RAPID RESPONSES FROM BMJ.COM
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《英国医生杂志》
I read with interest the article by Dietrich et al. It is indeed encouraging if telephone care management programs are effective for improving patient health outcomes and satisfaction in the treatment of depression. However, before we conclude the effectiveness of telephone management programs in the treatment of depression, we should see if other confounding variables besides telephone management could have accounted for the observed results.
One factor is the potential beneficial effects of increased physician visits for depression observed in the intervention group during the study.
Another factor is the increased training time for the clinicians and staff in the intervention group, which could have resulted in differences in interaction and management in patients in the two groups. Indeed, results from the study showed that the physicians in the intervention group asked more about suicidal thoughts, offered more educational materials and assisted more in setting self management goals, all of these could have accounted for better treatment outcomes.
In future studies, efforts should be made to see which parts of the intervention accounted for the improved outcomes, such that management could be tailored to maximize positive outcomes and minimize unnecessary use of resources. Moreover, before telephone management programs are implemented on a large scale in the community, the cost and time associated with increased physician visits and the beneficial but modest effects achieved with the intervention when compared to usual care should be considered carefully.
Samuel Y Wong, assistant professor
Department of Community and Family Medicine, School of Public Health, CUHK 4/F, School of Public Health, Prince of Wales Hospital, Chinese Universtiy of Hong Kong, Shatin, NT
Competing interests: None declared.
Dr. Wong comments that the process of care involved in the intervention for this study had a number of components, not just telephone care management. We agree about the importance of education to develop clinicians and practices that are prepared to manage depression well. Clinician education no doubt contributed to the improvement in suicide assessment and other aspects of the process of care described in Table 3 (online). The third component of our intervention, better linkage between mental health and primary care, is important as well in providing surpervision for care management and informal advice to primary care clinicians.
Distinguishing those aspects of the intervention that are critical to its impact from those that could be done without is an important next step in this research. We will gain insights in this area as we continue with data analysis.
Previous research suggests that multicomponent interventions are more likely than single component interventions to impact clinician behavior and to improve patient outcomes. For a clinical area as challenging as achieving remission from major depressive disorder, we would expect multicomponent interventions to be needed as well.
In addition to the process of care, this study addresses the process of change—helping clinicians implement and sustain changes in their routines with support from established quality improvement resources. Other studies have shown that certain changes in the process of care like telephone care management improve outcomes. This study adds to that literature by showing one way to achieve that enhanced process of care through a structured process of change.
One factor is the potential beneficial effects of increased physician visits for depression observed in the intervention group during the study.
Another factor is the increased training time for the clinicians and staff in the intervention group, which could have resulted in differences in interaction and management in patients in the two groups. Indeed, results from the study showed that the physicians in the intervention group asked more about suicidal thoughts, offered more educational materials and assisted more in setting self management goals, all of these could have accounted for better treatment outcomes.
In future studies, efforts should be made to see which parts of the intervention accounted for the improved outcomes, such that management could be tailored to maximize positive outcomes and minimize unnecessary use of resources. Moreover, before telephone management programs are implemented on a large scale in the community, the cost and time associated with increased physician visits and the beneficial but modest effects achieved with the intervention when compared to usual care should be considered carefully.
Samuel Y Wong, assistant professor
Department of Community and Family Medicine, School of Public Health, CUHK 4/F, School of Public Health, Prince of Wales Hospital, Chinese Universtiy of Hong Kong, Shatin, NT
Competing interests: None declared.
Dr. Wong comments that the process of care involved in the intervention for this study had a number of components, not just telephone care management. We agree about the importance of education to develop clinicians and practices that are prepared to manage depression well. Clinician education no doubt contributed to the improvement in suicide assessment and other aspects of the process of care described in Table 3 (online). The third component of our intervention, better linkage between mental health and primary care, is important as well in providing surpervision for care management and informal advice to primary care clinicians.
Distinguishing those aspects of the intervention that are critical to its impact from those that could be done without is an important next step in this research. We will gain insights in this area as we continue with data analysis.
Previous research suggests that multicomponent interventions are more likely than single component interventions to impact clinician behavior and to improve patient outcomes. For a clinical area as challenging as achieving remission from major depressive disorder, we would expect multicomponent interventions to be needed as well.
In addition to the process of care, this study addresses the process of change—helping clinicians implement and sustain changes in their routines with support from established quality improvement resources. Other studies have shown that certain changes in the process of care like telephone care management improve outcomes. This study adds to that literature by showing one way to achieve that enhanced process of care through a structured process of change.