Utilization of health promotion and wellness services among middle-aged and older adults with multiple sclerosis in the mid-west US

Investigating disparities in smoking cessation treatment for veterans with multiple sclerosis: A national analysis

BACKGROUND AND AIMS

Smoking is a risk factor for multiple sclerosis (MS) development, symptom burden, decreased medication efficacy, and increased disease-related mortality. Veterans with MS (VwMS) smoke at critically high rates; however, treatment rates and possible disparities are unknown. To promote equitable treatment, we aim to investigate smoking cessation prescription practices for VwMS across social determinant factors.

METHODS

We extracted data from the national Veterans Health Administration electronic health records between October 1, 2017, and September 30, 2018. To derive marginal estimates of the association of MS with receipt of smoking-cessation pharmacotherapy, we used propensity score matching through the extreme gradient boosting machine learning model. VwMS who smoke were matched with veterans without MS who smoke on factors including age, race, depression, and healthcare visits. To assess the marginal association of MS with different cessation treatments, we used logistic regression and conducted stratified analyses by sex, race, and ethnicity.

RESULTS

The matched sample achieved a good balance across most covariates, compared to the pre-match sample. VwMS (n = 3320) had decreased odds of receiving prescriptions for nicotine patches ([Odds Ratio]OR = 0.86, p < .01), non-patch nicotine replacement therapy (NRT; OR = 0.81, p < .001), and standard practice dual NRT (OR = 0.77, p < .01), compared to matches without MS (n = 13,280). Men with MS had lower odds of receiving prescriptions for nicotine patches (OR = 0.88, p = .05), non-patch NRT (OR = 0.77, p < .001), and dual NRT (OR = 0.72, p < .001). Similarly, Black VwMS had lower odds of receiving prescriptions for patches (OR = 0.62, p < .001), non-patch NRT (OR = 0.75, p < .05), and dual NRT (OR = 0.52, p < .01). The odds of receiving prescriptions for bupropion or varenicline did not differ between VwMS and matches without MS.

CONCLUSION

VwMS received significantly less smoking cessation treatment, compared to matched controls without MS, showing a critical gap in health services as VwMS are not receiving dual NRT as the standard of care. Prescription rates were especially lower for male and Black VwMS, suggesting that under-represented demographic groups outside of the white female category, most often considered as the "traditional MS" group, could be under-treated regarding smoking cessation support. This foundational work will help inform future work to promote equitable treatment and implementation of cessation interventions for people living with MS.

Characterizing fatigue phenotypes with other symptoms and clinically relevant outcomes among people with multiple sclerosis

PURPOSE

Fatigue is a common symptom of multiple sclerosis (MS) and can adversely affect all aspect of quality of life. The etiology of fatigue remains unclear, and its treatments are suboptimal. Characterizing the phenotypes of fatigued persons with MS may help advance research on fatigue's etiology and identify ways to personalize fatigue interventions to improve quality of life. The purpose of this study was to identify fatigue phenotypes; examine phenotype stability overtime; and characterize phenotypes by health and function, social and environmental determinants, psychosocial factors, and engagement in healthy behaviors.

METHODS

We conducted a longitudinal study over a 3-month period with 289 fatigued participants with MS. To identify fatigue phenotypes and determine transition probabilities, we used latent profile and transition analyses with valid self-report measures of mental and physical fatigue severity, the mental and physical impact of fatigue, depression, anxiety, and sleep quality. We used ANOVAs and effect sizes to characterize differences among phenotypes.

RESULTS

The best fitting model included six subgroups of participants: Mild Phenotype, Mild-to-Moderate Phenotype, Moderate-to-Severe Phenotype, Severe Phenotype, Fatigue-dominant Phenotype, and Mental Health-dominant Phenotype. The transition analysis indicated that phenotypic membership was highly stable. Variables with a large eta squared effect size included environmental barriers, self-efficacy, and fatigue catastrophizing.

CONCLUSION

These results indicate that the magnitude of fatigue experienced may be more important to consider than the type of fatigue when characterizing fatigue phenotypes. Future research should explore whether tailoring interventions to environmental barriers, self-efficacy, and fatigue catastrophizing reduce the likelihood of transitioning to a more severe phenotype.

Perceived facilitators, needs, and barriers to health related quality of life in people with multiple sclerosis: a qualitative investigation

Background

Multiple sclerosis (MS) is a chronic progressive neurological disease that influences an individual's physical, mental, emotional, and social functioning, otherwise known as health-related quality of life (HRQOL). To fully capture the impacts of MS on HRQOL, perspectives from the lived experience should be investigated.

Objective

The purpose of this study was to describe, in people with relapsing–remitting multiple sclerosis (RRMS), (1) the health and wellness needs and facilitators perceived to influence HRQOL, (2) determine which health needs are not being met, and (3) identify barriers to meeting health and wellness needs.

Methods

Participants with RRMS were recruited from a more extensive study for this cross-sectional, qualitative investigation guided by phenomenological theory. Semi-structured interviews were conducted until data saturation was reached (n = 15). The data were analyzed using a thematic analysis approach.

Results

Five themes emerged as facilitators of HRQOL; mental/emotional health, knowledge about MS, family/peer support, lifestyle behaviors, and social engagement. Identified barriers to achieving better HRQOL included limited access to specialized care, lack of communication/ empathy from providers, lack of comprehensive care, challenges caused by MS symptoms, and difficulty navigating the healthcare and insurance landscape.

Conclusions

Study participants described mental health and lifestyle behaviors as the primary promoters of overall HRQOL. Access to dietary guidelines, exercise instruction, and education about living healthy with MS were also identified as positive contributors to overall QOL. When these positive contributors are limited or absent, HRQOL was reported to decrease.

Distributive Pattern of Health Services Utilization Under Public Health Reform and Promotion in Turkey

OBJECTIVES

Inclusive health policies and health promotion to ensure strong primary healthcare systems are main tenets of health reforms in developing countries, such as Turkey. Nevertheless, there has been a lack of interest regarding the assessment of equity in health services utilization under public health reform and promotion of primary care. This study aims to analyze equity by measuring deviations from proportionality in the relationship between the utilization of health services and income using indices and curve approaches.

METHODS

A cross-sectional national Turkey Health Survey used the years 2008, 2010, 2012, and 2014. Gini and Kakwani indices and concentration curves were estimated, and the degree of regressivity was analyzed to understand the sources of equity in health services utilization.

RESULTS

Health services utilization for inpatient and outpatient services and family medicine and general practitioner services were regressive between the years 2008 and 2014. The most regressive pattern was observed in the year 2014 regarding medicine usage (Kakwani index = -0.1808904).

CONCLUSIONS

Differences in the utilization of health services have increased, hurting the poorest during the health reform in Turkey. Policies focused on health promotion to strengthen the primary health system and continuous monitoring of health services utilization by vulnerable groups are essential for ensuring a fairer health service usage in developing countries.

Health-Related Quality of Life in people with Multiple Sclerosis: How does this Population Compare to Population-based Norms in Different Health Domains?

PURPOSE

The purposes of this investigation were to (1) identify the domains of health-related quality of life most impacted in people with RRMS, (2) compare the health-related QOL in people with RRMS to general population norms, and (3) to describe subgroups within the RRMS population that have similar health and wellness needs.

METHODS

This was a cross-sectional QOL investigation of adults with RRMS. The SF-36v2 survey and demographic information were collected electronically via Qualtrics. Participants (n = 120) were recruited through social media and the National Multiple Sclerosis Society of the United States. One-sample Z-tests were completed for all subscales, and component mean scores to determine if a difference between the sample and population norms existed.

RESULTS

All values of z were statistically significant, p < .01, for all subscale and composite scores. Social function, physical function, and the mental health component scores had the lowest subscale means. A first stage depression screen revealed that 49% of the surveyed population were at risk for depression, compared to 18% in the general population. Further dividing the sample into years since MS diagnosis, the recently diagnosed group had 61% at risk for depression.

CONCLUSIONS

Challenges related to the mental health of individuals with RRMS are influencing overall health-related QOL. Early on in the disease course (0-3 years), mental health affected QOL more than physical health. More attention must be given to the nonphysical domains of health to advance the QOL for people with RRMS.

Free From Falls education and exercise program for reducing falls in people with multiple sclerosis: A randomized controlled trial

BACKGROUND

People with multiple sclerosis (PwMS) fall frequently. Community-delivered exercise and education reduce falls in older adults, but their efficacy in multiple sclerosis (MS) is unknown.

OBJECTIVES

To evaluate the impact of the Free From Falls (FFF) group education and exercise program on falls in PwMS.

METHODS

This was a prospective, assessor-blinded, two-arm parallel randomized controlled trial. Ninety-six participants were randomized to FFF (eight weekly 2 hour sessions) or the control condition (a fall prevention brochure and informing their neurologist of their fall history). Participants counted falls prospectively from enrollment through 6 months following intervention. Effects on fall frequency were evaluated by the Bayesian analysis.

RESULTS

The modeled mean fall frequency pre-intervention was 1.2 falls/month in the FFF group (95% credible intervals (CIs) = 0.8-2.0) and 1.4 falls/month in the control group (95% CI = 0.9-2.1). Fall frequency decreased by 0.6 falls/month in both groups over time (nadir 4-6 months post-intervention: FFF 0.6 falls/month (95% CI = 0.4-0.9); control 0.8 falls/month (95% CI = 0.5-1.1)).

CONCLUSION

In-person group exercise and education are not superior to written education and neurologist-initiated interventions for preventing falls in PwMS.

Response heterogeneity in a randomized controlled trial of telerehabilitation interventions among adults with multiple sclerosis

INTRODUCTION

Telerehabilitation may be effective on average but is not equally effective among all people with multiple sclerosis (MS). Thus, the purpose of this secondary analysis of a randomized controlled trial was to explore whether baseline characteristics of participants with MS influence fatigue and physical activity outcomes of three telerehabilitation interventions.

METHODS

Participants were randomized to contact-control intervention (CC), physical activity-only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). The 12-week interventions were delivered over the phone. Sociodemographic (age and income), clinical (comorbidities, mental function and physical function), psychosocial (self-efficacy, outcome expectations and goal-setting), and behavioural baseline characteristics (step count and fatigue self-management behaviors) were used in a moderated regression analysis and a responder analysis to examine their influence on the Fatigue Impact Scale (FIS) and Godin Leisure-Time Exercise Questionnaire (GLTEQ) at post-test (i.e. immediately post-interventions).

RESULTS

No interactions terms were statistically significant in the moderation analysis. However, the responder analysis showed that baseline psychosocial characteristics and mental function were significantly different (p < 0.05) between responders and non-responders. Specifically, non-responders on the FIS at post-test in the PA-only intervention had significantly lower baseline scores in goal setting for engaging in fatigue self-management behaviours. Also, non-responders on the GLTEQ at post-test in the FM+ intervention had significantly worse baseline scores in mental function.

DISCUSSION

Further research is needed to understand the complex relationship among baseline characteristics, telerehabilitation and response heterogeneity. We discuss how research on examining response heterogeneity may be advanced by conducting mega-clinical trials, secondary analyses of big data, meta-analyses and employing non-traditional research designs.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT01572714).

Factors Associated with Postrelapse Rehabilitation Use in Multiple Sclerosis: A Pilot Survey

Background

Most people with multiple sclerosis (MS) have periodic and unpredictable relapses as part of their disease course. Relapses often affect functional abilities, resulting in diminished productivity and lower quality of life. Considering the effects, rehabilitation can play an important role in facilitating recovery; yet, the current literature suggests a lack of postrelapse rehabilitation services use. This study aims to document postrelapse rehabilitation services use and estimate the extent to which predisposing characteristics, perceived need, and enabling resources were associated with postrelapse rehabilitation services use in adults with MS.

Methods

This cross-sectional study used convenience sampling, and data from 73 adults with MS who recently had a relapse in the United States and Canada were analyzed.

Results

A total of 25 participants (34.2%) reported using postrelapse rehabilitation services. The regression model identified three variables associated with postrelapse rehabilitation services use: age (odds ratio [OR], 1.075), self-reported quality of life (considerably affected by the most recent relapse [OR, 5.717]), and presence of helpful health care providers (for obtaining postrelapse rehabilitation services [OR, 5.382]).

Conclusions

Most participants experienced a range of symptoms or limitations because of their most recent relapse, affecting their daily activity and quality of life. However, only one-third of the participants reported using postrelapse rehabilitation services, which focused on the improvement of their physical health. Regression modeling revealed that three population characteristics of the Andersen Behavioral Model of Health Services Utilization were associated with postrelapse rehabilitation services use.

A concerns report survey of physical activity support needs of people with moderate-to-severe MS disability and family caregivers

Purpose: To identify the most pressing needs for community resources to support physical activity participation, determinants of perceived need, and barriers to co-participation in physical activity among people with multiple sclerosis (MS) who have moderate-to-severe disability and the family caregivers providing assistance to such individuals.Methods: Seventy-eight people with MS and 46 family caregivers participated in this cross-sectional survey study, guided by the Concerns Report Methodology.Results: The results show differences between groups in rankings for some need items. However, three need items were prioritized by both people with MS and the family caregivers: (1) information about available resources to support physical activity participation, with Need Indexes of 76.6% and 52.3%, respectively; (2) programs that support joint participation of people with MS together with their caregivers in physical activity, with Need Indexes of 62.0% and 68.9%, respectively; and (3) programs that have affordable total cost of participation, with Need Indexes of 50.7% and 52.3%, respectively. A broad range of factors (i.e., education, living situation, type of community, marital status, employment, and income, as well as comorbidity status) was significantly associated with one or more of these need items. Several modifiable impairment-related, personal and logistical factors were identified by both groups as barriers to co-participation in physical activity.Conclusions: The findings highlight the complexity of developing community resources that target physical activity promotion in MS dyads. Importantly, our findings suggest that resources designed to influence dyadic physical activity participation need to include content that are responsive and tailored to both the needs of the person with MS and the unique needs of the family caregiver. The results also underscore the importance of reinforcing physical activity as a shared behavior and providing information about affordable options for exercising together to the benefit of each individual and the dyad (i.e., partnership). Overall, our findings provide a possible starting point to guide the identification of potential participants that might benefit the most from future intervention development work.Implications for rehabilitationMS has life-altering consequences for people with the disease and the family caregivers who support such individuals.Rehabilitation professionals need to reinforce physical activity as a shared behavior and provide information about affordable options for exercising together to the benefit of each individual and the dyad.A "one-size-fits-all" approach is not appropriate, therefore, clinicians need to identify flexible and pragmatic strategies to increase dyadic participation in the presence of unique caregiver and care-recipients barriers that might impede such an increase.

A systematic review of behavioural techniques used in nutrition and weight loss interventions among adults with mobility-impairing neurological and musculoskeletal conditions

Obesity is a common comorbidity in adults with mobility-impairing neurological and musculoskeletal conditions, such as stroke and arthritis. The interaction between mobility impairments and environmental factors often compromises motivation and ability to engage in healthy behaviours. Such difficulties to engage in healthy behaviours can result in energy imbalance, weight gain and a cycle of functional declines; i.e. obesity can exacerbate mobility impairments and symptoms and increase the likelihood of other comorbid conditions, all of which make it more difficult to engage in healthy behaviours. To help disrupt this cycle, there is a need to identify strategies to optimize energy balance. Thus, this review summarizes clinical trials of nutrition and weight loss interventions in adults with mobility-impairing conditions. Although adults with osteoarthritis were represented in large rigorous clinical trials, adults with neurological conditions were typically represented in studies characterized by a small number of participants, a short-term follow-up and high attrition rates. Studies varied greatly in outcome measures, description and implementation of the interventions, and the strategies used to promote behaviour change. Nutrition and weight loss research in adults with mobility-impairing conditions is still in its formative stages, and there is a substantial need to conduct randomized controlled trials.

Multidimensional health risk appraisal among adults aging with acquired disabilities

BACKGROUND

The increasing older adult population includes people with disabilities facing added challenges of aging. The Affordable Care Act Section 4103 calls for an annual health risk appraisal (HRA) to be administered with older adults. HRAs show promise when used with older adults, yet little is known about their use with adults aging with acquired disabilities.

OBJECTIVES

1) Explore psychometrics of the multidimensional Stay Well and Healthy! Health Risk Appraisal tool (SWH-HRA) among persons aging with disabilities acquired in early or mid-life, and 2) Assess SWH-HRA application to characterize disability subgroup differences.

METHODS

Psychometric analysis conducted on SWH-HRA interview data collected with 93 participants with an acquired disability of at least five years or more post-onset. ANOVA and Chi-square to explore differences in risks by subgroups identified by etiology (traumatic brain injury, stroke, spinal cord injury, and movement disorders).

RESULTS

A high prevalence of health risks was noted. Risks were associated with health, participation and quality of life outcomes. With the exception of independence in basic activities of daily living and incontinence, few statistically significant differences were noted among disability subgroups. Patterns of risk clusters and prevalence within disability subgroup were consistent with findings in the literature.

CONCLUSION

The SWH-HRA provides a valid and comprehensive health risk assessment. When used in annual wellness visits among persons with disabilities, it has the potential to inform the partnership between health providers and individuals with disabilities as they collaborate to promote healthy aging.