Collaborative care for patients with depression and chronic illnesses.
Collaborative care for patients with depression and chronic illnesses.
复制标题
DOI：
10.1056/nejmoa1003955
复制
发表时间：
2010-12-30
期刊：
影响因子：
--
通讯作者：
McCulloch D
中科院分区：
文献类型：
--
作者：
Katon WJ;Lin EH;Von Korff M;Ciechanowski P;Ludman EJ;Young B;Peterson D;Rutter CM;McGregor M;McCulloch D
患有抑郁症和控制不佳的糖尿病、冠心病或两者兼而有之的患者，其不良后果的风险增加，医疗保健费用也较高。我们进行了一项研究，以确定多种情况的协调护理管理是否改善了这些患者的疾病控制。我们在华盛顿州综合医疗保健系统中的14家初级保健诊所进行了一项单盲、随机、对照试验，涉及214名患有控制不佳的糖尿病和/或冠心病并同时存在抑郁症的参与者。患者被随机分配到常规护理组或干预组，在干预组中，由一名医疗监督护士与每位患者的初级保健医生合作，提供基于指南的协作式护理管理，目标是控制与多种疾病相关的危险因素。主要结果是基于12个月时糖化血红蛋白、低密度脂蛋白(LDL)胆固醇、收缩压水平和症状自评量表(SCL-20)抑郁结果的同步建模；这种建模可以估计单一的整体治疗效果。与对照组相比，干预组患者在糖化血红蛋白水平(差值0.58%)、低密度脂蛋白水平(差值6.9毫克/升[0.2摩尔/升])、收缩压(差值5.1毫米汞柱)和SCL-20抑郁评分(差值0.40分)方面有更大的改善(P<；0.001)。干预组的患者也更有可能接受一次或多次胰岛素(P=0.006)、抗高血压药物(P<；0.001)和抗抑郁药物(P<；0.001)的调整，他们的生活质量更好(P<；0.001)，对糖尿病和/或冠心病的护理(P<；0.001)和抑郁症的护理(P<；0.001)有更高的满意度。与常规护理相比，由护士参与的干预显著改善了对内科疾病和抑郁症的控制，这些护士提供基于指导方针的、以患者为中心的抑郁症和慢性病管理。(由国家心理健康研究所资助；ClinicalTrials.gov编号，NCT00468676。)
Patients with depression and poorly controlled diabetes, coronary heart disease, or both have an increased risk of adverse outcomes and high health care costs. We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients. We conducted a single-blind, randomized, controlled trial in 14 primary care clinics in an integrated health care system in Washington State, involving 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression. Patients were randomly assigned to the usual-care group or to the intervention group, in which a medically supervised nurse, working with each patient’s primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases. The primary outcome was based on simultaneous modeling of glycated hemoglobin, low-density lipoprotein (LDL) cholesterol, and systolic blood-pressure levels and Symptom Checklist–20 (SCL-20) depression outcomes at 12 months; this modeling allowed estimation of a single overall treatment effect. As compared with controls, patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels (difference, 0.58%), LDL cholesterol levels (difference, 6.9 mg per deciliter [0.2 mmol per liter]), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points) (P<0.001). Patients in the intervention group also were more likely to have one or more adjustments of insulin (P = 0.006), antihypertensive medications (P<0.001), and antidepressant medications (P<0.001), and they had better quality of life (P<0.001) and greater satisfaction with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001). As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression. (Funded by the National Institute of Mental Health; ClinicalTrials.gov number, NCT00468676.)