Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.
Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.
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DOI：
10.1371/journal.pone.0137581
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发表时间：
2015
期刊：
影响因子：
3.7
通讯作者：
Patton G
中科院分区：
文献类型：
--
作者：
Sanci L;Chondros P;Sawyer S;Pirkis J;Ozer E;Hegarty K;Yang F;Grabsch B;Shiell A;Cahill H;Ambresin AE;Patterson E;Patton G
为了评估实施最佳做法指南的复杂干预措施的有效性，建议临床医生对多种心理社会风险因素进行筛查和咨询，并就临床医生对健康风险的检测和患者的冒险行为进行咨询，与关于年轻人健康的说教研讨会进行比较。实用型集群随机试验，志愿者的一般做法按邮政编码优势或劣势得分和计费类型(私人、免费国民健康、社区卫生中心)分层，然后使用计算机生成的随机序列随机分为干预组或对照组。干预3个月后，从所有诊所招募患者进行计算机辅助电话访谈，并在3个月和12个月后进行随访。研究人员招募、同意和采访患者和患者本身被掩盖在分配状态；临床医生不被掩盖。澳大利亚维多利亚州大都市和乡村的普通诊所至少有一名感兴趣的临床医生(全科医生或护士)及其14-24岁的患者。这一复杂的干预措施是利用循证实践在学习和改变临床医生行为和全科医疗系统中设计的，并包括激励青少年冒险行为改变的最佳实践方法。干预措施包括培训临床医生(9小时)进行健康风险筛查、筛查工具的使用和激励性访谈；培训所有执业工作人员(接待员和临床医生)吸引青年；向临床医生提供关于患者风险数据的反馈；以及两次实践访问，以支持新的筛查和转介资源。对比临床医生接受了一次关于青年参与和健康风险筛查的教育研讨会(三个小时)。主要结果是患者报告：(1)临床医生检测到六种健康风险行为(烟草、酒精和非法药物使用、性传播感染、性传播感染、计划外怀孕和道路风险)中的至少一种；以及(2)六种健康风险行为中的一种或多种在3个月或12个月时发生变化。次要结果是未来就诊的可能性，离职面谈后对临床医生的信任，临床医生在人际关系中发现的情绪困扰、恐惧和虐待，以及在3个月和12个月时的情绪困扰。对介入臂的筛查工具的患者可接受性也进行了描述。在适当的情况下，对执业地点和账单类型、患者的性别、年龄和招募方法以及过去的健康风险进行了分析调整。采用意向处理分析方法，包括对缺失结果数据的多水平多重归因。将42项练习随机分配到干预组或对照组。两项干预措施在培训前撤销了员额分配，留下19项干预措施(53名临床医生，377名患者)和21项对照工作(79名临床医生，524名患者)。在干预组(260例)和对照组(360例)中，69%的患者完成了12个月的随访。干预临床医生讨论的每个患者的健康风险(59.7%)比对照临床医生(52.7%)更高，因此更有可能发现至少有六种健康风险行为之一的年轻人的比例更高(38.4%比26.7%，风险差异[RD]11.6%，可信区间[CI]2.93%至20.3%；调整后的优势比[OR]1.7%，CI 1.1%至2.5)。与对照组相比，患者在干预3个月时报告的非法药物使用较少(RD-6.0，CI-11至-1.2；OR-0.52，CI为0.28~0.96)，发生STI的风险较低(RD-5.4，CI-11至0.2；OR 0.66，CI为0.46至0.96)，并在12个月时报告计划外妊娠(RD-4.4；CI-8.7至-0.1；OR 0.40，CI为0.20至0.80)。在其他健康风险方面，两个武器之间没有检测到差异。除了更多地发现滥用行为外，在次要结果上没有差异(OR 13.8，CI 1.71至111)。没有关于有害事件和干预的报道，ARM青年对筛查工具的接受度很高。与简单的实践教育研讨会相比，一种复杂的干预措施改善了对年轻人健康风险行为的检测。对健康结果的影响尚不确定。能够进行更有效、更系统的健康风险筛查的技术可能会使提供者能够针对高危个人进行咨询。进一步的试验需要更多的权力来确认健康益处。ISRCTN.com ISRCTN16059206。
To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians’ detection of health risks and patients’ risk taking behaviour, compared to a didactic seminar on young people’s health. Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. General practices in metropolitan and rural Victoria, Australia General practices with at least one interested clinician (general practitioner or nurse) and their 14–24 year old patients. This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients’ risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients’ sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. ISRCTN.com ISRCTN16059206.