Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America.
Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America.
PLoS One. 2021 Mar 25;16(3):e0249007. doi: 10.1371/journal.pone.0249007. eCollection 2021.
Health systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization.
Assessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention.
(i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics.
Data from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect.
The effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86).
Reduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations.
医疗系统正在广泛采用协作式慢性病管理模式（CCM）。以 CCM 为基础的护理可能会减少昂贵的精神科住院治疗。然而，对于 CCM 对精神科住院治疗的治疗效果（HTE）的时间过程或异质性知之甚少。
如果根据预期的时间过程来评估 CCM 实施支持对精神科住院治疗的影响，那么评估可能会更有效。此外，了解 HTE 可以帮助确定谁应该接受干预。
（i）估计 CCM 对精神科住院率的影响轨迹。（ii）探索 CCM 在人口统计学和临床特征方面的 HTE。
使用 CCM 治疗组的 5570 名患者和接受常规护理的 46443 名患者的分步楔形 CCM 实施试验数据进行重新分析。从常规医疗记录中构建了时间事件数据。使用扩展的 Cox 模型模拟了 CCM 对精神病住院的影响轨迹，该模型在实施支持的一年中使用。使用模拟没有估计亚组分层 Cox 模型中的协变量风险贡献。风险比（RHR）比率允许针对试验臂进行 HTE 分析，也无需模拟。没有使用标准 Cox 比例风险模型来估计时间过程或治疗效果的异质性。
CCM 实施支持的效果在实施开始后立即迅速增加，并且在研究的其余时间内逐渐增加。在研究的最后一天，治疗组的精神科住院率比对照组低 17%至 49%，调整了所有模型协变量（HR 0.66；95%CI 0.51-0.83）。我们对 HTE 的分析倾向于常规护理，对于有既往精神科住院治疗史的患者（RHR 4.92；95%CI 3.15-7.7），但对于患有抑郁症的患者（RHR 0.61；95%CI：0.41-0.91）则倾向于 CCM。与没有任何医疗诊断相比，只有一个医疗诊断更有利于 CCM（RHR 0.52；95%CI 0.31-0.86）。
CCM 实施支持开始后立即出现精神科住院治疗减少，但在效果大小开始稳定后，评估可能会更好，这可能最早在六个月后。CCM 的 HTE 发现可以指导未来在特定人群中使用 CCM 的效用研究。
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