Effectiveness of Integrating Suicide Care in Primary Care : Secondary Analysis of a Stepped-Wedge, Cluster Randomized Implementation Trial.

IF 19.6 1区医学 Q1 MEDICINE, GENERAL & INTERNAL Annals of Internal Medicine Pub Date : 2024-10-01 DOI:10.7326/M24-0024

Julie Angerhofer Richards, Maricela Cruz, Christine Stewart, Amy K Lee, Taylor C Ryan, Brian K Ahmedani, Gregory E Simon

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Abstract

Background: Primary care encounters are common among patients at risk for suicide.

Objective: To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention.

Design: Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777).

Setting: 19 primary care practices within a large health care system in Washington State, randomly assigned launch dates.

Patients: Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018.

Intervention: Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning.

Measurements: Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization.

Results: During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, -1.5 [CI, -2.6 to -0.4]).

Limitation: Suicide care was implemented in combination with care for depression and substance use.

Conclusion: Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits.

Primary funding source: National Institute of Mental Health.

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将自杀护理纳入初级保健的有效性：阶梯式楔形分组随机实施试验的二次分析》。

背景：在有自杀风险的患者中，基层医疗机构的接诊很常见：在有自杀风险的患者中，基层医疗机构是常见的：评估在初级保健中实施基于人群的自杀护理（SC）以预防自杀未遂的效果：设计：对阶梯式、分组随机实施试验进行二次分析。(临床试验：NCT02675777）：设置：华盛顿州一个大型医疗保健系统内的 19 个初级保健诊所，随机分配启动日期：成人患者（年龄≥18岁），2015年1月至2018年7月期间接受初级保健就诊：实践促进者、电子病历（EMR）临床决策支持和绩效监控支持抑郁症筛查、自杀风险评估和安全规划的实施：临床实践和患者测量依赖于 EMR 和保险理赔数据，以比较常规护理（UC）和 SC 阶段。主要结果包括基于人群的筛查和自杀风险评估后记录的安全计划，以及就诊后 90 天内的自杀未遂或死亡（有自残意图）。混合效应逻辑模型对 UC 和 SC 的二元结果指标进行了回归，并对随机分层和日历时间进行了调整，同时考虑了同一地点的重复结果。每月结果率（每 10,000 名患者中的百分比）通过边际标准化进行估算：在 UC 期间，255 789 名患者接受了 953 402 次初级保健就诊，而在 SC 期间，228 255 名患者接受了 615 511 次就诊。就诊安全计划的比例在就诊安全计划组高于综合治疗组（每 10,000 名患者中 38.3 对 32.8；比例差异为 5.5 [95% CI，2.3 至 8.7]）。在90天内自杀未遂的患者中，SC组少于UC组（每万名患者中4.5例 vs. 6.0例；比率差异为-1.5 [CI, -2.6 to -0.4]）：局限性：自杀护理与抑郁症和药物使用护理同时实施：主要资金来源：美国国家精神卫生研究所（National Institute of Mental Health）：主要资金来源：美国国家心理健康研究所。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Annals of Internal Medicine 医学-医学：内科

CiteScore

23.90

自引率

1.80%

发文量

1136

审稿时长

3-8 weeks

期刊介绍： Established in 1927 by the American College of Physicians (ACP), Annals of Internal Medicine is the premier internal medicine journal. Annals of Internal Medicine’s mission is to promote excellence in medicine, enable physicians and other health care professionals to be well informed members of the medical community and society, advance standards in the conduct and reporting of medical research, and contribute to improving the health of people worldwide. To achieve this mission, the journal publishes a wide variety of original research, review articles, practice guidelines, and commentary relevant to clinical practice, health care delivery, public health, health care policy, medical education, ethics, and research methodology. In addition, the journal publishes personal narratives that convey the feeling and the art of medicine.