The value of peer support for self-management of diabetes among veterans in the Empowering Patients In Chronic care intervention

AIM

To examine the value of peer support in the self-management of diabetes among veterans in an integrated health care system.

METHODS

We conducted semi-structured in-depth interviews with veterans and clinicians 6 months after their participation in Empowering Patients in Chronic Care (EPIC), a group-based diabetes intervention with a peer-support component. Interviews elicited clinicians' narratives of how peer support unfolded in the groups and veterans' experiences of giving and receiving support from their peers. Data analysis was guided by principles of framework analysis using Heisler's peer-support model.

RESULTS

Findings support Heisler's peer-support model and provide evidence supporting professional-led group visits with peer exchange. Clinicians and veterans endorsed informational and emotional support received in EPIC groups. Clinicians often referred to EPIC as an open forum or a support group where veterans could both give and receive help. Veterans noted the benefits of shared problem-solving and the support they received. Clinicians and veterans perceived the peer-support component of EPIC as facilitating increased empowerment in terms of self-efficacy, increased perceived social support and increased understanding of self-care. Ultimately, many veterans acknowledged that their participation in EPIC facilitated improved health-related quality of life, improved health behaviours and improved chronic disease control.

CONCLUSIONS

Findings emphasize the value of peer support in managing chronic illness. Peer-support programmes may address veterans' unique challenges and have the potential to improve physical and mental health.

Integrated Model for Patient-Centered Advanced Liver Disease Care

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Post-Traumatic Stress Disorder Symptoms from Multiple Stressors Predict Chronic Pain in Cancer Survivors

Background: Despite the association between chronic pain and post-traumatic stress disorder (PTSD), little is known about the longitudinal course of pain and PTSD during cancer treatment. Objectives: We examined the prevalence of PTSD and chronic pain at three time periods in veterans with a diagnosis of cancer, and the relationship between the experience of pain and PTSD. Methods: Participants (N = 123) with oral-digestive cancers were recruited from the Veterans Healthcare System (age M = 65.31 and SD = 9.13; 98.4% male) and completed face to face interviews at 6, 12, and 18 months post-diagnosis. Measures included the Post-traumatic Stress Disorder Checklist-Stressor-Specific version (PCL-S), Primary care PTSD (PC-PTSD), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Impact Scale. Results: About one-third (26.8%) of the sample had chronic pain, defined as elevated pain at two time periods. About one-fifth (20.3%) endorsed symptoms of combat-related PTSD at 6 months, and 22.8% endorsed symptoms of cancer-related PTSD, exceeding a clinical cutoff for older adults (12 months = 21.1%, 18 months = 23.1%). Changes over time were observed for cancer-related PTSD symptom clusters of hyperarousal (F = 3.85 and p = 0.023) and emotional numbing (F = 4.06 and p = 0.018) with a statistically significant quadratic function increasing at 18 months. In logistic regression, individuals with both combat and cancer-related PTSD symptoms at six months had 8.49 times higher odds of experiencing chronic pain (χ² = 25.91 and p < 0.001; R² = 0.28). Conclusions: Persisting pain may be a concern in veterans with cancer. Individuals who have experienced traumatic events with persisting PTSD symptoms may be at elevated risk for chronic pain. Veterans with PTSD symptoms from both cancer and combat are at the highest risk to experience chronic pain.

Development of a Hybrid, Interprofessional, Interactive Quality Improvement Curriculum as a Model for Continuing Professional Development

Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in-and eventually, lead-QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner's Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners-wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams-can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.

Empowering patients in chronic care to improve diabetes distress and glycaemic control: Protocol for a hybrid implementation-effectiveness clinical trial

OBJECTIVES

To evaluate the effectiveness of a collaborative goal-setting intervention (Empowering Patients in Chronic Care [EPIC]) to improve glycaemic control and diabetesrelated distress, and implementation into routine care across multiple primary care clinics.

DESIGN

Randomized controlled trial comparing the effectiveness of the EPIC intervention with enhanced usual care (EUC) at five clinic sites located in the greater Chicago and Houston areas. We will measure differences in haemoglobin A1c (HbA1c) and diabetes distress scale scores among study arms at post-intervention and maintenance (6 months post-intervention). We will evaluate implementation of the intervention across sites using the RE-AIM framework. We will evaluate reach by comparing the per cent and characteristics of enrolled study participants among all potentially eligible participants in the given clinic population. Adoption is reflected by the characteristics of the involved providers and the number of intervention sessions conducted. Implementation of EPIC will be evaluated by number of sessions delivered, participants' evaluation of group sessions, and evaluation of quality of goal-setting.

PATIENTS

We randomized 280 participants with equal allocation to EPIC and enhanced usual care (EUC).

RESULTS

At baseline, the groups were similar with the exception that EUC participants were more likely to have prior diabetes education. At baseline, participants were predominately older men who have poorly controlled diabetes (mean HbA1c = 76 mmol/mol [9.1%]) and moderate levels of diabetes distress (mean DDS = 2.43).

CONCLUSIONS

This hybrid effectiveness-implementation protocol is designed to accelerate the translation of a patient-centred diabetes care intervention from research to clinical practice.

Association of Patient Priorities-Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial

Importance

Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden.

Objective

To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC).

Design, Setting, and Participants

Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018).

Interventions

Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities.

Main Outcomes and Measures

Primary outcomes included change in patients' Older Patient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided.

Results

Of the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered.

Conclusions and Relevance

This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs.

Trial Registration

ClinicalTrials.gov identifier: NCT03600389.

When Women Rise, We All Rise: American Geriatrics Society Position Statement on Achieving Gender Equity in Geriatrics

Supporting gender equity for women working in geriatrics is important to the growth of geriatrics across disciplines and is critical in achieving our vision for a future in which we are all able to contribute to our communities and maintain our health, safety, and independence as we age. Discrimination can have a negative impact on public health, particularly with regard to those who care for the health of older Americans and other vulnerable older people. Women working in the field of geriatrics have experienced implicit and explicit discriminatory practices that mirror available data on the entire workforce. In this position article, we outline strategic objectives and accompanying practical recommendations for how geriatrics, as a field, can work together to achieve a future in which the rights of women are guaranteed and women in geriatrics have the opportunity to achieve their full potential. This article represents the official positions of the American Geriatrics Society. J Am Geriatr Soc 67:2447-2454, 2019.

Examining changes in interprofessional attitudes associated with virtual interprofessional training

Interprofessional care is essential in healthcare, but prior work has shown that physicians and nurses tend to have different perceptions about working interprofessionally (interprofessional attitudes). Although training has been shown to improve interprofessional attitudes, providing traditional face to face training is logistically challenging in the healthcare setting. The current study examined whether a virtual interprofessional training program could improve interprofessional attitudes for nurses and physicians. Among a sample of 35 physicians and nurses, results suggested that engagement in a virtual interprofessional training program was associated with improvements in interprofessional attitudes (i.e., perceived ability to work with, value in working with, and comfort in working with other professions) (p = .002), with attitudes improving an average of 0.25 points on a six-point scale (Cohen's d = 0.52). As a secondary aim, results showed that the magnitude of change in interprofessional attitudes did not differ significantly between physicians and nurses. Altogether, results suggest that virtual interprofessional training appears to be a suitable way to begin to improve interprofessional attitudes for both physicians and nurses.

Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

IMPORTANCE

Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care.

OBJECTIVE

To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat.

INTERVENTIONS

Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status.

MAIN OUTCOMES AND MEASURES

Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures.

RESULTS

Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01).

CONCLUSIONS AND RELEVANCE

Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01572389.

National Patterns of Urine Testing During Inpatient Admission

Background

Overuse of urine testing is a driver of inappropriate antimicrobial use. Limiting wasteful testing is important for patient safety. We examined the national prevalence and patterns of urine testing during adult inpatient admission in the United States.

Methods

We performed a retrospective cohort study using a national dataset of inpatient admissions from 263 hospitals in the United States from 2009 to 2014. We included all adult inpatient admissions, excluding those related to pregnancy, urology procedures, and with lengths of stay >30 days. A facility-level fixed-effects quasi-Poisson regression model was used to examine the incidence of urinalysis and urine culture testing for select diagnoses and patient factors.

Results

The cohort included 4473655 admissions. Charges for urinalysis were present for 2086697 (47%) admissions, with 584438 (13%) including >1 urinalysis. Charges for urine culture were present for 1197242 (27%) admissions, with 246211 (6%) having >1 culture. Urine culture testing varied by principal diagnosis. Heart failure and acute myocardial infarction had 29% and 35% fewer cultures sent on the first day of admission compared to all other admissions (P < .001). Female sex and receipt of antibiotics during the hospital admission consistently predicted increased culture testing, regardless of principal diagnosis or age.

Conclusions

Urine testing was common and frequently repeated during inpatient admission, suggesting large-scale overuse. The variation in testing by diagnosis suggests that clinical presentation modifies test use. The sex bias in urine testing is not clinically supported and must be addressed in interventions aimed at reducing excess urine testing.

Cancer-related cognitive impairment and associated factors in a sample of older male oral-digestive cancer survivors

OBJECTIVE

This study examines the demographic and clinical variables associated with cancer-related cognitive impairment (CRCI) in a sample of older, male, oral-digestive cancer survivors at VA Medical Centers in Boston and Houston.

METHODS

A two-time point, longitudinal design was used, with cognitive assessment conducted at 6 and 18 months post-diagnosis. Using ANCOVA, the cognitive functioning of 88 older adults with head and neck, esophageal, gastric, or colorectal cancers was compared with that of 88 healthy controls. Paired t-tests examined cognitive change over time in the cancer group. Hierarchical linear regression examined variables potentially associated with cognitive impairment at 18 months.

RESULTS

Forty-eight percent of cancer patients exhibited cognitive impairment 6 months post-cancer diagnosis, and 40% at 18 months. Cancer survivors were impaired relative to controls on measures of sustained attention, memory, and verbal fluency at 18 months, controlling for age. Older age, low hemoglobin, and cancer-related PTSD were associated with worse cognition at 18 months.

CONCLUSIONS

CRCI is more frequent in older adults than reported in studies of younger adults and may be more frequent in men. Potential areas of intervention for CRCI include psychotherapy for cancer-related PTSD, treatment of anemia, and awareness of particularly vulnerable cognitive domains such as sustained attention, memory, and verbal fluency.

Abstract 27: Mining Big Data to Estimate the Frailty Index in Patients with Congestive Heart Failure: Clinical Expert vs Machine Learning

Introduction: Early recognition of frailty in older adults with Congestive Heart Failure (CHF) is needed to target interventions to slow functional decline and improve patient-centered outcomes. Previous studies have used laboratory values and vital signs to measure a frailty index (FI) to predict mortality; however, variable selection was based on expert opinion alone.

Hypothesis: We hypothesize that a FI for CHF patients developed by mining laboratory values and vital signs with a machine learning algorithm will better predict mortality compared to a FI developed with expert opinion.

Methods: This is a retrospective cohort study of patients with hospital admissions for CHF in the Veterans Health Administration from 2012 to 2014. Outpatient laboratory tests and vital signs where more than 50% of the cohort had a reported value were collected for the year prior to admission. Two physicians reviewed the laboratory tests and vital signs and used expert opinion to determine which variables may be associated with physical frailty. The laboratory tests and vital signs were also fed to a machine learning algorithm to select variables. We used the accumulation of deficits method to calculate the FI. Cox survival models were developed with the machine variables, expert opinion variables, and a combination (machine and expert). The outcome of interest was mortality. The performance of the models was compared by time dependent area under the curve (AUC) with 10-fold cross validation.

Results: The cohort consisted of 24,457 patients (age 72±11 years, male 98%) with 70% mortality rate in six years. Out of 53 variables (49 laboratory tests and 4 vital signs), the physicians selected 29 variables, the machine selected 23, and the physicians and machine agreed on 14. The average AUC (95%CI) was 0.561 (0.561,0.562) for the expert opinion FI, 0.605 (0.604,0.606) for machine FI, and 0.607 (0.606,0.608) for combination FI.

Conclusions: The FI developed using machine learning was a better predictor of mortality than a FI developed with expert opinion and used fewer variables. This study shows the potential for operationalizing a FI using laboratory values and vital signs from Electronic Health Records. In future studies, we plan to feed additional clinical variables to the machine learning algorithm to improve the accuracy of the FI model.

Perspectives of Patients in Identifying Their Values-Based Health Priorities

OBJECTIVES

Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI.

DESIGN

Qualitative study using thematic analysis.

SETTING

In-depth semistructured telephone and in-person interviews.

PARTICIPANTS

Twenty-two older adults who participated in the PHPI process.

MEASUREMENTS

Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement.

RESULTS

Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits.

CONCLUSIONS

Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Telemedicine Training and Support for Community Health Workers: Improving Knowledge of Diabetes

Background: Community health workers (CHWs) are a well-established source to improve patient health care, yet their training and support remain suboptimal. This limits program expansion and potentially compromises patient safety. The objective of the study was to evaluate the feasibility and acceptability of weekly training and support by telemedicine (videoconferencing). Materials and Methods: CHWs (n = 6) who led diabetes group visits for low-income Latinos met weekly with a health care professional for training and support. Feasibility and acceptability outcome measures included telemedicine usability, knowledge of diabetes (baseline to 6 months), and program satisfaction. Results: Telemedicine training and support were found to be feasible and acceptable as measured by usability (Telehealth Usability Questionnaire: average 4.7/5.0, ±0.4), knowledge (Diabetes Knowledge Test: pretest 15.8 ± 1.3, posttest 21.8 ± 1.2, p < 0.001, respectively), and satisfaction (Texas Department of State Health Services survey: average 5.8/6.0, ±0.5). All CHWs preferred telemedicine to in-person training. Conclusions: Telemedicine is a feasible and acceptable modality to train and support CHWs.

Examining cancer survivorship trajectories: Exploring the intersection between qualitative illness narratives and quantitative screening instruments

OBJECTIVE

This article examines the associations of quantitatively refined trajectories of adjustment to cancer survivorship determined by previously published qualitative narrative analysis.

METHOD

Patients completed measures of cancer-related worry (Cancer Related Worries Scale), depression (Patient Health Questionnaire-9), posttraumatic growth (Benefit Finding Scale), and open-ended survey questions 6, 12, and 18 months postdiagnosis of head and neck, esophageal, gastric, or colorectal cancer. Previously published narrative analysis revealed five distinct survivorship "paths," which were combined into four paths in the present article: Moving On, Seeing the World Differently, Taking One Day at a Time, and Never the Same. To determine the association of qualitatively determined paths with quantitatively assessed adjustment (i.e., Cancer Related Worries Scale, Patient Health Questionnaire-9, Benefit Finding Scale), we used linear multilevel modeling to regress the adjustment variables on time, path, the time-by-path interaction, and relevant covariates (age, stage, cancer site, ethnicity, and Deyo score).

RESULTS

There was a significant main effect of path on cancer worry, depression, and posttraumatic growth (p < 0.02 for all). Patients in the Moving On group reported consistently low worry, depression, and growth compared to the other groups. Patients in the Seeing the World Differently and Taking One Day at a Time paths both reported moderate worry and depression; but those in the Seeing the World Differently path reported the highest posttraumatic growth, whereas patients in the Taking One Day at a Time path reported little growth. Finally, patients in the Never the Same path reported the highest worry and depression but lowest posttraumatic growth.Significance of resultsThis longitudinal study reinforces the notion that cancer survivorship is not a one-size-fits-all experience nor a dichotomized experience of "distress" or "no distress." Additionally, this hypothesis-generating study suggests future directions for potential self-report measures to help clinicians identify cancer survivors' trajectory to develop a more patient-centered survivorship care plan.

Cognitive and Perceptual Factors, Not Disease Severity, Are Linked with Anxiety in COPD: Results from a Cross-Sectional Study

PURPOSE

Guided by the Transactional Model of Stress and Coping, the purpose of this cross-sectional study was to examine clinical factors-demographics, chronic obstructive pulmonary disease (COPD) severity, cognitive/perceptual variables (appraisal and coping)-and their relationship to clinically elevated symptoms of anxiety in a sample of veterans with COPD.

METHOD

Participants included a sample of veterans with COPD, with or without comorbid congestive heart failure, and clinically significant symptoms of anxiety (n = 172, mean age = 65.3, SD = 8.1), who previously presented to an outpatient VA setting. Participants completed questionnaires examining COPD severity (respiratory impairment and dyspnea- and fatigue-related quality of life); perceptions of a stressor (COPD illness intrusiveness); perceptions of control (locus of health control, mastery over COPD, self-efficacy); coping strategies (adaptive and maladaptive); and anxiety and depressive symptoms.

RESULTS

Multivariable linear regressions revealed that anxiety was positively associated with more maladaptive coping and locus of control (attributed to other people), above and beyond disease severity, demographics, and depressive symptoms.

CONCLUSION

These findings suggest that cognitive and perceptual factors are concurrent with anxiety; however, longitudinal investigations are needed to fully understand this relationship. Future research should also focus on identifying optimal assessment and treatment procedures when evaluating and treating patients with COPD and symptoms of anxiety.

TRIAL REGISTRATION

NCT01149772.

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

Development of a Clinically Feasible Process for Identifying Individual Health Priorities

OBJECTIVES

To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making.

DESIGN

Prospective development and feasibility study.

SETTING

Primary care practice in Connecticut.

PARTICIPANTS

Older adults with 3 or more conditions or taking 10 or more medications (N=64).

INTERVENTION

The development team of patients, caregivers, and clinicians used a user-centered design framework-ideate → prototype → test →redesign-to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators.

MEASUREMENTS

We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions).

RESULTS

We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians.

CONCLUSION

Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Predictors of response to brief CBT in patients with cardiopulmonary conditions

OBJECTIVE

This study examined predictors of treatment outcome in a randomized controlled trial of brief cognitive-behavioral therapy (bCBT) for patients with a cardiopulmonary condition and comorbid, clinically significant symptoms of depression and/or anxiety.

METHOD

Only those who completed outcome assessments in the bCBT arm were studied (n = 132), to provide information about predictors of change in psychological symptoms. Multivariable linear regressions were conducted with baseline depression and anxiety symptoms, functional limitations, coping, self-efficacy, number of treatment sessions attended, and working alliance as potential predictors of change from pre- to postintervention on the dependent variables, depression [Patient Health Questionniare-9] and anxiety [Beck Anxiety Inventory]).

RESULTS

Significant predictors of improvement in depression and anxiety included baseline mental health symptoms, physical health functional impairment, and self-efficacy. Coping, working alliance, and number of sessions attended were not associated with change in depression or anxiety.

CONCLUSION

Patients with greater physical functioning limitations and lower self-efficacy may experience less change in depression and anxiety during brief CBT. Future research should examine how to boost treatment effectiveness for patients with these characteristics. (PsycINFO Database Record

Come, join, lead: Attracting students to careers in aging and promoting involvement in gerontological societies

Geriatric educators face the challenge of attracting more clinicians, scientists, and educators into geriatrics and gerontology, and promoting involvement in gerontological societies. A survey of psychologists (N = 100) examined factors that attract students in clinical/counseling psychology to practice with older adults, as well as experiences in organizational service. For 58%, interest in aging began at the undergraduate level, but for others interest developed later. About one half cited academic exposure such as mentorship (51%), research (47%), or coursework (45%) as sparking interest, along with family (68%) or work experience (61%). Involvement in professional organizations lags (58%), in part owing to misperceptions about what those activities require. A continued targeted effort at the undergraduate and graduate level is essential to attract students to careers in aging. To preserve vital professional organizations, enhanced outreach may be useful to dispel myths about service and encourage engagement.

Pain is associated with continuing depression in cancer survivors

Depression is common but under-diagnosed in cancer survivors. This study characterized depressive symptoms over one year in cancer survivors and examined disease-related and psychosocial predictors of depression severity. Participants (n = 122; M_age 65.33, SD = 9.17, 98.4% male) with head and neck, esophageal, gastric, or colorectal cancers were recruited through tumor registries at two regional Veterans Administration Medical Centers. Self-report measures assessing depressive symptoms (PHQ-9), combat-related PTSD symptoms (PC-PTSD), and health-related quality of life (PROMIS) were administered at six, twelve, and eighteen months after diagnosis. Symptoms consistent with major depression were endorsed by approximately one-quarter of the sample at six (24%), twelve (22%), and eighteen (26%) months post diagnosis, with 12% of participants reporting consistently significant depressive symptoms. In multivariate modeling, significant predictors of depression at eighteen months included prior depressive symptoms (β = .446, p < 0.001) and current pain interference (β = .231, p = .003). The present findings suggest that major depression is common and persistent one year following cancer diagnosis. Attention to pain management and routine monitoring of mood symptoms is critical to reducing risk of depression in cancer survivors.