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Mdege ND, Shah S, Dogar O, Pool ER, Weatherburn P, Siddiqi K, Zyambo C, Livingstone-Banks J. Interventions for tobacco use cessation in people living with HIV. Cochrane Database Syst Rev 2024; 8:CD011120. [PMID: 39101506 PMCID: PMC11299227 DOI: 10.1002/14651858.cd011120.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
BACKGROUND The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies. OBJECTIVES To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections. MAIN RESULTS We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT. AUTHORS' CONCLUSIONS There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.
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Affiliation(s)
- Noreen D Mdege
- Department of Health Sciences, University of York, York, UK
- Centre for Research in Health and Development, York, UK
| | - Sarwat Shah
- Department of Health Sciences, University of York, York, UK
| | - Omara Dogar
- Department of Health Sciences, University of York, York, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Erica Rm Pool
- Institute for Global Health, University College London, London, UK
| | - Peter Weatherburn
- Sigma Research, Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Kamran Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Cosmas Zyambo
- Department of Community and Family Medicine, School of Public Health, The University of Zambia, Lusaka, Zambia
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Haque LY, Leggio L. Integrated and collaborative care across the spectrum of alcohol-associated liver disease and alcohol use disorder. Hepatology 2024:01515467-990000000-00939. [PMID: 38935926 DOI: 10.1097/hep.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/08/2024] [Indexed: 06/29/2024]
Abstract
The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.
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Affiliation(s)
- Lamia Y Haque
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Baltimore and Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, Rhode Island, USA
- Division of Addiction Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
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3
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Harsono D, Deng Y, Chung S, Barakat LA, Friedland G, Villanueva M, Yager JE, Justen M, Edelman EJ. Prevalence and Correlates of Physical Inactivity Among Individuals with HIV During the First COVID-19 Wave: A Cross-sectional Survey. AIDS Behav 2024; 28:1531-1545. [PMID: 37824037 DOI: 10.1007/s10461-023-04170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
Physical activity is associated with improved health outcomes among people with HIV (PWH). In the recent pandemic context, policies designed to mitigate COVID-19 transmission may result in an increase in sedentary lifestyle and decreased physical activity. In this study, we aimed to characterize self-reported physical activity and factors associated with physical inactivity during the first wave of the COVID-19 pandemic among a sample of PWH engaged in care. We also described whether psychological coping strategies measured by the Brief COPE differed based on physical activity levels. Among 260 surveyed PWH in two HIV clinics in the US Northeast, 28.5% (n = 74) met the criteria for being physically active according to the Centers for Disease Control and Prevention (CDC)'s physical activity guidelines. Receiving care in New Haven, CT, presence of a detectable HIV viral load, every day tobacco use, and unhealthy alcohol use were associated with physical inactivity. Problem-focused coping, emotion-focused coping, and avoidance-focused coping strategies were found to be protective against physical inactivity. In adjusted analysis, only problem-focused coping continued to be significantly associated with lower odds of reporting physical inactivity. Efforts are urgently needed to promote physical activity among PWH, including among those without problem-focused coping strategies.
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Affiliation(s)
- Dini Harsono
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA.
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Sangyun Chung
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Lydia A Barakat
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gerald Friedland
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Merceditas Villanueva
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica E Yager
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | | | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Muvvala SB, Gan G, Morford KL, Dziura J, Esserman D, Porter E, Chan PA, Cornman DH, Reynolds J, Yager JE, Fiellin DA, Edelman EJ. Facilitation and Preferred Models for Delivering Substance Use Disorder Treatment in HIV Clinics: Results From a Multisite Randomized Trial. J Addict Med 2023; 17:e388-e391. [PMID: 37934538 PMCID: PMC10726383 DOI: 10.1097/adm.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Integrated addiction treatment in HIV clinics is associated with improved outcomes, yet it is offered inconsistently and with variable models of care. We sought to evaluate the impact of Implementation Facilitation ("Facilitation") on clinician and staff preference for provision of addiction treatment in HIV clinics with on-site resources (all trained or designated on-site specialist) versus outside resources (outside specialist or refer out). METHODS From July 2017 to July 2020, surveys assessed clinician and staff preferences for addiction treatment models during control (ie, baseline), intervention, evaluation, and maintenance phases in 4 HIV clinics in the Northeast United States. RESULTS During the control phase, among 76 respondents (response rate, 58%), the proportions who preferred treatment with on-site resources for opioid use disorder (OUD), alcohol use disorder (AUD), and tobacco use disorder (TUD) were 63%, 55%, and 63%, respectively. Compared with control, there were no significant differences in preferred model during the intervention and evaluation phases except for AUD where there was an increased preference for treatment with on-site resources in the intervention versus control phase. Compared with control, during the maintenance phase, a higher proportion of clinicians and staff preferred providing addiction treatment with on-site resources versus outside resources: OUD, 75% (odds ratio [OR; 95% confidence interval {CI}], 1.79 [1.06-3.03]); AUD, 73% (OR [95% CI], 2.23 [1.36-3.65]), and TUD, 76% (OR [95% CI], 1.88 [1.11-3.18]). CONCLUSIONS The findings from this study lend support for "Facilitation" as a strategy to enhance clinician and staff preference for integrated addiction treatment in HIV clinics with on-site resources.
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Affiliation(s)
- Srinivas B Muvvala
- From the Program in Addiction Medicine, Yale School of Medicine, New Haven, CT (SBM, KLM, DAF, EJE); Department of Psychiatry, Yale School of Medicine, New Haven, CT (SBM); Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT (GG, JD, DE); Department of Internal Medicine, Yale School of Medicine, New Haven, CT (KLM, EP, DAF, EJE); Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT (DAF, EJE); Department of Emergency Medicine, Yale School of Medicine, New Haven, CT (JD, DAF); Department of Biostatistics, Yale School of Public Health, New Haven, CT (JD, DE, JR); Department of Medicine, Brown University, Providence, RI (PAC); Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT (DHC); Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY (JEY)
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Falade-Nwulia O, Agee T, Kelly SM, Park JN, Schwartz S, Hsu J, Schweizer N, Jones J, Keruly J, Shah N, Lesko CR, Lucas GM, Sulkowski M. Implementing a peer-supported, integrated strategy for substance use disorder care in an outpatient infectious disease clinic is associated with improved patient outcomes. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 121:104191. [PMID: 37740989 PMCID: PMC10844957 DOI: 10.1016/j.drugpo.2023.104191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Substance use disorder (SUD) and infectious disease (ID) care integration may lead to improvements in SUD and ID outcomes. We assessed implementation of integrating peer-supported SUD care in an outpatient ID setting. METHODS In this implementation study, we describe REcovery in Specialty care Through medication and OutREach (RESTORE), a low-threshold SUD program implemented in a Baltimore outpatient ID clinic. Key program components were clinician training and support in SUD care, prescription of SUD treatment medications, and peer-based psychosocial support provided by peer recovery specialists. We assessed clinician adoption of RESTORE and compared patient outcomes from baseline to 6 months. RESULTS Between January 2019 and January 2022, the number of ID clinicians (N=61) who prescribed buprenorphine increased eightfold from 3 (5%) to 24 (39%). Of 258 ID patients referred to RESTORE, 182 (71%) engaged, 137 consented to study participation. Mean age in the study sample was 52.1 (SD=10.4), 63% were male, 84% were Black/African-American. Among 127 (93%) who completed 6-month follow-up, fewer participants reported illicit/non-prescribed opioid use in the past 30 days at follow-up (32%) compared to baseline (52%; p<0.001). Similar reductions were noted for cocaine use (47% to 34%; p=0.006), emergency department visits (23% to 9%; p=0.002), and inpatient hospitalizations (15% to 7%; p=0.025). CONCLUSION SUD care integration into an outpatient ID care setting using a peer-supported implementation strategy was adopted by clinicians and improved clinical outcomes for patients. This strategy is a promising approach to treating people with infectious diseases and SUD.
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Affiliation(s)
- Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224.
| | - Tracy Agee
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
| | - Sharon M Kelly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
| | - Ju Nyeong Park
- Division of General Internal Medicine, Warren Alpert Medical School, Brown University, 1125 N. Main St, Providence, RI 02904
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205
| | - Jeffrey Hsu
- Department of Psychiatry, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287
| | - Nicholas Schweizer
- Department of Psychiatry, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287
| | - Joyce Jones
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
| | - Jeanne Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
| | - Nishant Shah
- Department of Family and Community Medicine, University of Maryland, 29 South Paca St, Baltimore, MD 21201
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205
| | - Gregory M Lucas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
| | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Baltimore, MD 21224
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Jurczuk M, Thakar R, Carroll FE, Phillips L, van der Meulen J, Gurol-Urganci I, Sevdalis N. Design and management considerations for control groups in hybrid effectiveness-implementation trials: Narrative review & case studies. FRONTIERS IN HEALTH SERVICES 2023; 3:1059015. [PMID: 36926502 PMCID: PMC10012616 DOI: 10.3389/frhs.2023.1059015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/06/2023] [Indexed: 03/12/2023]
Abstract
Hybrid effectiveness-implementation studies allow researchers to combine study of a clinical intervention's effectiveness with study of its implementation with the aim of accelerating the translation of evidence into practice. However, there currently exists limited guidance on how to design and manage such hybrid studies. This is particularly true for studies that include a comparison/control arm that, by design, receives less implementation support than the intervention arm. Lack of such guidance can present a challenge for researchers both in setting up but also in effectively managing participating sites in such trials. This paper uses a narrative review of the literature (Phase 1 of the research) and comparative case study of three studies (Phase 2 of the research) to identify common themes related to study design and management. Based on these, we comment and reflect on: (1) the balance that needs to be struck between fidelity to the study design and tailoring to emerging requests from participating sites as part of the research process, and (2) the modifications to the implementation strategies being evaluated. Hybrid trial teams should carefully consider the impact of design selection, trial management decisions, and any modifications to implementation processes and/or support on the delivery of a controlled evaluation. The rationale for these choices should be systematically reported to fill the gap in the literature.
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Affiliation(s)
- Magdalena Jurczuk
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Ranee Thakar
- Obstetrics & Gynaecology, Croydon University Hospitals NHS Trust, London, United Kingdom
| | - Fran E Carroll
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Lizzie Phillips
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.,Maternity Services, University Hospital Plymouth NHS Trust, Plymouth, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ipek Gurol-Urganci
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, United Kingdom
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Edelman EJ, Gan G, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Helfrich CD, Reynolds J, Yager JE, Morford KL, Muvvala SB, Fiellin DA. Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2236904. [PMID: 36251291 PMCID: PMC9577676 DOI: 10.1001/jamanetworkopen.2022.36904] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Importance Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics. Objective To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD). Design, Setting, and Participants Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022. Interventions Multicomponent facilitation. Main Outcomes and Measures Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period. Results Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods. Conclusions and Relevance In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics. Trial Registration ClinicalTrials.gov Identifier: NCT02907944.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - William C. Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs
| | | | - Jesse Reynolds
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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Morford KL, Muvvala SB, Chan PA, Cornman DH, Doernberg M, Porter E, Virata M, Yager JE, Fiellin DA, Edelman EJ. Patients' perspectives of medications for addiction treatment in HIV clinics: A qualitative study. J Subst Abuse Treat 2022; 139:108767. [PMID: 35341613 PMCID: PMC9187601 DOI: 10.1016/j.jsat.2022.108767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/22/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND While substance use disorders (SUD) disproportionately impact people with HIV (PWH), HIV clinics inconsistently provide evidence-based medications for addiction treatment (MAT). Patient receptivity to MAT is critical to enhance addiction treatment in these settings. However, we know little from patients about how to best integrate MAT into HIV clinics. METHODS This qualitative study used four focus groups informed by the Promoting Action on Research Implementation in Health Services framework to identify barriers and facilitators to receiving opioid, alcohol, and tobacco use disorder care in HIV clinics. The study population included 28 patients with HIV and SUD receiving care at one of four HIV clinics in the northeastern United States. Focus groups were recorded and transcribed for content analysis. The study also performed a brief survey assessing demographics and behaviors. RESULTS Focus groups revealed several major themes related to MAT in HIV clinics. Barriers included stigma around MAT, knowledge deficits about available MAT options and the impact of substance use on PWH, concerns about medication side effects, substance use screening without adequate clinician follow-up, and peers who discouraged MAT. Facilitators included recognition of substance use as a threat to overall health, integrated care from HIV clinicians, and support for addiction treatment from peers with lived experience. CONCLUSIONS Efforts to enhance MAT in HIV clinics should include patient education to help them recognize addiction as a chronic disease with available medication treatment options; clinician and staff training to promote integrated, multidisciplinary screening and treatment; and thoughtful inclusion of peers with lived experience.
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Affiliation(s)
- Kenneth L Morford
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States.
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States
| | - Philip A Chan
- Department of Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, United States
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT 06269-1248, United States
| | - Molly Doernberg
- Yale School of Public Health, 60 College Street, New Haven, CT 06510, United States
| | - Elizabeth Porter
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Michael Virata
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States
| | - Jessica E Yager
- SUNY Downstate, 450 Clarkson Ave, Suite J, Brooklyn, NY 11203, United States
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States; Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue #260, New Haven, CT 06519, United States
| | - E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, Suite 417A, New Haven, CT 06510, United States; Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208056, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, United States
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Experiences with Telemedicine for HIV Care During the COVID-19 Pandemic: A Mixed-Methods Study. AIDS Behav 2022; 26:2099-2111. [PMID: 35064390 PMCID: PMC8782707 DOI: 10.1007/s10461-021-03556-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/14/2022]
Abstract
To characterize perspectives and experiences with telemedicine during the COVID-19 pandemic, we conducted a mixed-methods study in two HIV clinics in the US Northeast. Among surveyed patients with HIV (PWH) who had a telemedicine appointment (n = 205), 42.4% perceived telemedicine visits as useful during the pandemic. PWH and clinical staff identified benefits of telemedicine: (1) ability to engage and re-engage patients in care; (2) perceived patient-centeredness and flexibility; (3) opportunity to engage family and multidisciplinary care team members; and (4) opportunity to enhance telemedicine use proficiency through practice and support. Identified barriers included: (1) technical challenges; (2) privacy concerns; (3) loss of routine clinical experiences and interactions; (4) limited objective patient remote monitoring; and (5) reimbursement concerns. Efforts to optimize telemedicine for HIV care should consider strategies to improve technology support for PWH, flexible options to access care, additional platforms to allow patient remote monitoring, and appropriate billing and reimbursement methods.
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Kim B, Miller CJ, Ritchie MJ, Smith JL, Kirchner JE, Stolzmann K, Connolly SL, Drummond KL, Bauer MS. Time–motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221086275. [PMID: 37091094 PMCID: PMC9924237 DOI: 10.1177/26334895221086275] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time–motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time–motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time–motion data. Methods: We analyzed EF time–motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4–6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, “a two-week interval”) at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation’s beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation’s beginning, middle, and end differed from the interval data’s averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time–motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time–motion data.
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Affiliation(s)
- Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher J. Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Mona J. Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey L. Smith
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Samantha L. Connolly
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Karen L. Drummond
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mark S. Bauer
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Edelman EJ, Dziura J, Deng Y, Bold KW, Murphy SM, Porter E, Sigel KM, Yager JE, Ledgerwood DM, Bernstein SL. A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study. Contemp Clin Trials 2021; 110:106379. [PMID: 33794354 PMCID: PMC8478961 DOI: 10.1016/j.cct.2021.106379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/19/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial. METHODS In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made. CONCLUSIONS SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.
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Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Krysten W Bold
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Sean M Murphy
- CHERISH Center, Weill Cornell Medicine, New York, NY, United States of America
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Keith M Sigel
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jessica E Yager
- State University of New York Downstate Health Sciences University, Brooklyn, NY, United States of America
| | - David M Ledgerwood
- Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, United States of America
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America; Yale Center for Implementation Science, Yale School of Medicine, New Haven, CT, United States of America
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12
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Edelman EJ, Gan G, Dziura J, Esserman D, Morford KL, Porter E, Chan PA, Cornman DH, Oldfield BJ, Yager J, Muvvala SB, Fiellin DA. Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation. J Acquir Immune Defic Syndr 2021; 87:959-970. [PMID: 33675619 PMCID: PMC8192340 DOI: 10.1097/qai.0000000000002666] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics. SETTING Four HIV clinics in the northeastern United States. METHODS Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups. RESULTS Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork. CONCLUSIONS Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.
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Affiliation(s)
- E. Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Kenneth L. Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Philip A. Chan
- Department of Medicine, Brown University, Providence, RI
| | - Deborah H. Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT
| | | | | | - Srinivas B. Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - David A. Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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