协作护理模式可有效改善抑郁症和糖尿病患者的预后 作者： 发布时间：/8/19 16:23:15 印度马德拉斯糖尿病研究基金会Viswanathan Mohan联合格鲁吉亚埃默里大学Mohammed K. Ali团队，研究了协作护理模式对印度抑郁症和糖尿病患者的影响。8月18日出版的《美国医学会杂志》发表了这项成果。
全球范围内的心理健康合并症逐年增加，使糖尿病患者预后恶化，尤其是在医疗服务碎片化的情况下。
为了评价协作护理与常规护理相比是否能降低成人糖尿病和抑郁症患者的抑郁症状并改善心脏代谢指标，研究组在印度4个不同社会经济类型的诊所进行了一项平行、开放标签、实用的随机临床试验，3月9日至5月31日，招募了404名患有2型糖尿病、健康问卷9版至少10分（范围0-27分）、糖化血红蛋白A1c（HbA1c）至少8%、收缩压（SBP）至少140mmHg、或低密度脂蛋白（LDL）胆固醇至少130mg/dL的患者。
研究组将这些参与者随机分组，其中196名接受非医师协调员的12个月自我管理支持，决策支持电子健康记录，方便医生治疗调整和专家病例审查，之后在未干预的情况下再随访12个月（干预组）；208名接受超过24个月的常规护理（对照组）。主要结局为24个月时症状清单抑郁量表（SCL-20）得分至少降低50%，HbA1c至少降低0.5个百分点，SBP至少降低5mmHg，或LDL至少降低10mg/dL。
404例参与者的平均年龄为53岁，男性165例（40.8%），共有378例（93.5%）完成试验。干预组中有71.6%的患者达到主要结局，显著高于对照组（57.4%）。在16个预先指定的次要结局中，12个月时两组间有10个结局改善无统计学差异，24个月时两组间有13个结局改善无统计学差异。
干预组中发生的严重不良事件包括4例（2.0%）心血管事件或住院、2例死亡（1.0%）、8例严重低血糖（4.1%）；对照组则包括7例心血管事件或住院（3.4%）、3例中风（1.4%）、7例死亡（3.4%）。
总之，对于糖尿病和抑郁症患者中，一项为期12个月的协作护理干预与常规护理相比，在24个月时抑郁症状和心脏代谢指标的综合结局得以显著改善。
附：英文原文
Title: Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial
Author: Mohammed K. Ali, Lydia Chwastiak, Subramani Poongothai, Karl M. F. Emmert-Fees, Shivani A. Patel, Ranjit Mohan Anjana, Rajesh Sagar, Radha Shankar, Gumpeny R. Sridhar, Madhu Kosuri, Aravind R. Sosale, Bhavana Sosale, Deepa Rao, Nikhil Tandon, K. M. Venkat Narayan, Viswanathan Mohan
Issue Volume: /08/18
Abstract:
Importance Mental health comorbidities are increasing worldwide and worsen outcomes for people with diabetes, especially when care is fragmented.
Objective To assess whether collaborative care vs usual care lowers depressive symptoms and improves cardiometabolic indices among adults with diabetes and depression.
Design, Setting, and Participants Parallel, open-label, pragmatic randomized clinical trial conducted at 4 socioeconomically diverse clinics in India that recruited patients with type 2 diabetes; a Patient Health Questionnaire-9 score of at least 10 (range,0-27); and hemoglobin A1c (HbA1c) of at least 8%, systolic blood pressure (SBP) of at least 140 mm Hg, or low-density lipoprotein (LDL) cholesterol of at least 130 mg/dL. The first patient was enrolled on March 9, , and the last was enrolled on May 31, ; the final follow-up visit was July 14, .
Interventions Patients randomized to the intervention group (n=196) received 12 months of self-management support from nonphysician care coordinators, decision support electronic health records facilitating physician treatment adjustments, and specialist case reviews; they were followed up for an additional 12 months without intervention. Patients in the control group (n=208) received usual care over 24 months.
Main Outcomes and Measures The primary outcome was the between-group difference in the percentage of patients at 24 months who had at least a 50% reduction in Symptom Checklist Depression Scale (SCL-20) scores (range,0-4; higher scores indicate worse symptoms) and a reduction of at least 0.5 percentage points in HbA1c, 5 mm Hg in SBP, or 10 mg/dL in LDL cholesterol. Prespecified secondary outcomes were percentage of patients at 12 and 24 months who met treatment targets (HbA1c 7.0%, SBP 130 mm Hg, LDL cholesterol 100 mg/dL [ 70 mg/dL if prior cardiovascular disease]) or had improvements in individual outcomes ( 50% reduction in SCL-20 score, 0.5-percentage point reduction in HbA1c, 5-mm Hg reduction in SBP, 10-mg/dL reduction in LDL cholesterol); percentage of patients who met all HbA1c, SBP, and LDL cholesterol targets; and mean reductions in SCL-20 score, Patient Health Questionnaire-9 score, HbA1c, SBP, and LDL cholesterol.
Results Among 404 patients randomized (mean [SD] age, 53 [8.6] years; 165 [40.8%] men), 378 (93.5%) completed the trial. A significantly greater percentage of patients in the intervention group vs the usual care group met the primary outcome (71.6% vs 57.4%; risk difference, 16.9% [95% CI, 8.5%-25.2%]). Of 16 prespecified secondary outcomes, there were no statistically significant between-group differences in improvements in 10 outcomes at 12 months and in 13 outcomes at 24 months. Serious adverse events in the intervention and usual care groups included cardiovascular events or hospitalizations (4 [2.0%] vs 7 [3.4%]), stroke (0 vs 3 [1.4%]), death (2 [1.0%] vs 7 [3.4%]), and severe hypoglycemia (8 [4.1%] vs 0).
Conclusions and Relevance Among patients with diabetes and depression in India, a 12-month collaborative care intervention, compared with usual care, resulted in statistically significant improvements in a composite measure of depressive symptoms and cardiometabolic indices at 24 months. Further research is needed to understand the generalizability of the findings to other low- and middle-income health care settings.
DOI: 10.1001/jama..11747
Source:
期刊信息
JAMA-Journal of The American Medical Association：《美国医学会杂志》，创刊于1883年。隶属于美国医学协会，最新IF：51.273
官方网址：
投稿链接：
