神卫生提供者合作的儿科医生给出的工作量评分高于没有驻点工作人员的医生。
诊断和跨诊断复杂化因素均会增加初级保健中提供精神卫生服务所涉及的工作量。vignettes 研究可能有助于理解哪些精神卫生服务能够最容易地融入当前结构的初级保健中，并有助于指导培训项目和其他实施策略的设计。
