Blended Collaborative Care for Heart Failure and Co-Morbid Depression

描述（由申请人提供）：心力衰竭（HF）是一个重要的公共卫生问题，影响约660万美国人。尽管心脏护理有所改善，但它仍然是医疗保险患者住院的主要原因，也是过去十年中死亡率基本保持不变的唯一主要心血管疾病。这种未能改善HF结局的部分原因可能是HF患者中高度流行的未被识别和/或治疗不充分的抑郁症。然而，尽管新的HF治疗指南提倡对抑郁症进行常规筛查，但如果没有试验证据表明抑郁症护理可以改善预后并提供有效的方法，这一建议不太可能被广泛采用。“协作护理”策略正越来越多地用于改善HF和其他慢性疾病的护理，我们最近证明了它在治疗冠状动脉旁路移植术后抑郁症的临床和成本效益。然而，医疗保健提供系统支持HF和抑郁症的单独治疗方案可能是不切实际的。因此，我们感到鼓舞的是，新出现的证据表明，“混合”的合作护理策略，目标是精神和身体状况产生更大的改善情绪症状和心血管危险因素的控制，而不是计划只专注于抑郁症，提出测试一种新的适应，可以提供常规护理。 本项目的具体目标是：（1）评估有效性 电话传递的“混合”协作护理干预治疗心力衰竭和抑郁症，可以采用到常规的临床实践，如果证明有效;（2）推进我们的抑郁症治疗的临床结果的调节剂和介质的理解。我们将筛选患有收缩期心力衰竭的住院患者的抑郁症，然后将625名筛选阳性且在出院后两周内抑郁症状水平至少中度升高的患者随机分配至：（1）治疗心力衰竭和抑郁症的协作护理（“混合”）;（2）单独治疗HF的协作护理（增强型常规护理（eUC））;或（3）他们的医生的“常规护理”（UC）。此外，我们将入组125例非抑郁性HF患者，以更好地评价治疗抑郁症的获益（总N=750）。我们的共同主要假设将检验“混合”协作护理是否能在12个月随访时产生a：（A）与UC相比，健康相关生活质量（HRQoL）改善0.50效应量（ES）或更大;（B）与eUC相比，HRQoL改善0.30 ES或更大。次要假设将评估我们的“混合”干预对情绪，功能状态，坚持指南一致的护理，心血管事件的发生率，医疗保健利用和成本的影响。 改善医学复杂患者的慢性病护理是当今医学面临的主要挑战之一。我们建议测试一种创新、高效、可扩展和可持续的干预措施的有效性，这种干预措施可以改变HF和其他心血管疾病在常规实践中的治疗方式。

DESCRIPTION (provided by applicant): Heart failure (HF) is an important public health problem that affects approximately 6.6 million Americans. Despite improvements in cardiac care, it remains the leading cause for hospitalization among Medicare patients and the only major cardiovascular disease whose mortality rate has remained essentially unchanged over the past decade. This failure to improve HF outcomes may be due, in part, to unrecognized and/or inadequately treated depression that is highly prevalent in HF patients. Yet while new HF treatment guidelines advocate routine screening for depression, this recommendation is unlikely to be widely adopted without trial evidence that depression care improves outcomes and efficient methods to provide it. "Collaborative care" strategies are being increasingly utilized t improve care for HF and other chronic medical conditions, and we recently demonstrated its clinical and cost-effectiveness at treating depression following coronary artery bypass graft surgery. Yet it may be impractical for health care delivery systems to support separate treatment programs for HF and depression. Thus we are encouraged by emerging evidence indicating "blended" collaborative care strategies that target both psychiatric and physical conditions produce greater improvements in mood symptoms and control of cardiovascular risk factors than programs focused solely on depression to propose testing a novel adaptation that could be provided in routine care. The Specific Aims of this Project are to: (1) evaluate the effectiveness of a telephone-delivered "blended" collaborative care intervention for treating HF and depression that could be adopted into routine clinical practice if proven effective; and (2) advance our understanding of the moderators and mediators of depression treatment on clinical outcomes. We will screen hospitalized patients with systolic HF for depression, and then randomize 625 who screen positive and have at least a moderately elevated level of depressive symptoms at two-weeks following hospital discharge to either: (1) collaborative care for treating both HF and depression ("blended"); (2) collaborative care for treating HF alone (enhanced usual care (eUC)); or (3) their doctors' "usual care" (UC). Additionally, we will enroll 125 non-depressed HF patients to better evaluate the benefits derived from treating depression (total N=750). Our co-primary hypotheses will test whether "blended" collaborative care can produce at 12-months follow-up a: (A) 0.50 effect size (ES) or greater improvement in health-related quality of life (HRQoL) vs. UC; and (B) 0.30 ES or greater improvement in HRQoL vs. eUC. Secondary hypotheses will evaluate the effects of our "blended" intervention on mood, functional status, adherence with guideline-consistent care, incidence of cardiovascular events, health care utilization, and costs. Improving chronic illness care for medically complex patients is one of the major challenges facing medicine today. We propose to test the effectiveness of an innovative, efficient, scalable, and sustainable intervention that could transform the way HF and other cardiovascular disorders are treated in routine practice.