TRANSFORM DEPCARE: A Theoretical approach to improving patient engagement and shared decision making for minorities in collaborative depression care

TRANSFORM DEPCARE：一种在协作抑郁症护理中提高少数群体患者参与度和共同决策的理论方法

• 批准号: 9569610
• 负责人: Nathalie Moise
• 金额: $ 34.37万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-09-30 至 2022-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9569610
• 关键词: TRANSFORM; DEPCARE; Theoretical; approach; improving

The goal of this proposal is to test whether an electronic shared decision making (eSDM) tool can increase the uptake of collaborative care (CC) for depression in primary care. Depression is projected to be the second largest contributor to chronic disease burden in the world by 2030, and contributes to disparities in quality of life and mortality. CC integrates primary and behavioral health through depression care managers who provide antidepressant adherence counseling and/or psychotherapy. CC doubles the rate of depression remission in comparison to primary care provider-led depression treatment alone, particularly in racial and ethnic minorities, and results in a 24% reduction in mortality and nearly $1300 in net annual savings per patient. Despite this model's potential to improve access to mental health, implementation efforts reveal low provider CC referral rates and low patient engagement rates of 9-50%, particularly in minority patients. To identify factors contributing to poor patient engagement in CC, we conducted focus groups in 8 healthcare systems implementing CC, representing 33 clinics and 1 million predominantly Medicaid, minority patients. We learned that key physician-level barriers included limited time/resources to discuss treatment options and conduct “warm handoffs” to care managers; patient-level barriers included poor knowledge of treatment options, miscommunication, stigma, language barriers, and low motivation. We applied a theory- informed process of engaging stakeholders to select an acceptable, feasible intervention and determined that SDM would target the greatest number of barriers to CC engagement. SDM involves a collaborative process whereby providers and patients make health decision together, and is a proven approach for improving depression treatment initiation and guideline concordant care, particularly in minorities, but widespread use has been limited by time and resources. Accordingly, we developed and alpha tested an iPad delivered, video-assisted, interactive eSDM tool that would reduce barriers to SDM uptake and target CC engagement. We hypothesize that a state-of-the-art eSDM tool that automates the SDM process, activates providers, staff, and patients and interfaces with the electronic health record will improve efficient CC enrollment (primary outcome). We propose to refine and adapt the eSDM prototype (Aim 1) and conduct a stepped wedge trial across 4 primary care medical homes to assess the effectiveness of implementing our eSDM tool on provider behavior (Aim 2), patient enrollment in CC (Aim 3), patient adherence to depression treatment (therapy or antidepressants) and depressive symptoms (Exploratory Aims) amongst 1440 primary care patients in our healthcare system. Our study has the potential to produce a theory-informed, scalable eSDM tool that improves the reach of CC programs and potentially other team-based approaches.

本提案的目标是测试电子共享决策（eSDM）工具是否可以 在初级保健中增加对抑郁症的协作护理（CC）的使用。抑郁症预计将成为 到2030年，全球慢性病负担的第二大贡献者，并导致 生活质量和死亡率。CC通过抑郁症护理经理整合初级和行为健康 他们提供抗抑郁药物依从性咨询和/或心理治疗。CC使抑郁症发病率加倍 与单独由初级保健提供者主导的抑郁症治疗相比，病情得到缓解，特别是在种族和 少数民族，并导致死亡率降低24%，每年净节省近1300美元， 病人尽管这一模式有可能改善获得心理健康的机会，但实施工作显示， 提供者CC转诊率和低患者参与率为9- 50%，特别是少数民族患者。 为了确定导致患者参与CC的因素，我们在8个国家进行了焦点小组讨论。 实施CC的医疗保健系统，代表33家诊所和100万主要是医疗补助，少数 患者我们了解到，医生层面的关键障碍包括讨论治疗的时间/资源有限 选择和进行“温暖的关怀”，以照顾管理人员;病人层面的障碍，包括知识贫乏， 治疗选择，沟通不畅，耻辱，语言障碍和低动力。我们应用了一个理论- 使利益攸关方参与选择可接受的可行干预措施的知情过程，并确定 “可持续发展机制”将针对气候变化参与的最大障碍。SDM涉及一个协作过程 提供者和患者共同做出健康决定，这是一种行之有效的方法， 抑郁症治疗启动和指南一致的护理，特别是在少数民族，但广泛使用 受到时间和资源的限制因此，我们开发并测试了一款已交付的iPad， 视频辅助的、互动的eSDM工具，将减少SDM采用的障碍和有针对性的CC参与。 我们假设，一个最先进的eSDM工具，自动化的SDM过程，激活 提供者、工作人员和患者以及与电子健康记录的接口将提高CC的效率 入组（主要结局）。我们建议改进和调整eSDM原型（目标1），并进行 在4个初级保健医疗院进行的阶梯式楔形试验，以评估实施我们的 关于提供者行为（目标2）、CC患者入组（目标3）、患者对抑郁症的依从性的eSDM工具 治疗（治疗或抗抑郁药）和抑郁症状（探索性目的） 在我们的医疗系统中照顾病人。我们的研究有可能产生一个理论上知情的，可扩展的 eSDM工具，可提高CC计划和其他潜在的基于团队的方法的覆盖范围。