Depression Screening RCT in ACS patients: Quality of Life and Cost Outcomes

描述（由申请人提供）：急性冠脉综合征（ACS）合并抑郁的患者发生ACS复发和死亡的风险比非抑郁ACS患者高2倍，生活质量更差，护理费用更高。这些观察性发现的强度促使美国心脏协会（AHA）建议对ACS患者进行常规抑郁症筛查，并根据指示进行抑郁症诊断和治疗。不幸的是，目前还没有随机对照试验（RCT）来支持这种大规模的、潜在昂贵的筛查建议。而且，在缺乏随机对照试验证据的情况下，筛查指南/建议最近受到了广泛的批评（和撤回）。这给临床医生、卫生保健系统和卫生保健政策领导人带来了严重的困境。迫切需要一项随机对照试验来为这些不同成分提供证据，了解美国心脏协会抑郁症筛查和治疗算法的成本和收益。为了确定美国心脏协会对急性冠脉综合征后患者的抑郁筛查策略是否会改善公众健康，必须填补两个关键的知识空白：1)该策略是否能改善近期急性冠脉综合征患者的质量调整生命年？2)提供抑郁症筛查和任何类型的抑郁症治疗的费用是否在可接受和典型的医疗保健服务报销范围内？我们的具体目的是确定遵循美国心脏协会的建议进行抑郁症筛查，然后转诊进一步诊断和治疗acs后患者（如果发现抑郁症）的质量调整生命年收益和医疗保健费用。为了实现这一目标，我们将来自三个不同的、地理位置不同的健康维护组织的患者随机分为三个不同的组：1)接受美国心脏协会抑郁症筛查并在发现抑郁症时进行治疗（干预组）；2)不接受抑郁症筛查（强对照组）；3)接受筛查并通知初级保健提供者（最低限度增强对照组）。将获得所有患者的健康相关生活质量、抑郁症状和成本，以便比较这三种不同的抑郁症筛查策略的收益和成本。

DESCRIPTION (provided by applicant): Patients with an acute coronary syndrome (ACS) and comorbid depression have a 2-fold higher risk for recurrent ACS and mortality, worse quality of life, and higher costs of care than nondepressed ACS patients. The strength of these observational findings prompted the American Heart Association (AHA) to advise that routine depression screening for ACS patients and referral for depression diagnosis and treatment as indicated occur. Unfortunately, there are no randomized controlled trials (RCT) to inform this large, potentially expensive screening recommendation. And, screening guidelines/advisories in the absence of RCT evidence have recently been extensively criticized (and withdrawn). This poses a serious dilemma for clinicians, health care systems, and for health care policy leaders. A RCT is urgently needed to provide evidence for these different constituents about the costs and benefits of the AHA depression screen and treat algorithm. Two critical gaps in knowledge must be filled to determine if public health would be improved by the AHA strategy for depression screening in post-ACS patients: 1) Does this strategy improve quality-adjusted life years for patients with a recent ACS? 2) Is the cost of providing depression screening and any type of depression treatment within the acceptable and typical amounts reimbursed for health care services? Our specific aim is to determine the quality-adjusted life year benefits and health care costs of following the AHA's advisory for depression screening and then referral for further diagnosis and treatment in post-ACS patients, if depression is found. To accomplish this aim, we will randomize patients from three different, geographically diverse health maintenance organizations to three different groups: 1) to the AHA depression screen and treat if depression is found algorithm (intervention group) or: 2) to receive no depression screening (strong control group) or: 3) to be screened and a primary care provider notified (minimally enhanced control group). Health-related quality of life, depressive symptoms, and costs will be obtained from all patients, so that the benefits and the costs of these three different depression screening strategies can be compared.