Tees Esk and Wear Valleys NHS Foundation Trust, Durham, England.
University of York, York, England.
PLoS One. 2019 Apr 9;14(4):e0214715. doi: 10.1371/journal.pone.0214715. eCollection 2019.
England's national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective.
英格兰国家改善心理治疗途径（IAPT）计划提倡阶梯式护理，作为其向常见心理健康问题提供心理治疗的组织方式。关于阶梯式护理作为一种服务提供模式的疗效，研究和常规实践中定义的异质性以及模型实施的差异，因此很难就模型的有效性进行结果比较。尽管有充分的证据表明低强度干预措施有效，但似乎仍然存在这样一种观念，即严重程度和复杂性只能通过高强度干预来治疗，通过继续分层护理模式。然而，没有一种心理治疗方法被发现比另一种更优越，并且对于帮助治疗决策的匹配，对于哪些方法对哪些人有效知之甚少。由于不了解精确的治疗因素是否有利于康复，因此更好地了解服务提供模式的影响，以及不同的模式是否会产生不同的结果可能会有所帮助。本研究旨在为关于阶梯式护理的定义和实施的讨论做出贡献，并探讨在同一服务中实施不同类型的阶梯式护理对临床结果的影响。一项观察性队列研究分析了为期 4 年的单一 IAPT 服务中的回顾性数据（n=16723），其中治疗方式从一种阶梯式护理模式转变为另一种。我们比较了分层护理模型和进展护理模型的治疗完成者的结果。我们还探讨了这样一种假设，即心理测量评分严重的患者，因此可能复杂，在分层模型中会取得更好的结果。比较了每种模型类型的结果，以及基线因素变量。在恢复结果和模型类型之间观察到显著关联，进展式交付模型中患者恢复的可能性是分层模型的 1.5 倍。这可能意味着，采用进展式阶梯式护理服务提供模式，更多的患者可以接受低强度干预，即使最初表现严重，也可以确保只有那些需要高强度 CBT 或同等治疗的患者才会得到强化。这可以为服务提供一种有效且高效的临床模型，并且具有潜在的成本效益。
