CALM: Improving Primary Care Outcomes

描述（由申请人提供）：虽然现在已经确定，协作的慢性疾病管理方法在临床上和成本效益上都适用于治疗初级保健中的抑郁症，但我们对这种模型如何治疗焦虑症知之甚少，焦虑症在初级保健中比抑郁症更常见，并且特别难以管理。为了解决这一差距，我们提出了第一个大规模的有效性研究，以测试一个合作的护理方法来治疗初级保健焦虑。这项工作直接建立在我们的合作护理恐慌研究，临床医生，患者和诊所管理人员的关键线人访谈，以及最近在初级保健抑郁症的研究。基于这些考虑，我们开发了一种单一的、专门设计的干预措施，称为CALM（协调焦虑学习和管理），可以为初级保健中流行的四种焦虑症中的任何一种患者提供循证治疗（恐慌症[PD]、广泛性焦虑症[GAD]、社交焦虑症[SAD]和创伤后应激障碍[PTSD]），包括那些患有共病抑郁症和/或中度药物滥用的患者。这种干预允许患者选择治疗（CBT和/或药物治疗），使用技术来最大限度地提高患者的参与度，并包括阶梯式护理算法-在大规模初级保健抑郁症研究中成功采用的方法。我们还纳入了一个种族多样化的研究人群，以及讲西班牙语的患者，并提出定性研究，以更好地了解如何CALM应量身定制的个人诊所，并检查CALM的可接受性为弱势患者。这些定性研究将为今后推广这一方法提供所需的宝贵资料。主要目标是：（1）使用实验、定量的方法来确定CALM与常规治疗（CALM）相比对上述四种焦虑症的临床有效性（作为一个群体和个人），并比较CALM和TAU的中间结果，如护理质量，自我效能和社会耻辱;（2）使用定性方法评估CALM在参与诊所、提供者和患者中的可接受性和可持续性障碍。次要目标是：（1）使用准实验方法（例如工具变量）检查适当治疗对功能和其他临床结果的影响，独立于干预分配;（2）估计CALM的医疗保健成本和成本效益。

DESCRIPTION (provided by applicant): Although it is now well established that collaborative, chronic disease management approaches are clinically and cost effective for treating depression in primary care, we know very little about how such models perform for anxiety disorders, which occur more commonly than depression in primary care and are particularly difficult to manage. To address this gap, we propose the first large-scale effectiveness study to test a collaborative care approach to treating primary care anxiety. This work builds directly on our Collaborative Care for Panic study, key informant interviews of clinicians, patients and clinic administrators, and more recent studies in primary care depression. Based on these considerations, we have developed a single, specially designed intervention called CALM (Coordinated Anxiety Learning and Management), that can deliver evidence-based treatment to patients with any of four anxiety disorders prevalent in primary care (Panic Disorder [PD], Generalized Anxiety Disorder [GAD], Social Anxiety Disorder [SAD], and Posttraumatic Stress Disorder [PTSD]), including those patients with comorbid depression and/or moderate substance abuse. This intervention allows patients treatment choice (CBT and/or medication), uses techniques to maximize patient engagement, and includes stepped care algorithms - approaches successfully employed in large-scale studies of primary care depression. We have also included an ethnically diverse study population, as well as Spanish-speaking patients, and propose qualitative studies to better understand how CALM should be tailored to individual clinics and to examine the acceptability of CALM for disadvantaged patients. These qualitative studies will provide valuable information needed for future dissemination of this approach. The primary aims are: (1) to use experimental, quantitative methods to determine the clinical effectiveness of CALM compared to treatment as usual (TAD) for the above four anxiety disorders (as a group and individually) and to compare CALM and TAU in terms of intermediate outcomes such as quality of care, self-efficacy, and social stigma; and (2) to use qualitative methods to assess acceptability and barriers to sustainability of CALM in participating clinics, providers, and patients. The secondary aims are: (1) to use quasi-experimental methods (e.g. instrumental variables) to examine the effects of appropriate treatment, independent of intervention assignment, on functioning and other clinical outcomes; and (2) to estimate health care costs and cost effectiveness of CALM.