Optimizing treatment cascades for mental healthcare in Mozambique: preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)
Optimizing treatment cascades for mental healthcare in Mozambique: preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)
复制标题
DOI：
10.1093/heapol/czaa114
复制
发表时间：
2020-12-01
影响因子：
3.2
通讯作者：
Wagenaar, Bradley H.
中科院分区：
文献类型：
--
作者：
Fabian, Katrin E.;Muanido, Alberto;Wagenaar, Bradley H.
低收入和中等收入国家正在进行大量投资，以扩大获得精神卫生保健的机会，但对新兴公共部门精神卫生保健系统的质量和绩效的关注较少。本研究测试了莫桑比克优化常规门诊精神保健级联绩效的实施策略的初步有效性[精神健康系统分析和改进方法（SAIA-MH）]。这项研究采用了 2018 年 9 月至 2019 年 8 月期间的事前设计，涉及卫生部的四个诊所，共 810 名患者和 3234 名门诊心理健康就诊者。有效性结果评估了护理级联的进展，包括：（1）初步诊断和药物选择； (2) 参加后续护理； （三）初诊后60天内返回； （四）按时回访随访； (5) 坚持用药回访；(6) 实现功能改善。聚类广义线性模型评估了干预前后完成级联步骤的几率。设施优先改进的重点是后续级联，其中 62.5%（16 中的 10）每月系统修改针对药物依从性。在基线时，只有 4.2% 的就诊患者实现了功能改善；在 SAIA-MH 实施的 6 个月期间，患者就诊率提高至 13.1%。多级逻辑回归发现，实施 SAIA-MH 后，按时返回且依从性 [aOR = 1.53, 95% CI (1.21, 1.94), P = 0.0004] 以及按时返回、依从性且功能改善 [aOR = 3.68, 95% CI (2.57, 5.44), P < 0.0001] 的几率增加。对于其他级联步骤没有观察到显着差异。 SAIA-MH 实施策略有望快速显着改善精神保健级联结果，包括改善患者功能的最终目标。鉴于精神卫生保健级联基线绩效较差，迫切需要基于证据的实施策略来优化低收入和中等收入国家精神卫生保健级联的绩效。
Substantial investments are being made to scale-up access to mental healthcare in low- and middle-income countries, but less attention has been paid to quality and performance of nascent public-sector mental healthcare systems. This study tested the initial effectiveness of an implementation strategy to optimize routine outpatient mental healthcare cascade performance in Mozambique [the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)]. This study employed a pre-post design from September 2018 to August 2019 across four Ministry of Health clinics among 810 patients and 3234 outpatient mental health visits. Effectiveness outcomes evaluated progression through the care cascade, including: (1) initial diagnosis and medication selection; (2) enrolling in follow-up care; (3) returning after initial consultation within 60 days; (4) returning for follow-up visits on time; (5) returning for follow-up visits adherent to medication and (6) achieving function improvement. Clustered generalized linear models evaluated odds of completing cascade steps pre- vs post-intervention. Facilities prioritized improvements focused on the follow-up cascade, with 62.5% (10 of 16) monthly system modifications targeting medication adherence. At baseline, only 4.2% of patient visits achieved function improvement; during the 6 months of SAIA-MH implementation, this improved to 13.1% of patient visits. Multilevel logistic regression found increased odds of returning on time and adherent [aOR = 1.53, 95% CI (1.21, 1.94), P = 0.0004] and returning on time, adherent and with function improvement [aOR = 3.68, 95% CI (2.57, 5.44), P < 0.0001] after SAIA-MH implementation. No significant differences were observed regarding other cascade steps. The SAIA-MH implementation strategy shows promise for rapidly and significantly improving mental healthcare cascade outcomes, including the ultimate goal of patient function improvement. Given poor baseline mental healthcare cascade performance, there is an urgent need for evidence-based implementation strategies to optimize the performance of mental healthcare cascades in low- and middle-income countries.