Improving care for minorities: Can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial
Improving care for minorities: Can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial
复制标题
DOI：
10.1111/1475-6773.00136
复制
发表时间：
2003-04-01
影响因子：
3.4
通讯作者：
Wells, KB
中科院分区：
文献类型：
--
作者：
Miranda, J;Duan, NH;Wells, KB
目标。与白人患者相比，少数民族患者通常接受的护理质量较差，结果也较差，但尚未发现基于实践的方法来减少这种差异。我们确定实践发起的质量改善（QI）干预措施是否能改善不同种族的抑郁症初级保健患者的护理，并减少结果差异。研究设置。样本包括6个美国管理式医疗机构的46个初级保健实践；181年临床医生;398个拉丁裔，93个。非裔美国人和778名可能患有抑郁症的白人患者。研究设计。匹配的实践被随机分配到常规护理或培训当地专家教育临床医生的两个QI项目之一；护士对患者进行教育、评估和随访；和心理治疗师进行认知行为疗法。病人和医生选择治疗方法。干预措施的特点是为少数民族患者提供适当的住宿（例如，翻译，临床医生的文化培训）。数据提取方法。多水平逻辑回归分析评估了种族群体内部和种族群体之间的干预效果。主要的发现。在基线时，所有种族（拉丁裔、非裔美国人、白人）的适当护理率为低至中等，干预措施显著提高了每个种族6个月时的适当护理（提高了8-20个百分点），不同种族的反应无显著差异。干预措施显著降低了拉丁裔和非裔美国人在第6个月和第12个月报告抑郁的可能性；在两次随访中，白人干预组的抑郁症发生率与对照组并无差异。虽然干预显著提高了白人的就业率，而不是少数族裔的就业率，但比较干预反应对这一结果的准确性很低。值得注意的是，少数族裔仍然不太可能得到适当的治疗，而且比白人患者更容易抑郁。实施质量改善干预措施，为少数族裔患者提供适当的住宿，可以提高白人和服务不足的少数族裔的护理质量，而少数族裔可能特别有可能受益
Objective. Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities.Study Setting. The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93. African Americans, and 778 white patients with probable depressive disorder.Study Design. Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians).Data Extraction Methods. Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups.Principal Findings. At baseline, all ethnic groups (Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients.Conclusions. Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit