Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial
Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial
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DOI：
10.1176/appi.ajp.2012.12050696
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发表时间：
2013-04-01
影响因子：
17.7
通讯作者：
Rost, Kathryn M.
中科院分区：
文献类型：
--
作者：
Fortney, John C.;Pyne, Jeffrey M.;Rost, Kathryn M.
目标：基于实践的协作护理是一种复杂的循证实践，很难在缺乏现场心理健康人员的小型初级保健机构中实施。基于远程医疗的协作护理实际上将心理健康提供者整合到初级护理机构中。这项多地点随机实用比较有效性试验的目的是比较分配到基于实践和基于远程医疗的协作护理的患者的结果。方法：从 2007 年到 2009 年，在为医疗服务不足人群提供服务的联邦合格健康中心对患者进行了抑郁症筛查，并入组了 364 名筛查结果呈阳性的患者，并随访了 18 个月。那些被分配到基于实践的协作护理的人接受了现场初级保健提供者和护士护理经理的循证护理。那些被分配到基于远程医疗的协作护理的人接受来自现场初级保健提供者和异地团队的循证护理：一名护士护理经理和一名药剂师通过电话，以及一名心理学家和一名精神科医生通过视频会议。主要临床结局指标是治疗反应、缓解和抑郁严重程度的变化。 结果：在缓解（比值比=7.74，95% CI=3.94-15.20）和缓解（比值比=12.69，95% CI=4.81-33.46）方面观察到显着的组主效应，并且在霍普金斯症状上的抑郁严重程度方面观察到显着的总体组别交互作用检查表，随着时间的推移，严重程度会更大程度地降低。基于远程医疗的组中的患者。结果的改善似乎归因于远程医疗组中对协作护理证据库的更高保真度。结论：与基于异地远程医疗的协作护理团队签订合同可以比与当地工作人员实施基于实践的协作护理产生更好的结果。 （《美国精神病学杂志》2013 年；170：414-425）
Objective: Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on:site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care.Method: From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity.Results: Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94-15.20) and remission (odds ratio=12.69, 95% CI=4.81-33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for. patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group.Conclusions: Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff. (Am J Psychiatry 2013; 170:414-425)