Wu Shinyi, Ell Kathleen, Jin Haomiao, Vidyanti Irene, Chou Chih-Ping, Lee Pey-Jiuan, Gross-Schulman Sandra, Sklaroff Laura Myerchin, Belson David, Nezu Arthur M, Hay Joel, Wang Chien-Ju, Scheib Geoffrey, Di Capua Paul, Hawkins Caitlin, Liu Pai, Ramirez Magaly, Wu Brian W, Richman Mark, Myers Caitlin, Agustines Davin, Dasher Robert, Kopelowicz Alex, Allevato Joseph, Roybal Mike, Ipp Eli, Haider Uzma, Graham Sharon, Mahabadi Vahid, Guterman Jeffrey
Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States.
Roybal Institute on Aging, University of Southern California, Los Angeles, CA, United States.
J Med Internet Res. 2018 Apr 23;20(4):e147. doi: 10.2196/jmir.7692.
Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers.
The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes.
DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design.
DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001).
Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.
共病抑郁症对安全网初级保健系统来说是一项重大挑战。基于团队的协作式抑郁症护理是有效的，但安全网组织中的复杂系统因素阻碍了其采用，并导致结果持续存在差异。糖尿病-抑郁症护理管理采用试验（DCAT）评估了利用信息和通信技术对患者症状和治疗依从性进行常规筛查和监测，并允许与提供者及时沟通，是否能显著改善抑郁症护理。
本研究的目的是比较技术辅助护理模式与常规护理模式以及支持性护理模式的6个月结局，后者涉及为安全网初级保健机构中患有2型糖尿病的成年患者提供基于团队的协作式抑郁症护理。
DCAT是一项与美国第二大安全网护理系统洛杉矶县卫生服务部合作开展的转化研究。在三组成年2型糖尿病患者中进行了一项采用准实验设计的比较效果研究，以比较三种护理模式：常规护理、支持性护理和技术辅助护理。6个月的结局包括抑郁症和糖尿病护理指标以及患者报告的结局。通过线性或逻辑回归模型估计比较治疗效果，这些模型使用广义倾向得分来调整非随机设计中固有的抽样偏差。
DCAT招募了1406名患者（常规护理组484名，支持性护理组480名，技术辅助护理组442名），其中大多数是西班牙裔或拉丁裔女性。与常规护理相比，支持性护理组和技术辅助护理组在通过9项患者健康问卷得分衡量的抑郁症状方面均显著减轻（最小二乘估计，LSE：常规护理=6.35，支持性护理=5.05，技术辅助护理=5.16；P值：支持性护理组与常规护理组比较=.02，技术辅助护理组与常规护理组比较=.02）；重度抑郁症患病率降低（比值比，OR：支持性护理组与常规护理组比较=0.45，技术辅助护理组与常规护理组比较=0.33；P值：支持性护理组与常规护理组比较=.02，技术辅助护理组与常规护理组比较=.007）；以及通过希恩残疾量表得分衡量的功能残疾减轻（LSE：常规护理=3.21，支持性护理=2.61，技术辅助护理=2.59；P值：支持性护理组与常规护理组比较=.04，技术辅助护理组与常规护理组比较=.03）。技术辅助护理与抑郁症缓解显著相关（技术辅助护理组与常规护理组比较：OR=2.98，P=.04）；抑郁症患者对情绪问题护理的满意度提高（LSE：常规护理=3.20，技术辅助护理=3.70；P=.05）；总胆固醇水平降低（LSE：常规护理=176.40，技术辅助护理=160.46；P=.01）；对糖尿病护理的满意度提高（LSE：常规护理=4.01，技术辅助护理=4.20；P=.05）；以及进行糖化血红蛋白检测的几率增加（技术辅助护理组与常规护理组比较：OR=3.40，P<.001）。
技术辅助护理模式和支持性护理模式在改善6个月的抑郁症和功能残疾结局方面均显示出潜力。技术辅助护理模式更有可能改善抑郁症缓解、患者满意度和糖尿病护理质量。
