New strategies to improve both effectiveness and access to care.
New strategies to improve both effectiveness and access to care.
复制标题
提高有效性和获得护理的机会的新策略。
DOI：
10.1016/s2215-0366(16)30039-6
复制
发表时间：
2016
期刊：
影响因子：
--
通讯作者：
Bruce,MarthaL
中科院分区：
文献类型：
--
作者：
Bruce,MarthaL
在《柳叶刀精神病学》上，克里斯·索尔兹伯里和他的同事们介绍了他们在一项大型、务实的试验中的发现，该试验测试了将多组分远程健康干预整合到治疗和管理抑郁症的一般实践中的有效性。1抑郁症被选为慢性病的典范：这是一种间歇性疾病，虽然对积极的治疗(药物或心理治疗)有反应，但往往需要时间来建立最有效的治疗方案，持续管理以最大限度地提高缓解的可能性，并进行长期维持治疗以最大限度地减少复发。2尽管有这种复杂性，大多数抑郁症是由全科医生(GP)治疗的，他们通常开抗抑郁药，但可能没有时间、劳动力或资源来提供最佳的持续治疗和管理。3因此，尽管抑郁症的治疗和管理有大量的证据基础，但许多抑郁症患者得不到有效的护理。4、5研究结果表明，技术有望改善慢性病管理的覆盖范围和有效性，同时潜在地减轻全科医生的负担。这种干预的独特之处在于，将抑郁症治疗的几种循证远程保健策略(例如，在线认知行为疗法)和管理(例如，基于电话的动机访谈)结合在一起，并将干预措施整合到常规的一般实践中。该计划是为每个参与者的需求和偏好量身定做的。因此，远程医疗为更多的患者提供了比以前更多的选择。对从43个全科诊所招募的参与者实施这一复杂的干预措施是一项了不起的成就。事实上，在单一环境下将简单的干预措施落实到常规做法中也是具有挑战性的。由于需要一种研究方法来证明有效性，这一挑战变得更加复杂。研究人员使用这些实践的共享电子病历(EMR)来识别潜在的合格患者并随机抽样，从而增加了研究的潜在普适性。这项研究招募并随机分配了609名报告临床显著症状并符合诊断标准的参与者，其中85%的参与者在一年内被保留。结果显示，与接受常规护理的患者相比，随机分配到远程健康干预组的患者抑郁严重程度的改善更快。4个月后，接受远程健康干预的255名参与者中有68名(27%)对治疗有反应，而在常规护理组的270名参与者中，有50名(19%)有反应(调整后的优势比1·7，95%可信区间1·1-2·5，p=0.019)。这些参与者是谁有关系吗？研究小组最初联系了16570名符合EMR资格标准并得到他们的全科医生批准的患者。然而，只有2375名患者(14%)表示有兴趣参与。大多数疗效试验，特别是药物治疗研究，都着眼于结果，期望结果将广泛推广。然而，招募方法(例如，广告或临床医生推荐)几乎肯定会产生与总体不同的样本。6.
In The Lancet Psychiatry, Chris Salisbury and colleagues present their findings from a large, pragmatic trial testing the effectiveness of integrating a multicomponent telehealth intervention into general practice for the treatment and management of depression. 1 Depression was chosen as an exemplar of chronic disease: an episodic disorder that, although responsive to active treatments (medication or psychotherapy), often requires time to establish the most effective regimen, ongoing management to maximise the likelihood of remission, and long-term maintenance treatment to minimise recurrence. 2 Despite this complexity, most depression is treated by general practitioners (GPs) who commonly prescribe antidepressants, but might not have the time, workforce, or resources to provide optimum ongoing treatment and management. 3 Thus, despite a large evidence base for depression treatment and management, many individuals with depression lack access to effective care. 4, 5 The study findings show the promise of technology to improve the reach and effectiveness of chronic disease management while potentially reducing the burden on GPs. The intervention is unique by both combining several evidence-based telehealth strategies for depression treatment (eg, online cognitive behavioural therapy) and management (eg, telephone-based motivational interviewing) into a single package and by integrating the intervention into routine general practice. The programme is tailored to each participant’s needs and preferences. Thus telehealth offers more patients more access to more options than have previously been available. Implementation of this complex intervention for participants recruited from 43 general practices is a remarkable accomplishment. Indeed, implementation of even simple interventions into routine practice in a single setting is challenging. This challenge is compounded by the need for a research methodology to demonstrate effectiveness. The investigators used the practices’ shared electronic medical records (EMRs) to identify potentially eligible patients and draw a random sample, thereby increasing the study’s potential generalisability. The study recruited and randomly assigned an impressively large sample of609 participants who reported clinically significant symptoms and met diagnostic criteria and 85% of participants were retained during 1 year. The results showed that patients randomly assigned to the telehealth intervention had more rapid improvement in depression severity than did patients receiving usual care. After 4 months, 68 (27%) of 255 participants who received the telehealth intervention responded to treatment, compared with 50 (19%) of 270 participants in the usual care group (adjusted odds ratio 1· 7, 95% CI 1· 1–2· 5, p= 0· 019).Does it matter who these participants were? The research team initially contacted 16 570 patients who met the EMR eligibility criteria and were approved by their GP. However, only 2375 patients (14%) expressed interest in participating. Most efficacy trials, especially medication treatment studies, focus on outcomes with an expectation that the results will be broadly generalisable. However, the recruitment methodology (eg, advertisements or clinician referral) is almost guaranteed to accrue a sample that differs from the population at large. 6