Improving PTSD Management in Primary Care

改善初级保健中的创伤后应激障碍 (PTSD) 管理

• 批准号: 8072027
• 负责人: Lisa Seidel Meredith
• 金额: $ 62.49万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-08-20 至 2014-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8072027
• 关键词: Address; Adoption; Anxiety; Caring; Case Manager; Clinical; Collaborations; Communities; Community Health Centers; Community Services; Complement; Continuity of Patient Care; Data; Data Analyses; Data Sources; Development; Direct Costs; Disease; Disease Management; Education; Effectiveness; Exposure to; Feedback; General Population; Goals; Guidelines; Health; Health Services; Health behavior; Healthcare; Immigrant; Intervention; Interview; Knowledge; Learning; Literature; Mediating; Mental Depression; Mental Health; Mental Health Services; Mental disorders; Methods; Modeling; National Institute of Mental Health; Outcome; Patient Education; Patients; Population; Population Intervention; Post-Traumatic Stress Disorders; Prevalence; Preventive; Primary Health Care; Process; Public Health; Randomized; Reporting; Research; Research Methodology; Research Project Grants; Resources; Safety; Screening procedure; Services; Specialist; Stigmata; Structure; Symptoms; System; Testing; Time; Trauma; Underrepresented Minority; Underserved Population; Violence; Wages; Work; Writing; base; community based participatory research; experience; health related quality of life; improved; interest; patient registry; practice-based research network; prevent; primary care setting; primary outcome; programs; psychologic; public health relevance; randomized trial; resource guides; satisfaction; social stigma; success; theories; treatment as usual

DESCRIPTION (provided by applicant): Post-traumatic stress disorder (PTSD) is common in the general population (9-17% lifetime prevalence; Bruce et al., 2001; Fifer et al., 1994; Gillock et al., 2005; Neria et al., 2006; Stein et al., 2000) and among primary care patients (up to 35%; Gillock et al., 2005). Most people with common mental health disorders do not seek treatment from mental health specialists (Kessler et al., 1994; 1995) but from primary care clinicians (PCCs). Despite the availability of treatments for PTSD, patient, clinician, and system barriers prevent most from receiving adequate care (Lecrubier, 2004; Samson et al, 1999; Stein et al., 2000; Stein 2003; Kessler, 2000; Jaycox et al., 2004). Therefore, approaches are needed to eliminate barriers and increase treatment opportunities for those suffering from PTSD. We address this gap by drawing upon the abundant work on improving primary care for depression (Wells et al., 2000, 2004; Rost et al., 2002; Dietrich et al., 2004; Rubenstein et al., 2006; Meredith et al., 2000, 2006) and from our exploratory/developmental work (R34MH070683) that used a community-based participatory research (CBPR) approach to identify viable strategies for overcoming barriers to providing and receiving care for PTSD. We propose a 5-year follow-on randomized trial to test the impact of a PTSD Care Management (PCM) program for patients seeking primary care from community health centers (CHCs). Our proposal addresses NIMH priorities for "understanding effective means of organizing, implementing, financing, and delivering mental health services in primary care" outlined in PA-07-312 "Mental Health Consequences of Violence and Trauma (R01)". We will randomize 400 patients from six CHCs to either the PCM intervention (N=200) or to a control condition (N=200). The intervention includes components and strategies implemented through a Care Manager (CM): 1) patient education, 2) patient screening and feedback to PCCs, 3) clinician education and use of guidelines, 4) structured feedback between primary care and mental health clinicians, 5) continuity of patient care, and 6) a resource guide detailing available community services. The control condition includes only the clinician education and patient screening without feedback. Specifically, we aim to: 1. Evaluate the effectiveness of the PCM program compared to control in reducing PTSD and other mental health symptoms and improving health-related quality-of-life; and examine the mediating and moderating effects for use of, perceived barriers to, and satisfaction with health care (at 6 and 12 months). 2. Assess the success of the PCM program implementation through descriptive analysis of monthly reports and patient registry data maintained by CMs e.g., level of implementation for each intervention component and percent of patients assessed, treated, and referred over 12 month's time. 3. Examine the direct cost of the PCM program compared to control using exploratory analysis of staffing time, salaries, and resources data obtained from participating CHC staff. PUBLIC HEALTH RELEVANCE: This proposed research project is relevant to public health because its goal is to improve the health of underserved populations seen in community health centers. We propose to implement and evaluate a primary care program that addresses multiple patient-, clinician-, and system- level barriers to services for those who suffer from post-traumatic stress disorder (PTSD), a common disorder in these settings.

说明(申请人提供)：创伤后应激障碍在普通人群中很常见(9-17%的终生患病率；Bruce等人，2001年；Fier等人，1994；Gillock等人，2005年；Neria等人，2006年；Stein等人，2000年)，在初级保健患者中(高达35%；Gillock等人，2005年)。大多数患有常见精神健康障碍的人不寻求精神健康专家的治疗(Kessler等人，1994；1995)，而是向初级保健临床医生(PCCs)寻求治疗。尽管有治疗创伤后应激障碍的方法，但患者、临床医生和系统障碍阻碍了大多数人获得适当的护理(Lecrubier，2004；Samson等人，1999；Stein等人，2000；Stein 2003；Kessler，2000；Jaycox等人，2004)。因此，需要采取措施消除障碍，增加创伤后应激障碍患者的治疗机会。我们通过借鉴关于改善抑郁症初级保健的大量工作(Wells等人，2000,2004；Rost等人，2002；Dietrich等人，2004；Rubenstein等人，2006；Meredith等人，2000,2006)和我们的探索性/发展工作(R34MH070683)来解决这一差距，这些工作使用基于社区的参与性研究(CBPR)方法来确定克服提供和接受创伤后应激障碍护理的障碍的可行策略。我们提出了一项为期5年的跟踪随机试验，以测试创伤后应激障碍护理管理(PCM)计划对寻求社区卫生中心(CHC)初级护理的患者的影响。我们的提案涉及NIMH在PA-07-312“暴力和创伤的精神健康后果(R01)”中概述的“了解在初级保健中组织、实施、资助和提供精神卫生服务的有效手段”的优先事项。我们将400名患者从6个CHC随机分为PCM干预组(N=200)或对照组(N=200)。干预措施包括通过护理经理(CM)实施的组成部分和战略：1)患者教育，2)患者筛查和对PCC的反馈，3)临床医生教育和指南的使用，4)初级保健和精神健康临床医生之间的结构化反馈，5)患者护理的连续性，以及6)详细说明可用社区服务的资源指南。控制条件仅包括临床医生教育和患者筛查，不反馈。具体地说，我们的目标是：1.与对照组相比，评估PCM计划在减少创伤后应激障碍和其他精神健康症状以及提高与健康相关的生活质量方面的有效性；并在6个月和12个月时检查对卫生保健的使用、感知障碍和满意度的中介和调节效果。2.通过对CMS维护的月度报告和患者登记数据的描述性分析，评估PCM计划实施的成功程度，例如，每个干预组成部分的实施水平，以及12个月时间内评估、治疗和转介的患者百分比。3.通过对参与CHC工作人员的人员时间、工资和资源数据的探索性分析，检查PCM计划与对照的直接成本。 公共卫生相关性：这项拟议的研究项目与公共卫生相关，因为它的目标是改善社区卫生中心服务不足人群的健康。我们建议实施和评估初级保健计划，解决患者、临床医生和系统层面的多个障碍，为患有创伤后应激障碍(PTSD)的人提供服务，创伤后应激障碍是这些环境中的一种常见障碍。