IMPROVING QUALITY OF PRIMARY CARE FOR ANXIETY DISORDERS

恐慌和广泛性焦虑症(PD/GAD)在初级保健实践中很普遍，是导致严重发病率的原因，没有得到充分的认识和治疗，并与过度使用卫生服务有关。鉴于PD/GAD的有效治疗方法的可用性，这项有效性研究假设，使患者能够参与他们的护理，同时通过电子病历(EMR)将基于指南的治疗传播给他们的初级保健医生(PCP)，将产生比仅仅通知医生和患者诊断结果更好的临床结果。我们的患者干预将基于公共领域和商业可用的信息/自我管理材料进行修改，以供当地使用。PCP将收到基于美国精神病学协会的焦虑指南和其他通过EMR提供给他们的循证治疗算法的治疗建议。在两个研究地点，大约20名经过董事会认证的PCP将被随机分配到我们的干预组或对照组(通常护理)。使用有效的快速筛查和面谈程序的研究助理将在18个月的时间内识别247名在初级保健期间出现PD/GAD的患者。所有研究患者和初级保健医生将收到调查人员关于焦虑症诊断的通知。之后，根据PCP的分配：(1)患者可能会收到关于焦虑症的额外信息，以及训练有素的辅导员通过电话实施的结构化焦虑自我管理计划；以及(2)PCP可能会在临床会面时通过EMR接受指导建议。对PCP随机状态视而不见的研究助理将在0、2、4、8和12个月对每个研究患者进行标准化电话评估。主要的结果标准是，受试者在4个月后焦虑症状水平下降50%，这将使用汉密尔顿焦虑量表进行评估。次要结果标准，如功能状态和卫生服务利用情况，将在12个月时使用平行分析进行评估。这项研究将加深我们对实施以指南为基础的护理的新方法以及可预期的益处的了解。研究结果可以：确定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；以及区分最有可能对治疗衰弱的慢性精神疾病的协作管理方法做出反应的患者亚群。

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.