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农村初级保健患者体重管理计划中不同医生转诊策略的达成结果与成本:3型混合有效性-实施试验

Reach Outcomes and Costs of Different Physician Referral Strategies for a Weight Management Program Among Rural Primary Care Patients: Type 3 Hybrid Effectiveness-Implementation Trial.

作者信息

Porter Gwenndolyn, Michaud Tzeyu L, Schwab Robert J, Hill Jennie L, Estabrooks Paul A

机构信息

Department of Health Promotion, University of Nebraska Medical Center, Omaha, NE, United States.

Center for Reducing Health Disparities, University of Nebraska Medical Center, Omaha, NE, United States.

出版信息

JMIR Form Res. 2021 Oct 20;5(10):e28622. doi: 10.2196/28622.

Abstract

BACKGROUND

Rural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming.

OBJECTIVE

The purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients.

METHODS

A total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry-derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ≥25 and approved patients for participation to receive a personalized referral letter via mail.

RESULTS

Out of a potential 991 referrals, 573 (57.8%) referrals were made over 16 weeks, and 98 (9.9%) patients were enrolled in the program (58/98, 59.2% female). Differences based on letter (485/991, 48.9%) versus POC (506/991, 51.1%) referrals were identified for completion (100% vs 7%; P<.001) and for proportion screened (36% vs 12%; P<.001) but not for proportion enrolled (12% vs 8%; P=.10). Patients receiving ATF were more likely to be screened (47% vs 7%; P<.001) and enrolled (15% vs 7%; P<.001) than those not receiving ATF. On the basis of the number of referrals made in each condition, we found variations in the proportion and number of enrollees (POC with ATF: 27/190, 50%; POC no ATF: 14/316, 41%; letter ATF: 30/199; 15.1%; letter no ATF: 27/286, 9.4%). Across all conditions, participants were representative of the racial and ethnic characteristics of the region (60% female, P=.15; 94% White individuals, P=.60; 94% non-Hispanic, P=.19). Recruitment costs totaled US $6192, and the overall recruitment cost per enrolled participant was US $63. Cost per enrolled participant ranged from POC with ATF (US $47), registry-derived letter without ATF (US $52), and POC without ATF (US $56) to registry-derived letter with ATF (US $91).

CONCLUSIONS

Letter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557.

摘要

背景

农村居民肥胖风险较高;然而,用于应对这一不成比例的疾病负担的资源却很少。初级保健可能为将超重和肥胖的初级保健患者与有效的体重管理计划联系起来提供契机。

目的

本研究旨在探讨不同的医生转诊和参与流程对于扩大一项基于证据且通过技术提供、有咨询支持的体重管理计划对农村初级保健患者的覆盖范围的效用。

方法

总共5名农村初级保健医生被随机分配采用四种转诊策略的顺序:即时医疗(POC)转诊并进行主动电话随访(ATF);POC转诊,无ATF;基于人群健康登记处的信件转诊并进行ATF;信件转诊,无ATF。对于基于登记处的转诊,医生筛选出体重指数(BMI)≥25的患者名单,并批准符合条件的患者参与,通过邮件收到个性化转诊信。

结果

在可能的991次转诊中,16周内进行了573次(57.8%)转诊,98名(9.9%)患者参与了该计划(58/98,女性占59.2%)。在转诊完成率(100%对7%;P<.001)和筛选比例(36%对12%;P<.001)方面发现了基于信件转诊(485/991,48.9%)与POC转诊(506/991,51.1%)的差异,但在参与比例方面无差异(12%对8%;P = 0.10)。与未接受ATF的患者相比,接受ATF的患者更有可能接受筛选(47%对7%;P<.001)和参与(15%对7%;P<.001)。根据每种情况下进行的转诊数量,我们发现参与患者的比例和数量存在差异(POC转诊并进行ATF:27/190,50%;POC转诊无ATF:14/316,41%;信件转诊并进行ATF:30/199,15.1%;信件转诊无ATF:27/286,9.4%)。在所有情况下,参与者均代表该地区的种族和民族特征(女性占60%,P = 0.15;白人占94%,P = 0.60;非西班牙裔占94%,P = 0.19)。招募成本总计6192美元,每位参与招募的患者的总体招募成本为63美元。每位参与招募的患者的成本范围从POC转诊并进行ATF(47美元)、基于登记处的信件转诊无ATF(52美元)、POC转诊无ATF(56美元)到基于登记处的信件转诊并进行ATF(91美元)。

结论

信件转诊并进行ATF似乎是让大量患者参与数字提供的体重管理计划的最佳选择;然而,POC转诊并进行ATF和信件转诊无ATF以较低成本产生了相似的参与人数。最佳转诊选择可能取决于与临床资源的最佳匹配。

试验注册

ClinicalTrials.gov NCT03690557;http://clinicaltrials.gov/ct2/show/NCT03690557

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