Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health A Randomized Clinical Trial
Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health A Randomized Clinical Trial
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DOI：
10.1001/jamanetworkopen.2019.0230
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发表时间：
2019-03-01
影响因子：
13.8
通讯作者：
Weaver, Kendra
中科院分区：
文献类型：
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作者：
Bauer, Mark S.;Miller, Christopher J.;Weaver, Kendra
重要性协作慢性护理模式（CCM）有广泛的随机临床试验证据证明其在严重精神疾病中的有效性，但很少有证据表明其在典型实践条件下的可行性或效果。目的确定在精神卫生团队中建立CCM的实施促进的有效性以及对团队治疗个体的健康结果的影响。这项准实验性的随机阶梯楔形实施试验于2016年2月至2018年2月进行，与美国退伍军人事务部（VA）心理健康和自杀预防办公室合作。从美国所有VA机构中招募了9家机构，以获得CCM实施支持。所有退伍军人（n = 5596）治疗指定的门诊一般心理健康小组住院分析，并随机选择的样本（n = 1050）确定的健康状况访谈。痴呆症患者被排除在外。对这些机构的临床医生（n = 62）进行了调查，并对研究中心流程总结与CCM流程的一致性进行了评级。CCM实施开始时间在3个波中随机分配。2018年6月至9月对该可评价人群进行了数据分析。干预内外促进，将研究资助的外部促进者和机构资助的内部促进者与指定团队合作1年。主要结果和指标假设促进与实施和干预结果的改善相关（混合II型试验）。实施结果包括临床医生团队发展措施（TDM）和CCM一致的团队护理过程的比例。该研究的主要健康结局，心理健康评分（MCS）。住院率来自行政data.Results退伍军人人口（n = 5596）包括881名妇女（15.7%），平均（SD）年龄为52.2（14.5）岁。受访样本（n = 1050）相似，但女性样本过多（n = 210 [20.0%]）。促进与TDM子量表中角色清晰度（53.4%-68.6%; delta = 15.3; 95%CI，4.4 - 26.2; P = 0.01）和团队首要性（50.0%-68.6%; delta = 18.6; 95%CI，8.3 - 28.9; P = 0.001）的改善相关。达到CCM一致性工艺的百分比各不相同，从44%到89%不等。老兵的自我评价没有改善，包括主要结果。在事后分析中，与其他人相比，接受过3次或3次以上心理健康诊断的退伍军人的MCS有所改善（ss = 5.03; 95%CI，2.24 - 7.82; P
IMPORTANCE Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions.OBJECTIVE To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals.DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018.INTERVENTIONS Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year.MAIN OUTCOMES AND MEASURES Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data.RESULTS The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [ 20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; delta = 15.3; 95% CI, 4.4-26.2; P=.01) and team primacy (50.0%-68.6%; delta = 18.6; 95% CI, 8.3-28.9; P=.001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (ss = 5.03; 95% CI, 2.24-7.82; P