Kaiser Permanente Washington Heath Research Institute and Department of Health Systems and Population Health, University of Washington, Seattle, Washington (J.A.R.).
Kaiser Permanente Washington Heath Research Institute and Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington (M.C.).
Ann Intern Med. 2024 Nov;177(11):1471-1481. doi: 10.7326/M24-0024. Epub 2024 Oct 1.
Primary care encounters are common among patients at risk for suicide.
To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention.
Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777).
19 primary care practices within a large health care system in Washington State, randomly assigned launch dates.
Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018.
Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning.
Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization.
During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, -1.5 [CI, -2.6 to -0.4]).
Suicide care was implemented in combination with care for depression and substance use.
Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits.
National Institute of Mental Health.
在有自杀风险的患者中，初级保健就诊很常见。
评估在初级保健中实施基于人群的自杀护理（SC）对预防自杀未遂的效果。
一项阶梯式、群组随机实施试验的二次分析。（ClinicalTrials.gov：NCT02675777）。
华盛顿州一个大型医疗保健系统内的 19 个初级保健诊所，随机分配启动日期。
2015 年 1 月至 2018 年 7 月期间有初级保健就诊的成年患者（年龄≥18 岁）。
实践促进者、电子病历（EMR）临床决策支持和绩效监测支持实施抑郁筛查、自杀风险评估和安全计划。
临床实践和患者测量依赖于 EMR 和保险索赔数据，以比较常规护理（UC）和 SC 期间的情况。主要结果包括基于人群筛查和自杀风险评估后的有记录的安全计划以及在就诊后 90 天内自杀未遂或死亡（有自我伤害意图）。混合效应逻辑模型将二项结果指标回归到 UC 与 SC 之间，调整了随机分层和日历时间，考虑了来自同一地点的重复结果。通过应用边缘标准化来估计每月结果发生率（每 10000 名患者的百分比）。
在 UC 期间，255789 名患者进行了 953402 次初级保健就诊，228255 名患者进行了 615511 次就诊。在 SC 组中安全计划的比例高于 UC 组（每 10000 名患者中分别为 38.3 比 32.8；差异率为 5.5 [95%CI，2.3 至 8.7]）。在 SC 组中，90 天内自杀未遂的比例低于 UC 组（每 10000 名患者中分别为 4.5 比 6.0；差异率为 -1.5 [CI，-2.6 至 -0.4]）。
自杀护理是与抑郁和物质使用护理同时实施的。
在初级保健中同时实施基于人群的 SC 与物质使用计划，可使 90 天内的自杀未遂率降低 25%。
美国国家心理健康研究所。
