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

描述(申请人提供)：与非抑郁的急性冠脉综合征患者相比，患有急性冠脉综合征的患者复发的风险和死亡率高2倍，生活质量更差，护理费用更高。这些观察结果的力量促使美国心脏协会(AHA)建议对ACS患者进行常规的抑郁症筛查，并根据指示进行抑郁症诊断和治疗的转介。不幸的是，没有随机对照试验(RCT)来告知这一大规模、可能昂贵的筛查建议。而且，在缺乏随机对照试验证据的情况下的筛查指南/建议最近受到了广泛的批评(并被撤回)。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两难境地。迫切需要一项随机对照试验，为这些不同的成分提供关于AHA抑郁症筛查和治疗算法的成本和好处的证据。必须填补知识中的两个关键空白，以确定AHA对急性冠脉综合征后患者进行抑郁症筛查是否会改善公共健康：1)该战略是否改善了最近急性冠脉综合征患者的质量调整后的生命年？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的和典型的医疗服务报销金额之内？我们的具体目标是确定遵循AHA关于抑郁症筛查的建议，并在发现抑郁症的情况下转诊为ACS后患者进行进一步诊断和治疗的质量调整生命年收益和医疗成本。为了实现这一目标，我们将把来自三个不同地理位置的不同健康维护组织的患者随机分为三组：1)接受AHA抑郁症筛查并在发现抑郁症时进行治疗(干预组)或：2)不接受抑郁症筛查(强对照组)或：3)接受筛查并通知初级保健提供者(最低限度增强对照组)。将从所有患者那里获得与健康相关的生活质量、抑郁症状和成本，以便可以比较这三种不同抑郁筛查策略的好处和成本。

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 And, screening guidelines/advisories in the absence of RCT evidence have recently been extensively criticized (and withdrawn).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.