Blended Collaborative Care for Heart Failure and Co-Morbid Depression

描述（由申请人提供）：心力衰竭（HF）是影响约660万美国人的重要公共卫生问题。尽管心脏护理有所改善，但它仍然是医疗保险患者住院治疗的主要原因，也是过去十年中死亡率基本保持不变的唯一主要心血管疾病。未能改善心衰结局的部分原因可能是心衰患者普遍存在的未被认识和/或治疗不充分的抑郁症。然而，虽然新的心衰治疗指南提倡对抑郁症进行常规筛查，但如果没有试验证据表明抑郁症护理可以改善结果和提供有效方法，这一建议不太可能被广泛采用。“协同护理”策略越来越多地用于改善心衰和其他慢性疾病的护理，我们最近证明了它在治疗冠状动脉搭桥手术后抑郁症方面的临床和成本效益。然而，卫生保健系统支持心衰和抑郁症的单独治疗方案可能不切实际。因此，新出现的证据表明，针对精神和身体状况的“混合”协作护理策略在情绪症状和心血管风险因素的控制方面比仅关注抑郁症的计划产生更大的改善，我们受到鼓舞，提出了一种可以在常规护理中提供的新适应性测试。本项目的具体目的是：(1)评估有效性

DESCRIPTION (provided by applicant): Heart failure (HF) is an important public health problem that affects approximately 6.6 million Americans. Despite improvements in cardiac care, it remains the leading cause for hospitalization among Medicare patients and the only major cardiovascular disease whose mortality rate has remained essentially unchanged over the past decade. This failure to improve HF outcomes may be due, in part, to unrecognized and/or inadequately treated depression that is highly prevalent in HF patients. Yet while new HF treatment guidelines advocate routine screening for depression, this recommendation is unlikely to be widely adopted without trial evidence that depression care improves outcomes and efficient methods to provide it. "Collaborative care" strategies are being increasingly utilized t improve care for HF and other chronic medical conditions, and we recently demonstrated its clinical and cost-effectiveness at treating depression following coronary artery bypass graft surgery. Yet it may be impractical for health care delivery systems to support separate treatment programs for HF and depression. Thus we are encouraged by emerging evidence indicating "blended" collaborative care strategies that target both psychiatric and physical conditions produce greater improvements in mood symptoms and control of cardiovascular risk factors than programs focused solely on depression to propose testing a novel adaptation that could be provided in routine care. The Specific Aims of this Project are to: (1) evaluate the effectiveness of a telephone-delivered "blended" collaborative care intervention for treating HF and depression that could be adopted into routine clinical practice if proven effective; and (2) advance our understanding of the moderators and mediators of depression treatment on clinical outcomes. We will screen hospitalized patients with systolic HF for depression, and then randomize 625 who screen positive and have at least a moderately elevated level of depressive symptoms at two-weeks following hospital discharge to either: (1) collaborative care for treating both HF and depression ("blended"); (2) collaborative care for treating HF alone (enhanced usual care (eUC)); or (3) their doctors' "usual care" (UC). Additionally, we will enroll 125 non-depressed HF patients to better evaluate the benefits derived from treating depression (total N=750). Our co-primary hypotheses will test whether "blended" collaborative care can produce at 12-months follow-up a: (A) 0.50 effect size (ES) or greater improvement in health-related quality of life (HRQoL) vs. UC; and (B) 0.30 ES or greater improvement in HRQoL vs. eUC. Secondary hypotheses will evaluate the effects of our "blended" intervention on mood, functional status, adherence with guideline-consistent care, incidence of cardiovascular events, health care utilization, and costs. Improving chronic illness care for medically complex patients is one of the major challenges facing medicine today. We propose to test the effectiveness of an innovative, efficient, scalable, and sustainable intervention that could transform the way HF and other cardiovascular disorders are treated in routine practice.