Effectiveness of integrated care for older adults with depression and hypertension in rural China: A cluster randomized controlled trial.
Effectiveness of integrated care for older adults with depression and hypertension in rural China: A cluster randomized controlled trial.
复制标题
DOI：
10.1371/journal.pmed.1004019
复制
发表时间：
2022-10
期刊：
影响因子：
15.8
通讯作者：
中科院分区：
文献类型：
--
作者：
在低收入和中等收入国家（LMICs），对常见、共病的身体和精神障碍的综合护理管理的有效性尚未得到充分审查。我们检验了在中国农村初级保健诊所接受合并抑郁和高血压（HTN）治疗的老年人在抑郁症状严重程度和HTN控制方面比接受常规治疗的老年人有更大改善的假设。该研究已在ClinicalTrials.gov注册为识别符NCT01938963，是一项为期12个月的随机对照试验，随访时间为2014年1月1日至2018年9月30日，分析时间为2020年至2021年。参与者是中国浙江省随机抽取的10个乡镇218个农村的居民。每个村设有一个初级保健诊所，为所有居民服务。随机选择10个乡镇，每个乡镇包含大约20个村庄，向符合条件的村诊所患者提供中国老年人卫生合作（COACH）干预或增强照护（eCAU）。COACH干预包括由乡村初级保健医生在乡村非专业工作人员的支持下进行算法驱动的抑郁症和HTN治疗，并由位于中心的精神科医生进行电话咨询。参与者包括年龄≥60岁的临床患者，诊断为HTN并有临床显著的抑郁症状（患者健康问卷-9 [PHQ-9]评分≥10）。在2899名符合条件的村民中，有2365人（82%）同意参加。他们的平均年龄为74.5岁，67%是女性，55%没有受过教育，59%已婚，20%独居。观察者、老年参与者和他们的初级保健提供者（pcp）对研究假设不知情，但对分组分配不知情。主要结局是通过汉密尔顿抑郁评定量表（HDRS）总分测量抑郁症状严重程度的变化和控制HTN的比例，定义为收缩压(BP) <130 mm Hg或舒张压<80，糖尿病，冠心病或肾脏疾病的参与者，收缩压<140或舒张压<90。采用广义线性混合效应模型进行分析，目的是治疗。分配到eCAU的1133名参与者中的67名和1232名COACH参与者中的85名在12个月的随访中丢失。36名参与者死于自然原因，22名在COACH组，14名接受eCAU。40名COACH参与者因副作用停用抗抑郁药物。与接受eCAU治疗的患者相比，COACH患者的抑郁症状明显减轻（Cohen’SD[±SD] = - 1.43 [- 1.71, - 1.15]; p < 0.001），获得HTN控制的可能性也更大（优势比[OR] [95% CI] = 18.24 [8.40, 39.63]; p < 0.001）。该研究的局限性包括无法掩盖研究评估者和参与者被分配到哪个村庄的条件，以及缺乏关于参与者遵守HTN和抑郁症的生活方式和药物管理建议的信息。该模型在中国其他地区或其他中低收入国家的推广可能有限。与eCAU相比，综合护理管理的COACH模式在中国农村老年居民的抑郁症状严重程度和HTN控制方面都有更大的改善。ClinicalTrials.gov标识符NCT01938963 https://clinicaltrials.gov/ct2/show/NCT01938963。在一项集群随机对照试验中，Shulin Chen及其同事调查了在中国农村初级保健诊所就诊的老年人中，与常规护理相比，抑郁症和高血压的综合护理管理是否能带来更大的改善。抑郁症和高血压（HTN）的结合在晚年生活中很常见，并使两种情况恶化。在高收入国家进行的研究发现，当初级保健医生提供的护理与精神保健相结合时，患有内科疾病和临床显著抑郁症的老年人的结果会更好。在低收入和中等收入国家，老年人护理的综合方法尚未得到充分检验。我们在中国农村初级保健诊所开发了一种针对老年人合并抑郁症和HTN的综合护理模型，并将其与常规护理方法进行了比较。这项干预被称为中国老年人健康合作（COACH），由一个由村诊所的初级保健医生、一名被称为“老龄工作者”的村居民（帮助加强治疗并解决影响健康的社会因素）和一名精神科医生的电话咨询组成的小组进行管理。在12个月的参与中，接受COACH干预的1232名参与者在抑郁症状和HTN控制率方面的改善明显大于接受常规护理的1133名参与者。综合护理管理对资源不足的初级保健机构中获得精神卫生保健的机会有限的中国老年人的共病抑郁症和HTN的管理有效。抗抑郁药处方和老龄工作者支持对抑郁症治疗和高血压控制的独特益处，以及在该模型中添加易于管理的心理治疗，需要进一步研究。在精神卫生资源很少的地区广泛传播该模式可能需要使用远程保健技术，以便更好地获得护理。
Effectiveness of integrated care management for common, comorbid physical and mental disorders has been insufficiently examined in low- and middle-income countries (LMICs). We tested hypotheses that older adults treated in rural Chinese primary care clinics with integrated care management of comorbid depression and hypertension (HTN) would show greater improvements in depression symptom severity and HTN control than those who received usual care. The study, registered with ClinicalTrials.gov as Identifier NCT01938963, was a cluster randomized controlled trial with 12-month follow-up conducted from January 1, 2014 through September 30, 2018, with analyses conducted in 2020 to 2021. Participants were residents of 218 rural villages located in 10 randomly selected townships of Zhejiang Province, China. Each village hosts 1 primary care clinic that serves all residents. Ten townships, each containing approximately 20 villages, were randomly selected to deliver either the Chinese Older Adult Collaborations in Health (COACH) intervention or enhanced care-as-usual (eCAU) to eligible village clinic patients. The COACH intervention consisted of algorithm-driven treatment of depression and HTN by village primary care doctors supported by village lay workers with telephone consultation from centrally located psychiatrists. Participants included clinic patients aged ≥60 years with a diagnosis of HTN and clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10). Of 2,899 eligible village residents, 2,365 (82%) agreed to participate. They had a mean age of 74.5 years, 67% were women, 55% had no schooling, 59% were married, and 20% lived alone. Observers, older adult participants, and their primary care providers (PCPs) were blinded to study hypotheses but not to group assignment. Primary outcomes were change in depression symptom severity as measured by the Hamilton Depression Rating Scale (HDRS) total score and the proportion with controlled HTN, defined as systolic blood pressure (BP) <130 mm Hg or diastolic BP <80 for participants with diabetes mellitus, coronary heart disease, or renal disease, and systolic BP <140 or diastolic BP <90 for all others. Analyses were conducted using generalized linear mixed effect models with intention to treat. Sixty-seven of 1,133 participants assigned to eCAU and 85 of 1,232 COACH participants were lost to follow-up over 12 months. Thirty-six participants died of natural causes, 22 in the COACH arm and 14 receiving eCAU. Forty COACH participants discontinued antidepressant medication due to side effects. Compared with participants who received eCAU, COACH participants showed greater reduction in depressive symptoms (Cohen’s d [±SD] = −1.43 [−1.71, −1.15]; p < 0.001) and greater likelihood of achieving HTN control (odds ratio [OR] [95% CI] = 18.24 [8.40, 39.63]; p < 0.001). Limitations of the study include the inability to mask research assessors and participants to which condition a village was assigned, and lack of information about participants’ adherence to recommendations for lifestyle and medication management of HTN and depression. Generalizability of the model to other regions of China or other LMICs may be limited. The COACH model of integrated care management resulted in greater improvement in both depression symptom severity and HTN control among older adult residents of rural Chinese villages who had both conditions than did eCAU. ClinicalTrials.gov Identifier NCT01938963 https://clinicaltrials.gov/ct2/show/NCT01938963. In a cluster randomized controlled trial, Shulin Chen and colleagues investigate whether integrated care management of depression and hypertension leads to greater improvements as compared to usual care in older adults attending rural Chinese primary care clinics. The combination of depression and hypertension (HTN) is common in later life and makes both conditions worse. Studies in high-income countries have found that older adults with both medical illness and clinically significant depression have better outcomes when the care delivered by their primary care doctor is integrated with mental healthcare. The integrated approach to care for older adults has been insufficiently tested in low- and middle-income countries (LMICs). We developed a model of integrated care for combined depression and HTN among older adults in rural village primary care clinics in China and compared it with usual approaches to care. The intervention, called Chinese Older Adult Collaborations in Health (COACH), was administered by a team consisting of the village clinic’s primary care doctor, a village resident called an “Aging Worker” to help reinforce treatment and address social factors affecting health, and telephone-based consultation with a psychiatrist. Over 12 months of participation, the 1,232 participants who received the COACH intervention had a significantly greater improvement in both depressive symptoms and the rate of HTN control than the 1,133 participants who received usual care. Integrated care management appears effective for management of comorbid depression and HTN in Chinese older adults in underresourced primary care settings that have limited access to mental healthcare. The unique benefits to depression treatment and hypertension control of antidepressant prescription and Aging Worker support, and the addition of easily administered psychotherapy to the model, require further study. Wide dissemination of the model in areas with few mental health resources will likely require use of telehealth technologies to enable better access to care.
登录
查看更多内容
影响因子：
5.6
作者：
Fugger, Gernot;Dold, Markus;Kasper, Siegfried
通讯作者：
Kasper, Siegfried
影响因子：
9.7
作者：
Arora, Sanjeev;Kalishman, Summers;Yutzy, Sean
通讯作者：
Yutzy, Sean
影响因子：
64.3
作者：
Chen, Shulin;Conwell, Yeates;Wu, Jiayan
通讯作者：
Wu, Jiayan
影响因子：
4.1
作者：
Chen S;Conwell Y;Xue J;Li LW;Tang W;Bogner HR;Dong H
通讯作者：
Dong H
影响因子：
64.8
作者：
Collins, Pamela Y.;Patel, Vikram;Joestl, Sarah S.;March, Dana;Insel, Thomas R.;Daar, Abdallah S.
通讯作者：
Daar, Abdallah S.