IMPROVING QUALITY OF PRIMARY CARE FOR ANXIETY DISORDERS

惊恐和广泛性焦虑障碍（PD/GAD）在初级保健实践中普遍存在;导致显著的发病率;未得到充分的认识和治疗;并与过度的卫生服务利用有关。 鉴于PD/GAD的有效治疗方法的可用性，本有效性研究假设，使患者能够参与其护理，同时通过电子病历（EMR）向其初级保健医生（PCP）传播基于指南的治疗，将产生优于仅通知医生和患者诊断所实现上级临床结局。我们的患者干预将基于公共领域和商业可用的信息/自我管理材料，这些材料经过修改以供当地使用。 PCP将根据美国精神病学协会的焦虑指南和通过EMR向他们提供的其他循证治疗算法获得治疗建议。 两个研究中心的约20名委员会认证的PCP将被随机分配到我们的干预组或对照组（常规护理）。 研究助理使用经验证的快速筛查和访谈程序，将在18个月内确定247例接受初级保健的PD/GAD患者。 所有研究患者和PCP将收到研究者的焦虑诊断通知。之后，根据PCP分配：（1）患者可能会收到有关焦虑症的额外信息，并通过电话接受训练有素的主持人进行的结构化焦虑自我管理计划;（2）PCP可能会在临床就诊时通过EMR获得指南建议。 对PCP随机化状态设盲的研究助理将在0、2、4、8和12个月时对每例研究患者进行标准化电话评估。主要结局标准，即4个月时受试者的焦虑水平降低50%，将使用汉密尔顿焦虑评定量表进行评估。 次要结局标准，如功能状态和卫生服务利用，将在12个月时使用平行分析进行评估。这项研究将提高我们对实施基于指南的护理的新方法的理解，以及可以预期的益处的大小。 研究结果可以：识别有助于适当和有效护理的过程因素;刺激其他患者自我管理策略的发展;区分最有可能对协作管理方法治疗慢性精神障碍做出反应的患者亚组。

Panic and generalized anxiety disorders (PD/GAD) are prevalent in primary care practice; responsible for significant morbidity; inadequately recognized and treated; and associated with excessive health services utilization. Given the availability of efficacious treatments for PD/GAD, this effectiveness study hypothesizes that enabling patients to participate in their care while simultaneously disseminating guideline-based treatments to their primary care physicians (PCP) via electronic medical record (EMR) will produce superior clinical outcomes to those achieved by simply notifying the physician and patient of the diagnosis alone. Our patient intervention will be based on public-domain and commercially available information/self-management materials modified for local use. PCPs will receive treatment advice based on the American Psychiatric Association's anxiety guideline and other evidence-based treatment algorithms presented to them via EMR. Approximately 20 board-certified PCPs at two study sites will be randomized to either our intervention or control ( usual care ) group. Research assistants using a validated rapid screening and interview procedure will identify 247 patients experiencing PD/GAD upon presentation for primary care over an 18-month period. All study patients and PCPs will receive notification of the anxiety diagnosis from the investigators. Afterwards, according to PCP assignment: (1) patients may receive additional information on anxiety disorders and a structured anxiety self-management program administered over the telephone by a trained facilitator; and (2) PCPs may be exposed to guideline advice presented via EMR at the time of the clinical encounter. A research assistant blinded to the PCPs randomization status will conduct standardized telephone assessments with each study patient at 0, 2, 4, 8, and 12 months. The primary outcome criterion, a 50 percent reduction in subjects' levels of anxiety symptomatology at 4 months, will be assessed using the Hamilton Rating Scale for Anxiety. Secondary outcome criteria, such as functional status and health services utilization, will be assessed using parallel analyses at 12 months. This study will enhance our understanding of new methods to implement guideline-based care and the magnitude of benefits that can be expected. Study findings can: identify process factors that contribute to appropriate and effective care; stimulate the development of other patient self-management strategies; and distinguish patient subgroups most likely to respond to a collaborative-management approach for treatment of a debilitating chronic mental disorder.