A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care
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DOI：
10.1370/afm.1842
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发表时间：
2015-09-01
影响因子：
4.4
通讯作者：
Glasgow, Russell E.
中科院分区：
文献类型：
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作者：
Solberg, Leif I.;Crain, A. Lauren;Glasgow, Russell E.
扩大和传播循证实践是卫生保健面临的最重要挑战之一。我们测试了一项全州范围内的倡议，“明尼苏达州抑郁症改善-提供新方向”（DIAMOND），在75个初级保健诊所实施抑郁症合作护理模式，是否导致患者预后改善，与随机对照试验报告的结果相对应。方法：健康计划在6个月的强化培训项目后，向参与的诊所提供新的每月付款，并持续提交数据、建立网络和咨询。实施是错开的，每6个月有5个顺序，10到40个诊所。支付方每周向参与处方抗抑郁药的诊所的成员提供联系信息，我们对1578名患者进行了基线和6个月的调查，了解他们的治疗和结果。结果DIAMOND诊所实施前（UCB）接受常规护理的患者466例，实施后（UCA）接受常规护理的患者559例，实施后（DCA）接受DIAMOND护理的患者245例，比较诊所（UC）接受常规护理的患者308例。实施后接受DIAMOND护理的患者比3个对照组报告了更多的抑郁症合作护理服务（10.9 vs 6.4-6.7，在0到14的范围内，数字越高表明服务越多；P < .001）和对护理的满意度（4.0 vs 3.4，在1到5的范围内，得分越高表明满意度越高；P = .001）。4组患者抑郁缓解率差异无统计学意义（DCA组36.4% vs UCB组35.8%，UCA组35.0%，UC组33.9%;P = 0.94）。结论：尽管有支援性支付改变的激励，强化培训和支持诊所自愿参与，但没有记录抑郁结局的差异。在试验中出现但在这些诊所中没有出现的特定的未测量的行动可能对成功的结果改善至关重要。
PURPOSE Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials.METHODS Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes.RESULTS There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P < .001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P = .001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94).CONCLUSIONS Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement.