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Hoogendoorn CJ, Krause-Steinrauf H, Uschner D, Wen H, Presley CA, Legowski EA, Naik AD, Golden SH, Arends VL, Brown-Friday J, Krakoff JA, Suratt CE, Waltje AH, Cherrington AL, Gonzalez JS. Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:629-637. [PMID: 38227900 PMCID: PMC10973907 DOI: 10.2337/dc23-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/18/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations. RESULTS At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence. CONCLUSIONS Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.
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Affiliation(s)
- Claire J. Hoogendoorn
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Heidi Krause-Steinrauf
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Diane Uschner
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Hui Wen
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Caroline A. Presley
- General Internal and Preventive Medicine, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Elizabeth A. Legowski
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
- University of Texas Health Science Center (UTHealth) School of Public Health, Houston, TX
- Consortium on Aging, University of Texas Health Science Center (UTHealth), Houston, TX
| | - Sherita Hill Golden
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Valerie L. Arends
- Advanced Research and Diagnostic Laboratory, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Janet Brown-Friday
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jonathan A. Krakoff
- Obesity and Diabetes Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ
| | - Colleen E. Suratt
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | - Andrea L. Cherrington
- General Internal and Preventive Medicine, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Jeffrey S. Gonzalez
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
- New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY
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Cherrington AL, Bebu I, Krause-Steinrauf H, Hoogendoorn CJ, Crespo-Ramos G, Presley C, Naik AD, Balasubramanyam A, Gramzinski MR, Killean T, Arends VL, Gonzalez JS. Does Emotional Distress Predict Worse Glycemic Control Over Time? Results From the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:620-628. [PMID: 38252848 PMCID: PMC10973910 DOI: 10.2337/dc23-0642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/09/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To evaluate whether baseline levels of depressive symptoms and diabetes-specific distress are associated with glycemic control in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing the metabolic effects of four common glucose-lowering medications when combined with metformin in individuals with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS The primary and secondary outcomes were defined as an HbA1c value ≥7%, subsequently confirmed, and an HbA1c value >7.5%, subsequently confirmed, respectively. Separate Cox proportional hazards models assessed the association between baseline levels of each exposure of interest (depressive symptoms measured with the eight-item Patient Health Questionnaire and diabetes distress measured with the Diabetes Distress Scale) and the subsequent risk of metabolic outcomes. RESULTS This substudy included 1,739 participants (56% of whom were non-Hispanic White, 18% non-Hispanic Black, 17% Hispanic, and 68% male; mean [SD] age 58.0 [10.2] years, diabetes duration 4.2 [2.8] years, and HbA1c 7.5% [0.48%]). A total of 1,157 participants reached the primary outcome, with time to event of 2.1 years on average, while 738 participants reached the secondary outcome at 3 years on average. With adjustment for sex, race/ethnicity, treatment group, baseline age, duration of T2DM, BMI, and HbA1c, there were no significant associations between the depressive symptoms or diabetes distress and the subsequent risk of the primary or secondary outcomes. CONCLUSIONS The current findings suggest that, at least for individuals with diabetes of relatively short duration, baseline levels of emotional distress are not associated with glycemic control over time.
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Affiliation(s)
- Andrea L. Cherrington
- General Internal and Preventive Medicine, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Ionut Bebu
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Heidi Krause-Steinrauf
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Claire J. Hoogendoorn
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Gladys Crespo-Ramos
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Caroline Presley
- Division of Preventative Medicine, University of Alabama, Birmingham, AL
| | - Aanand D. Naik
- University of Texas Health Science Center (UTHealth) School of Public Health, Houston, TX
| | - Ashok Balasubramanyam
- University of Texas Health Science Center (UTHealth) School of Public Health, Houston, TX
| | - Michaela R. Gramzinski
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Tina Killean
- Obesity and Diabetes Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ
| | - Valerie L. Arends
- Advanced Research and Diagnostic Laboratory, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Jeffrey S. Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
- New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY
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Gonzalez JS, Bebu I, Krause-Steinrauf H, Hoogendoorn CJ, Crespo-Ramos G, Presley C, Naik AD, Kuo S, Johnson ML, Wexler D, Crandall JP, Bantle AE, Arends V, Cherrington AL. Differential Effects of Type 2 Diabetes Treatment Regimens on Diabetes Distress and Depressive Symptoms in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:610-619. [PMID: 38416773 PMCID: PMC10973899 DOI: 10.2337/dc23-2459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE We evaluated whether adding basal insulin to metformin in adults with early type 2 diabetes mellitus (T2DM) would increase emotional distress relative to other treatments. RESEARCH DESIGN AND METHODS The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) of adults with T2DM of <10 years' duration, HbA1c 6.8-8.5%, and taking metformin monotherapy randomly assigned participants to add insulin glargine U-100, sulfonylurea glimepiride, the glucagon-like peptide-1 receptor agonist liraglutide, or the dipeptidyl peptidase 4 inhibitor sitagliptin. The Emotional Distress Substudy enrolled 1,739 GRADE participants (mean [SD] age 58.0 [10.2] years, 32% female, 56% non-Hispanic White, 18% non-Hispanic Black, 17% Hispanic) and assessed diabetes distress and depressive symptoms every 6 months. Analyses examined differences at 1 year and over the 3-year follow-up. RESULTS Across treatments, diabetes distress (-0.24, P < 0.0001) and depressive symptoms (-0.67, P < 0.0001) decreased over 1 year. Diabetes distress was lower at 1 year for the glargine group than for the other groups combined (-0.10, P = 0.002). Diabetes distress was also lower for liraglutide than for glimepiride or sitagliptin (-0.10, P = 0.008). Over the 3-year follow-up, there were no significant group differences in total diabetes distress; interpersonal diabetes distress remained lower for those assigned to liraglutide. No significant differences were observed for depressive symptoms. CONCLUSIONS Contrary to expectations, this randomized trial found no evidence for a deleterious effect of basal insulin on emotional distress. Glargine lowered diabetes distress modestly at 1 year rather than increasing it. Liraglutide also reduced diabetes distress at 1 year. Results can inform treatment decisions for adults with early T2DM.
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Affiliation(s)
- Jeffrey S. Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Division of Endocrinology and Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY
- New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Ionut Bebu
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Claire J. Hoogendoorn
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Division of Endocrinology and Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Gladys Crespo-Ramos
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Division of Endocrinology and Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Caroline Presley
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Aanand D. Naik
- School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Shihchen Kuo
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | | | - Deborah Wexler
- Diabetes Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jill P. Crandall
- Division of Endocrinology and Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Anne E. Bantle
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Valerie Arends
- Advanced Research and Diagnostic Laboratory, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Andrea L. Cherrington
- Department of Medicine (General Internal and Preventive Medicine), University of Alabama at Birmingham, Birmingham, AL
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Samper-Ternent R, Razjouyan J, Dindo L, Halaszynski J, Silva J, Fried T, Naik AD. Patient Priorities Care Increases Long-Term Service and Support Use: Propensity Match Cohort Study. J Am Med Dir Assoc 2024:S1525-8610(24)00002-1. [PMID: 38320742 DOI: 10.1016/j.jamda.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/11/2023] [Accepted: 12/25/2023] [Indexed: 02/29/2024]
Abstract
OBJECTIVES Patient priorities care (PPC) is an evidence-based approach designed to help patients achieve what matters most to them by identifying their health priorities and working with clinicians to align the care they provide to the patient's priorities. This study examined the impact of the PPC approach on long-term service and support (LTSS) use among veterans. DESIGN Quasi-experimental study examining differences in LTSS use between veterans exposed to PPC and propensity-matched controls not exposed to PPC adjusting for covariates. SETTING AND PARTICIPANTS Fifty-six social workers in 5 Veterans Health Administration (VHA) sites trained in PPC in 2018, 143 veterans who used the PPC approach, and 286 matched veterans who did not use the PPC approach. METHODS Veterans with health priorities identified through the PPC approach were the intervention group (n = 143). The usual care group included propensity-matched veterans evaluated by the same social workers in the same period who did not participate in PPC (n = 286). The visit with the social worker was the index date. We examined LTSS use, emergency department (ED), and urgent care visits, 12 months before and after this date for both groups. Electronic medical record notes were extracted with a validated natural language processing algorithm (84% sensitivity, 95% specificity, and 92% accuracy). RESULTS Most participants were white men, mean age was 76, and 30% were frail. LTSS use was 48% higher in the PPC group compared with the usual care group [odds ratio (OR), 1.48; 95% CI, 1.00-2.18; P = .05]. Among those who lived >2 years after the index date, new LTSS use was higher (OR, 1.69; 95% CI, 1.04-2.76; P = .036). Among nonfrail individuals, LTSS use was also higher in the PPC group (OR, 1.70; 95% CI, 1.06-2.74; P = .028). PPC was not associated with higher ED or urgent care use. CONCLUSIONS AND IMPLICATIONS PPC results in higher LTSS use but not ED or urgent care in these veterans. LTSS use was higher for nonfrail veterans and those living longer. The PPC approach helps identify health priorities, including unmet needs for safe and independent living that LTSS can support.
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Affiliation(s)
- Rafael Samper-Ternent
- Department of Management, Policy, and Community Health, UTHealth Houston, Houston, TX, USA; Institute on Aging, UTHealth Houston, Houston, TX, USA.
| | - Javad Razjouyan
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Big Data Scientist Training Enhancement Program (BD-STEP), VA Office of Research and Development, Washington, DC, USA
| | - Lilian Dindo
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jaime Halaszynski
- Social Work Service, Butler VA Health Care System, Butler, PA, USA; VA National Social Work Program, Care Management and Social Work Services, Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
| | - Jennifer Silva
- VA National Social Work Program, Care Management and Social Work Services, Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, USA; Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Terri Fried
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA; Connecticut Veterans Administration Health System, West Haven, CT, USA
| | - Aanand D Naik
- Department of Management, Policy, and Community Health, UTHealth Houston, Houston, TX, USA; Institute on Aging, UTHealth Houston, Houston, TX, USA; VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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5
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Vaughan EM, Cardenas VJ, Chan W, Amspoker AB, Johnston CA, Virani SS, Ballantyne CM, Naik AD. Implementation and Evaluation of a mHealth-Based Community Health Worker Feedback Loop for Hispanics with and at Risk for Diabetes. J Gen Intern Med 2024; 39:229-238. [PMID: 37803098 PMCID: PMC10853118 DOI: 10.1007/s11606-023-08434-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Gaps in accessibility and communication hinder diabetes care in poor communities. Combining mobile health (mHealth) and community health workers (CHWs) into models to bridge these gaps has great potential but needs evaluation. OBJECTIVE To evaluate a mHealth-based, Participant-CHW-Clinician feedback loop in a real-world setting. DESIGN Quasi-experimental feasibility study with intervention and usual care (UC) groups. PARTICIPANTS A total of 134 participants (n = 67/group) who were all low-income, uninsured Hispanics with or at-risk for type 2 diabetes. INTERVENTION A 15-month study with a weekly to semimonthly mHealth Participant-CHW-Clinician feedback loop to identify participant issues and provide participants monthly diabetes education via YouTube. MAIN MEASURES We used pre-defined feasibility measures to evaluate our intervention: (a) implementation, the execution of feedback loops to identify and resolve participant issues, and (b) efficacy, intended effects of the program on clinical outcomes (baseline to 15-month HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight changes) for each group and their subgroups (at-risk; with diabetes, including uncontrolled (HbA1c ≥ 7%)). KEY RESULTS CHWs identified 433 participant issues (mean = 6.5 ± 5.3) and resolved 91.9% of these. Most issues were related to supplies, 26.3% (n = 114); physical health, 23.1% (n = 100); and medication access, 20.8% (n = 90). Intervention participants significantly improved HbA1c (- 0.51%, p = 0.03); UC did not (- 0.10%, p = 0.76). UC DBP worsened (1.91 mmHg, p < 0.01). Subgroup analyses revealed HbA1c improvements for uncontrolled diabetes (intervention: - 1.59%, p < 0.01; controlled: - 0.72, p = 0.03). Several variables for UC at-risk participants worsened: HbA1c (0.25%, p < 0.01), SBP (4.05 mmHg, p < 0.01), DBP (3.21 mmHg, p = 0.01). There were no other significant changes for either group. CONCLUSIONS A novel mHealth-based, Participant-CHW-Clinician feedback loop was associated with improved HbA1c levels and identification and resolution of participant issues. UC individuals had several areas of clinical deterioration, particularly those at-risk for diabetes, which is concerning for progression to diabetes and disease-related complications. CLINICAL TRIAL NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.
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Affiliation(s)
- Elizabeth M Vaughan
- Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX, USA.
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Victor J Cardenas
- Department of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX, USA
| | - Wenyaw Chan
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, Houston, USA
| | - Amber B Amspoker
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Craig A Johnston
- Department of Health and Human Perfomance, University of Houston, Houston, TX, USA
| | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Aga Khan University, Karachi, Pakistan
- Texas Heart Institute, Houston, TX, USA
| | | | - Aanand D Naik
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, Houston, USA
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Tinetti ME, Hashmi A, Ng H, Doyle M, Goto T, Esterson J, Naik AD, Dindo L, Li F. Patient Priorities-Aligned Care for Older Adults With Multiple Conditions: A Nonrandomized Controlled Trial. JAMA Netw Open 2024; 7:e2352666. [PMID: 38261319 PMCID: PMC10807252 DOI: 10.1001/jamanetworkopen.2023.52666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/01/2023] [Indexed: 01/24/2024] Open
Abstract
Importance Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying and aligning care with patients' health priorities may improve outcomes. Objective To assess the association of receiving patient priorities care (PPC) vs usual care (UC) with relevant clinical outcomes. Design, Setting, and Participants In this nonrandomized controlled trial with propensity adjustment, enrollment occurred between August 21, 2020, and May 14, 2021, with follow-up continuing through February 26, 2022. Patients who were aged 65 years or older and with 3 or more chronic conditions were enrolled at 1 PPC and 1 UC site within the Cleveland Clinic primary care multisite practice. Data analysis was performed from March 2022 to August 2023. Intervention Health professionals at the PPC site guided patients through identification of values, health outcome goals, health care preferences, and top priority (ie, health problem they most wanted to focus on because it impeded their health outcome goal). Primary clinicians followed PPC decisional strategies (eg, use patients' health priorities as focus of communication and decision-making) to decide with patients what care to stop, start, or continue. Main Outcomes and Measures Main outcomes included perceived treatment burden, Patient-Reported Outcomes Measurement Information System (PROMIS) social roles and activities, CollaboRATE survey scores, the number of nonhealthy days (based on healthy days at home), and shared prescribing decision quality measures. Follow-up was at 9 months for patient-reported outcomes and 365 days for nonhealthy days. Results A total of 264 individuals participated, 129 in the PPC group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) and 135 in the UC group (mean [SD] age, 75.6 [6.5] years; 55 women [42.6%]). Characteristics between sites were balanced after propensity score weighting. At follow-up, there was no statistically significant difference in perceived treatment burden score between groups in multivariate models (difference, -5.2 points; 95% CI, -10.9 to -0.50 points; P = .07). PPC participants were almost 2.5 times more likely than UC participants to endorse shared prescribing decision-making (adjusted odds ratio, 2.40; 95% CI, 0.90 to 6.40; P = .07), and participants in the PPC group experienced 4.6 fewer nonhealthy days (95% CI, -12.9 to -3.6 days; P = .27) compared with the UC participants. These differences were not statistically significant. CollaboRATE and PROMIS Social Roles and Activities scores were similar in the 2 groups at follow-up. Conclusions and Relevance This nonrandomized trial of priorities-aligned care showed no benefit for social roles or CollaboRATE. While the findings for perceived treatment burden and shared prescribing decision-making were not statistically significant, point estimates for the findings suggested that PPC may hold promise for improving these outcomes. Randomized trials with larger samples are needed to determine the effectiveness of priorities-aligned care. Trial Registration ClinicalTrials.gov Identifier: NCT04510948.
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Affiliation(s)
- Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Ardeshir Hashmi
- Center for Geriatric Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Henry Ng
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Margaret Doyle
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Toyomi Goto
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Jessica Esterson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Institute on Aging, University of Texas Health Science Center, Houston
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Lilian Dindo
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut
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7
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Chary A, Hernandez N, Rivera AP, Ramont V, Obi T, Santangelo I, Ritchie C, Singh H, Hayden E, Naik AD, Liu S, Kennedy M. Perceptions of Acute Care Telemedicine Among Caregivers for Persons Living with Dementia: A Qualitative Study. J Appl Gerontol 2024; 43:69-77. [PMID: 37682526 PMCID: PMC10693729 DOI: 10.1177/07334648231198018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers' perspectives about the acceptability of telemedicine for acute complaints. We performed telephone interviews with 28 caregivers of PLWD from two academic EDs, one in the Northeast and another in the South. Using a combined deductive-inductive approach, we coded interview transcripts and elucidated common themes by consensus. All caregivers reported they would need to participate in the telemedicine visit to help overcome communication and digital literacy challenges. People from racial/ethnic minority groups reported lower comfort with the virtual format. In both sites, participants expressed uncertainty about illness severity that could preclude using telemedicine for acute complaints. Overall, respondents deemed acute care telemedicine acceptable, but caregivers describe specific roles as crucial intermediaries to facilitate virtual care.
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Affiliation(s)
- Anita Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Norvin Hernandez
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Vivian Ramont
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
| | - Tracey Obi
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Emily Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
- Consortium on Aging, University of Texas Health Science Center, Houston, TX, USA
| | - Shan Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Jamieson K, Ogedengbe O, Naik AD, Kiefer L, Tak C, Atkins C, Woodall T. Implementation of patient priorities-aligned care in a home-based primary care program. J Am Pharm Assoc (2003) 2024; 64:96-103. [PMID: 38453664 DOI: 10.1016/j.japh.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Older adults may be limited in their ability to access care that meets their health goals owing to disease burden, financial instability, and psychosocial barriers. A home-based primary care (HBPC) program established in 2020 within a large family medicine practice uses the Patient Priorities Care (PPC) approach to identify and address patients' health priorities. When incorporated as part of the HBPC model of care, the PPC approach has the potential to enhance person-centered care for older adults in a way that best supports their health goals. OBJECTIVE The objective of this study is to summarize common recommendations for alignment of care with patients' health outcome goals after implementation of the PPC approach in an HBPC population. METHODS This retrospective study was exempt from review by an institutional review board. After enrollment in the HBPC program, patients participated in a PPC priorities identification conversation to identify their health outcome goals and care preferences. Through chart review, 2 researchers independently categorized these goals based on the set of values they most reflect: connecting, managing health, enjoying life, and functioning. Aspects of care in place before enrollment in HBPC were considered to determine any adjustments that needed to be made to align care with patients' identified priorities. RESULTS The most common value associated with patients' most desired health outcome goal was functioning (n = 33, 66%). For secondary and tertiary health outcome goals, the most common value identified was managing health (secondary, n = 28, 56%; tertiary, n = 22, 44%). Common recommendations made to align care with patients' identified priorities included stopping potentially harmful medications, starting medications for untreated conditions, starting physical or occupational therapy, and adjusting medications. CONCLUSION Through the PPC approach, patients' values were identified and care was assessed to aid in attainment of individualized health outcome goals and tailor care to What Matters most.
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Banks J, Amspoker AB, Vaughan EM, Woodard L, Naik AD. Ascertainment of Minimal Clinically Important Differences in the Diabetes Distress Scale-17: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2342950. [PMID: 37966840 PMCID: PMC10652154 DOI: 10.1001/jamanetworkopen.2023.42950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023] Open
Abstract
Importance The Diabetes Distress Scale-17 (DDS-17) is a common measure of diabetes distress. Despite its popularity, there are no agreed-on minimal clinically important difference (MCID) values for the DDS-17. Objective To establish a distribution-based metric for MCID in the DDS-17 and its 4 subscale scores (interpersonal distress, physician distress, regimen distress, and emotional distress). Design, Setting, and Participants This secondary analysis of a randomized clinical trial used baseline and postintervention data from a hybrid (implementation-effectiveness) trial evaluating Empowering Patients in Chronic Care (EPICC) vs an enhanced form of usual care (EUC). Participants included adults with uncontrolled type 2 diabetes (glycated hemoglobin A1c [HbA1c] level >8.0%) who received primary care during the prior year in participating Department of Veterans Affairs clinics across Illinois, Indiana, and Texas. Data collection was completed in November 2018, and data analysis was completed in June 2023. Interventions Participants in EPICC attended 6 group sessions led by health care professionals based on collaborative goal-setting theory. EUC included diabetes education. Main Outcomes and Measures The main outcome was distribution-based MCID values for the total DDS-17 and 4 DDS-17 subscales, calculated using the standard error of measurement. Baseline to postintervention changes in DDS-17 and its 4 subscale scores were grouped into 3 categories: improved, no change, and worsened. Multilevel logistic and linear regression models examined associations between treatment group and MCID change categories and whether improvement in HbA1c varied in association with MCID category. Results A total of 248 individuals with complete DDS-17 data were included (mean [SD] age, 67.4 [8.3] years; 235 [94.76%] men), with 123 participants in the EPICC group and 125 participants in the EUC group. The MCID value for DDS-17 was 0.25 and MCID values for the 4 distress subscales were 0.38 for emotional and interpersonal distress and 0.39 for physician and regimen distress. Compared with EUC, more EPICC participants were in the MCID improvement category on DDS-17 (63 participants [51.22%] vs 40 participants [32.00%]; P = .003) and fewer EPICC participants were in the worsened category (20 participants [16.26%] vs 39 participants [31.20%]; P = .008). There was no direct association of DDS-17 MCID improvement (β = -0.25; 95% CI, -0.59 to 0.10; P = .17) or worsening (β = 0.18; 95% CI, -0.22 to 0.59; P = .38) with HbA1c levels among all participants. Conclusions and Relevance In this secondary analysis of data from a randomized clinical trial, an MCID improvement or worsening of more than 0.25 on the DDS-17 was quantitatively significant and patients in the EPICC group were more likely to experience improvement than those in the EUC group. Trial Registration ClinicalTrials.gov Identifier: NCT01876485.
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Affiliation(s)
- Jack Banks
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Institute on Aging, University of Texas Health Science Center, Houston
- Houston Center for Innovations in Quality, Safety, and Effectiveness, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
| | - Amber B. Amspoker
- Houston Center for Innovations in Quality, Safety, and Effectiveness, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas
| | - Elizabeth M. Vaughan
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - LeChauncy Woodard
- Houston Center for Innovations in Quality, Safety, and Effectiveness, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
- Tilman J. Fertitta Family College of Medicine and Humana Integrated Health Systems Sciences Institute, University of Houston, Houston, Texas
| | - Aanand D. Naik
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Institute on Aging, University of Texas Health Science Center, Houston
- Houston Center for Innovations in Quality, Safety, and Effectiveness, Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
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Vaughan EM, Virani S, Al Rifai M, Cardenas VJ, Johnston CA, Porterfield L, Santiago Delgado Z, Samson SL, Schick V, Naik AD. Determining call-to-entry rate and recruitment barriers in clinical studies for community clinics serving low-income populations: a cohort study. BMJ Open 2023; 13:e077819. [PMID: 37898484 PMCID: PMC10619090 DOI: 10.1136/bmjopen-2023-077819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Recruitment for clinical studies is challenging. To overcome barriers, investigators have previously established call-to-entry rates to assist in planning. However, rates specific to low-income minority populations are needed to account for additional barriers to enrolment these individuals face. OBJECTIVE To obtain a call-to-entry rate in a low-income uninsured Hispanic population with chronic disease. METHODS We used data from four of our randomised clinical studies to determine the call-to-entry rate for individuals (n=1075) with or at risk for type 2 diabetes: participants needed/potential participants contacted=recruitment rate (yield). Research staff contacted potential participants to enrol in a study that evaluated 6 month diabetes programmes at community clinics from 2015 to 2020. We recorded call-to-entry rates, reasons for declining the study, show rates, and attrition. RESULTS The call-to-entry rate was 14.5%. Forty per cent of potential participants could not be contacted, and 30.6%, 19.1%, and 5.4% responded yes, no, and maybe, respectively. No show percentages were 54% for yes and 91.4% for maybe responders. The majority (61.6%) declined due to inability to attend; reasons to decline included work (43%), eligibility (18%), transportation (10%), out of town (9%), did not think they needed the programme (7%) and other/unknown (14%). Being a physician predicted inability to reach participants (adjusted OR 2.91, 95% CI 1.73 to 4.90). Attrition was 6.8%. CONCLUSIONS We described a call-to-entry rate and detailed recruitment data, including reasons to decline the study. This valuable information can assist investigators in study planning and overcoming enrolment barriers in low-income populations. Telehealth-based or strategies that limit transportation needs may increase participant involvement. TRIAL REGISTRATION NUMBER NCT03394456.
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Affiliation(s)
- Elizabeth M Vaughan
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Salim Virani
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Houston Center for Quality of Care and Utilization Studies, Center for Innovations in Quality Effectiveness and Safety, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Michael E DeBakey VA Medical Center, Houston, Texas, USA
- Houston Methodist Debakey Heart & Vascular Center, Houston, Texas, USA
| | - Victor J Cardenas
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Craig A Johnston
- Health and Human Performance, The University of Houston, Houston, Texas, USA
| | - Laura Porterfield
- Department of Family Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Zuleica Santiago Delgado
- Department of Family Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Susan L Samson
- Department of Internal Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Vanessa Schick
- Deparrtment of Management, Policy, and Community Health, University of Texas School of Public Health, Houston, Texas, USA
| | - Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Deparrtment of Management, Policy, and Community Health, University of Texas School of Public Health, Houston, Texas, USA
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Naik AD. Pragmatic Evidence for Theory-Based Innovations in Diabetes Primary Care. Diabetes Care 2023; 46:1750-1752. [PMID: 37729505 DOI: 10.2337/dci23-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX
- Institute on Aging, University of Texas Health Science Center, Houston, TX
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
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Nguyen AC, Amspoker AB, Karel M, Stevenson A, Naik AD, Moye J. The what matters most survey: A measurement evaluation of a self-reported patient values elicitation tool among cancer survivors. Patient Educ Couns 2023; 115:107899. [PMID: 37467595 DOI: 10.1016/j.pec.2023.107899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES Patients with multiple chronic conditions, especially cancer survivors, face challenges in medical decision making. Previous research demonstrates how patient values can guide medical decisions, however facilitating patient values elicitation remains a challenge. This study aims to evaluate the psychometric properties of and refine the What Matters Most (WMM) Survey, a self-reported values elicitation tool, in a cohort of older veteran cancer survivors. METHODS An observational cohort study was conducted to evaluate the psychometric properties of the WMM Survey in older, multimorbid cancer survivors. 262 patients were administered the assessment at two timepoints, between 14 and 30 days apart. RESULTS Exploratory factor analyses revealed four factors for assessing healthcare values among older adults with good internal consistency for all factors: Functioning (Cronbach's alpha coefficient, α = 0.88), Enjoying Life (α = 0.79), Connecting (α = 0.84), and Managing Health (α = 0.88). Demographic and clinical characteristics were not uniformly associated with specific healthcare values. CONCLUSIONS Future studies are required to refine the proposed assessment and to evaluate its application in a general patient population. PRACTICE IMPLICATIONS The WMM Survey is an innovative resource in health values elicitation, allowing for facilitation of patient-clinician communication for whole-person medical approaches and measurement of health values for research.
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Affiliation(s)
- Aaron C Nguyen
- Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX, USA.
| | - Amber B Amspoker
- Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX, USA
| | - Michele Karel
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, D.C., USA
| | - Autumn Stevenson
- The University of Queensland-Ochsner MD Program, Brisbane, Australia; Ochsner Health, Brisbane, Australia
| | - Aanand D Naik
- Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX, USA
| | - Jennifer Moye
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Crespo-Ramos G, Bebu I, Krause-Steinrauf H, Hoogendoorn CJ, Fang R, Ehrmann D, Presley C, Naik AD, Katona A, Walker EA, Cherrington A, Gonzalez JS. Emotional distress and cardiovascular disease risk among participants enrolled in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study. Diabetes Res Clin Pract 2023; 203:110808. [PMID: 37394014 PMCID: PMC10592312 DOI: 10.1016/j.diabres.2023.110808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023]
Abstract
AIMS People with type 2 diabetes (T2DM) have an increased risk of cardiovascular disease (CVD). We examined depressive symptoms (DS) and diabetes distress (DD) in relation to the estimated 10-year risk of CVD in adults with T2DM enrolled in the GRADE Emotional Distress Substudy. METHODS Linear regression models examined the associations of baseline DS and DD with estimated 10-year risk of CVD using the Atherosclerotic Cardiovascular Disease (ASCVD) risk score, adjusting for age, sex, race/ethnicity, education, income, diabetes duration, diabetes-related complications, and HbA1c. RESULTS A total of 1,605 GRADE participants were included: 54% Non-Latino (NL) White, 18% Latino, 19% NL-Black, 66% male, mean age 57.5 (SD = 10.25) years, diabetes duration 4.2 (SD = 2.8) years, and HbA1c 7.5% (SD = 0.5%). After incorporating covariates, only DS, especially cognitive-affective symptoms, were associated with ASCVD risk (estimate = 0.15 [95% CI: 0.04, 0.025], p = 0.006). Higher DS remained significantly associated with higher ASCVD risk when adding DD to covariates (estimate = 0.19 [95% CI: 0.07, 0.30], p = 0.002). DD was not associated with ASCVD risk when accounting for covariates. CONCLUSIONS Depressive symptoms, particularly cognitive-affective symptoms, are associated with increased 10-year predicted ASCVD risk among adults with early T2DM. Diabetes distress is not significantly associated with the predicted ASCVD risk when accounting for covariates.
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Affiliation(s)
- Gladys Crespo-Ramos
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ionut Bebu
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, USA
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, USA
| | | | - Ran Fang
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Caroline Presley
- Department of Medicine (General Internal and Preventive Medicine) University of Alabama, Birmingham, Birmingham, AL, USA
| | - Aanand D Naik
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | | | - Elizabeth A Walker
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Cherrington
- Department of Medicine (General Internal and Preventive Medicine) University of Alabama, Birmingham, Birmingham, AL, USA
| | - Jeffrey S Gonzalez
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA; Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA; New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY, USA.
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Ritchey KC, Solberg LM, Citty SW, Kiefer L, Martinez E, Gray C, Naik AD. Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center. Geriatrics (Basel) 2023; 8:74. [PMID: 37489322 PMCID: PMC10366719 DOI: 10.3390/geriatrics8040074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/01/2023] [Accepted: 06/25/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC). METHODS PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC. RESULTS Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS. CONCLUSIONS The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.
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Affiliation(s)
- Katherine C Ritchey
- Puget Sound Veterans Health Care System, Geriatric Research and Education Clinical Center (GRECC), Tacoma, WA 98498, USA
- Division of Geriatrics and Gerontology, Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - Laurence M Solberg
- North Florida/South Georgia Veterans Health System, Geriatric Research and Education Clinical Center (GRECC), Gainesville, FL 32608, USA
| | - Sandra Wolfe Citty
- North Florida/South Georgia Veterans Health System, Geriatric Research and Education Clinical Center (GRECC), Gainesville, FL 32608, USA
- College of Nursing, University of Florida, Gainesville, FL 32611, USA
| | - Lea Kiefer
- Michael E. DeBakey Veterans Health Care System, Houston, TX 77030, USA
| | - Erica Martinez
- Puget Sound Veterans Health Care System, Geriatric Research and Education Clinical Center (GRECC), Tacoma, WA 98498, USA
| | - Caroline Gray
- Palo Alto Veterans Health Care System, Palo Alto, CA 94304, USA
| | - Aanand D Naik
- Michael E. DeBakey Veterans Health Care System, Houston, TX 77030, USA
- Institute on Aging, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Amenta E, Grigoryan L, Rajan SS, Ramsey D, Kramer JR, Walder A, Chou A, Van JN, Krein SL, Hysong S, Naik AD, Trautner BW. Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria. Antimicrob Steward Healthc Epidemiol 2023; 3:e115. [PMID: 37502251 PMCID: PMC10369447 DOI: 10.1017/ash.2023.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 07/29/2023]
Abstract
Objective The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.
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Affiliation(s)
- Eva Amenta
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Suja S. Rajan
- UTHealth Science Center, Institute for Stroke and Cerebral Vascular Disease, Houston, TX, USA
| | - David Ramsey
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer R. Kramer
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Annette Walder
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Andrew Chou
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John N. Van
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sylvia Hysong
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D. Naik
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA
- UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, TX, USA
| | - Barbara W. Trautner
- Michael E. DeBakey Veteran Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Chary A, Brickhouse E, Torres B, Santangelo I, Carpenter CR, Liu SW, Godwin KM, Naik AD, Singh H, Kennedy M. Using the Electronic Health Record to Support Implementation of Emergency Department Delirium Screening: A Qualitative Study. Appl Clin Inform 2023. [PMID: 37054983 DOI: 10.1055/a-2073-3736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Objective To understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening. Materials and Methods We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used HIT resources to implement delirium screening. Interviews focused on challenges participants experienced when implementing ED delirium screening and EHR-based strategies they used to overcome them. We coded interview transcripts using dimensions from the Singh and Sittig socio-technical model, which addresses use of HIT in complex adaptive healthcare systems. Subsequently, we analyzed data for common themes across dimensions of the socio-technical model. Results Three themes emerged about how the EHR could be used to address challenges in implementation of delirium screening: (1) staff adherence to screening, (2) communication among ED team members about a positive screen, and (3) linking positive screening to delirium management. Participants described several HIT-based strategies including visual nudges, icons, hard stop alerts, order sets, and automated communications that facilitated implementation of delirium screening. An additional theme emerged about challenges related to the availability of HIT resources. Discussion Building delirium screening tools and reminders to perform screening into the EHR may prompt adherence to screening. Automating related workflows, team communication, and management of patients who screen positive for delirium may help save staff members' time. Staff education, engagement, and access to HIT resources may support successful screening implementation. Conclusion Our findings provide practical HIT-based strategies for healthcare institutions planning to adopt geriatric screenings.
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Affiliation(s)
- Anita Chary
- Emergency Medicine, Baylor College of Medicine, Houston, United States
- Baylor College of Medicine Department of Medicine, Houston, United States
- Michael E. DeBakey VA Medical Center, Center for Innovations in Quality Effectiveness and Safety, Houston, United States
| | - Elise Brickhouse
- School of Medicine, Baylor College of Medicine, Houston, United States
| | - Beatrice Torres
- UT Health Science Center, University of Texas School of Public Health, Houston, United States
| | | | - Christopher R Carpenter
- Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, United States
| | - Shan W Liu
- Emergency Medicine, Massachusetts General Hospital, Boston, United States
- Harvard Medical School, Boston, United States
| | - Kyler M Godwin
- Baylor College of Medicine Department of Medicine, Houston, United States
- Center for Innovations in Quality Effectiveness and Safety, Houston, United States
| | - Aanand D Naik
- Center for Innovations in Quality Effectiveness and Safety, Houston, United States
- UT Health Science Center, University of Texas School of Public Health, Houston, United States
- Consortium on Aging, The University of Texas Health Science Center at Houston, Houston, United States
| | - Hardeep Singh
- Medicine, Baylor College of Medicine, Houston, United States
- Center for Innovations in Quality Effectiveness and Safety, Houston, United States
| | - Maura Kennedy
- Emergency Medicine, Massachusetts General Hospital, Boston, United States
- Harvard Medical School, Boston, United States
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Chary AN, Torres B, Brickhouse E, Santangelo I, Godwin KM, Naik AD, Carpenter CR, Liu SW, Kennedy M. Language discordance in emergency department delirium screening: Results from a qualitative interview-based study. J Am Geriatr Soc 2023; 71:1328-1331. [PMID: 36451059 PMCID: PMC10089935 DOI: 10.1111/jgs.18147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
| | - Beatrice Torres
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas
| | | | | | - Kyler M. Godwin
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas
- University of Texas Health Consortium on Aging, Houston, Texas
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, Washington University School of Medicine, Emergency Care Research Core
| | - Shan W. Liu
- Department of Emergency Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital
- Harvard Medical School
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Chary A, Brickhouse E, Torres B, Cameron‐Comasco L, Lee S, Punches B, Skains RM, Naik AD, Quatman‐Yates CC, Kennedy M, Southerland LT, Liu S. Physical therapy consultation in the emergency department for older adults with falls: A qualitative study. J Am Coll Emerg Physicians Open 2023; 4:e12941. [PMID: 37090953 PMCID: PMC10114865 DOI: 10.1002/emp2.12941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Objectives Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies. Methods We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation. Results Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available. Conclusion ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.
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Affiliation(s)
- Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
| | | | - Beatrice Torres
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
| | - Lauren Cameron‐Comasco
- Beaumont HospitalRoyal OakMichiganUSA
- School of MedicineOakland University William Beaumont School of MedicineRochesterMichiganUSA
| | - Sangil Lee
- College of MedicineUniversity of Iowa CarverIowa CityIowaUSA
| | - Brittany Punches
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
- College of NursingThe Ohio State UniversityColumbusOhioUSA
| | - Rachel M. Skains
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
- Consortium on AgingUniversity of Texas Health Science CenterHoustonTexasUSA
| | | | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Shan Liu
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Razjouyan J, Horstman MJ, Orkaby AR, Virani SS, Intrator O, Goyal P, Amos CI, Naik AD. Developing a Parsimonious Frailty Index for Older, Multimorbid Adults With Heart Failure Using Machine Learning. Am J Cardiol 2023; 190:75-81. [PMID: 36566620 PMCID: PMC9951585 DOI: 10.1016/j.amjcard.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/13/2022] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
Frailty is associated with adverse outcomes in heart failure (HF). A parsimonious frailty index (FI) that predicts outcomes of older, multimorbid patients with HF could be a useful resource for clinicians. A retrospective study of veterans hospitalized from October 2015 to October 2018 with HF, aged ≥50 years, and discharged home developed a 10-item parsimonious FI using machine learning from diagnostic codes, laboratory results, vital signs, and ejection fraction (EF) from outpatient encounters. An unsupervised clustering technique identified 5 FI strata: severely frail, moderately frail, mildly frail, prefrail, and robust. We report hazard ratios (HRs) of mortality, adjusting for age, gender, race, and EF and odds ratios (ORs) for 30-day and 1-year emergency department visits and all-cause hospitalizations after discharge. We identified 37,431 veterans (age, 73 ± 10 years; co-morbidity index, 5 ± 3; 43.5% with EF ≤40%). All frailty groups had a higher mortality than the robust group: severely frail (HR 2.63, 95% confidence interval [CI] 2.42 to 2.86), moderately frail (HR 2.04, 95% CI 1.87 to 2.22), mildly frail (HR 1.60, 95% CI 1.47 to 1.74), and prefrail (HR 1.18, 95% CI: 1.07 to 1.29). The associations between frailty and mortality remained unchanged in the stratified analysis by age or EF. The combined (severely, moderately, and mildly) frail group had higher odds of 30-day emergency visits (OR 1.62, 95% CI 1.43 to 1.83), all-cause readmission (OR, 1.75, 95% CI 1.52 to 2.02), 1-year emergency visits (OR 1.70, 95% CI 1.53 to 1.89), rehospitalization (OR 2.18, 95% CI 1.97 to 2.41) than the robust group. In conclusion, a 10-item FI is associated with postdischarge outcomes among patients discharged home after a hospitalization for HF. A parsimonious FI may aid clinical prediction at the point of care.
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Affiliation(s)
- Javad Razjouyan
- VA HSR&D, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas; Big Data Scientist Training Enhancement Program, VA Office of Research and Development, Washington, District of Columbia.
| | - Molly J Horstman
- VA HSR&D, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ariela R Orkaby
- New England Geriatrics Research, Education, and Clinical Center, VA Boston Health Care System, Boston Massachusetts; Brigham and Women's Hospital, Harvard Medical School, Boston Massachusetts
| | - Salim S Virani
- VA HSR&D, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Veterans Health Administration, Canandaigua, New York; University of Rochester, Rochester, New York
| | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Medical College of Cornell University, New York, New York; Division of Cardiology, Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | | | - Aanand D Naik
- VA HSR&D, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas; Big Data Scientist Training Enhancement Program, VA Office of Research and Development, Washington, District of Columbia; Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX; UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, TX
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Gonzalez JS, Krause-Steinrauf H, Bebu I, Crespo-Ramos G, Hoogendoorn CJ, Naik AD, Waltje A, Walker E, Ehrmann D, Brown-Friday J, Cherrington A. Emotional distress, self-management, and glycemic control among participants enrolled in the glycemia reduction approaches in diabetes: A comparative effectiveness (GRADE) study. Diabetes Res Clin Pract 2023; 196:110229. [PMID: 36549506 PMCID: PMC9974790 DOI: 10.1016/j.diabres.2022.110229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We examined emotional distress in relation to metformin adherence, overall diabetes self-management, and glycemic control among adults with early type 2 diabetes (T2DM) enrolled in the GRADE study. METHODS Linear regression models examined cross-sectional associations of baseline depression symptoms and diabetes distress with adherence to metformin, self-management, and HbA1c, adjusting for covariates. Cognitive-affective (e.g., sadness) and somatic (e.g., sleep/appetite disturbance) depression symptoms and diabetes distress subscales were also examined. RESULTS This substudy of 1,739 GRADE participants (56 % Non-Hispanic White, 18 % Non-Hispanic Black, 17 % Hispanic, 68 % male, mean[SD] age = 57.96[10.22] years, diabetes duration = 4.21[2.81] years, and HbA1c = 7.51[0.48]) found that the prevalence of clinically significant depression and diabetes distress was 8.7 % and 25 %, respectively. Fully adjusted models showed that depression symptoms were associated with lower self-management (p < 0.0001); this effect was only significant for somatic symptoms. Diabetes distress was associated with lower adherence (p = 0.0001) and self-management (p < 0.0001); effects were significant for all subscales, except physician-related distress. No significant relationships of total depression symptom severity or diabetes distress with HbA1c were found. CONCLUSIONS Depression symptoms and diabetes distress were robustly associated with problematic diabetes self-management among participants in GRADE. These findings highlight the need for routine assessment of depression symptoms and diabetes distress early in T2DM care.
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Affiliation(s)
- Jeffrey S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA; Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA; New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, USA
| | - Ionut Bebu
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, USA
| | - Gladys Crespo-Ramos
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Claire J Hoogendoorn
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA; Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aanand D Naik
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | | | - Elizabeth Walker
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA; New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
| | - Janet Brown-Friday
- Department of Medicine (Endocrinology), Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Cherrington
- Department of Medicine (General Internal and Preventive Medicine), University of Alabama, Birmingham, Birmingham, AL, USA
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Chary AN, Naik AD, Kennedy M. Reply to: Expanding options to include language barriers for predicting postoperative delirium in geriatric patients. J Am Geriatr Soc 2023; 71:294-295. [PMID: 36254368 DOI: 10.1111/jgs.18083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
This letter comments on the letter by Streetman et al.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, USA
- University of Texas Health Consortium on Aging, Houston, Texas, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Eysenbach G, Nowakowski S, Agrawal R, Sharafkhaneh A, Kunik ME, Naik AD, Xu H, Razjouyan J. Sentiment Analysis of Insomnia-Related Tweets via a Combination of Transformers Using Dempster-Shafer Theory: Pre- and Peri-COVID-19 Pandemic Retrospective Study. J Med Internet Res 2022; 24:e41517. [PMID: 36417585 PMCID: PMC9822178 DOI: 10.2196/41517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has imposed additional stress on population health that may result in a change of sleeping behavior. OBJECTIVE In this study, we hypothesized that using natural language processing to explore social media would help with assessing the mental health conditions of people experiencing insomnia after the outbreak of COVID-19. METHODS We designed a retrospective study that used public social media content from Twitter. We categorized insomnia-related tweets based on time, using the following two intervals: the prepandemic (January 1, 2019, to January 1, 2020) and peripandemic (January 1, 2020, to January 1, 2021) intervals. We performed a sentiment analysis by using pretrained transformers in conjunction with Dempster-Shafer theory (DST) to classify the polarity of emotions as positive, negative, and neutral. We validated the proposed pipeline on 300 annotated tweets. Additionally, we performed a temporal analysis to examine the effect of time on Twitter users' insomnia experiences, using logistic regression. RESULTS We extracted 305,321 tweets containing the word insomnia (prepandemic tweets: n=139,561; peripandemic tweets: n=165,760). The best combination of pretrained transformers (combined via DST) yielded 84% accuracy. By using this pipeline, we found that the odds of posting negative tweets (odds ratio [OR] 1.39, 95% CI 1.37-1.41; P<.001) were higher in the peripandemic interval compared to those in the prepandemic interval. The likelihood of posting negative tweets after midnight was 21% higher than that before midnight (OR 1.21, 95% CI 1.19-1.23; P<.001). In the prepandemic interval, while the odds of posting negative tweets were 2% higher after midnight compared to those before midnight (OR 1.02, 95% CI 1.00-1.07; P=.008), they were 43% higher (OR 1.43, 95% CI 1.40-1.46; P<.001) in the peripandemic interval. CONCLUSIONS The proposed novel sentiment analysis pipeline, which combines pretrained transformers via DST, is capable of classifying the emotions and sentiments of insomnia-related tweets. Twitter users shared more negative tweets about insomnia in the peripandemic interval than in the prepandemic interval. Future studies using a natural language processing framework could assess tweets about other types of psychological distress, habit changes, weight gain resulting from inactivity, and the effect of viral infection on sleep.
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Affiliation(s)
| | - Sara Nowakowski
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Ritwick Agrawal
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Amir Sharafkhaneh
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Mark E Kunik
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Aanand D Naik
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Hua Xu
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Javad Razjouyan
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Freytag J, Mishra RK, Street RL, Catic A, Dindo L, Kiefer L, Najafi B, Naik AD. Using Wearable Sensors to Measure Goal Achievement in Older Veterans with Dementia. Sensors (Basel) 2022; 22:9923. [PMID: 36560290 PMCID: PMC9782012 DOI: 10.3390/s22249923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 06/17/2023]
Abstract
Aligning treatment with patients' self-determined goals and health priorities is challenging in dementia care. Wearable-based remote health monitoring may facilitate determining the active participation of individuals with dementia towards achieving the determined goals. The present study aimed to demonstrate the feasibility of using wearables to assess healthcare goals set by older adults with cognitive impairment. We present four specific cases that assess (1) the feasibility of using wearables to monitor healthcare goals, (2) differences in function after goal-setting visits, and (3) goal achievement. Older veterans (n = 17) with cognitive impairment completed self-report assessments of mobility, then had an audio-recorded encounter with a geriatrician and wore a pendant sensor for 48 h. Follow-up was conducted at 4-6 months. Data obtained by wearables augments self-reported data and assessed function over time. Four patient cases illustrate the utility of combining sensors, self-report, notes from electronic health records, and visit transcripts at baseline and follow-up to assess goal achievement. Using data from multiple sources, we showed that the use of wearable devices could support clinical communication, mainly when patients, clinicians, and caregivers work to align care with the patient's priorities.
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Affiliation(s)
- Jennifer Freytag
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Ram Kinker Mishra
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- BioSensics, Boston, MA 02458, USA
| | - Richard L. Street
- Department of Communications, Texas A&M University, College Station, TX 77843, USA
| | - Angela Catic
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Lilian Dindo
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Lea Kiefer
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Bijan Najafi
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Aanand D. Naik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA
- UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, TX 77030, USA
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Krishnamurthy A, Naik AD, Kiefer L, Tak C, Ogedengbe O, Jamieson K, Goswami R, Woodall T. Pharmacist Identification of Older Patients’ Priorities in a Home-Based Primary Care Program. Sr Care Pharm 2022; 37:631-640. [DOI: 10.4140/tcp.n.2022.631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Background Patient Priorities Care (PPC) aims to identify and integrate patient goals and preferences into health care decision-making to provide more personalized care for multimorbid older individuals. Home-based primary care (HBPC) is a model of care delivery that supports
aging in place. HBPC-integrated pharmacists can identify patient priorities and communicate with the team to ensure care is aligned with what matters most. Objectives Evaluate patients’ perceptions of having priorities identification conversations with the pharmacist;
identify the value domains represented by patients’ health outcome goals. Setting HBPC program at a large family medicine practice where pharmacists are core members of the interdisciplinary team. Intervention Pharmacists led priorities identification
conversations for patients newly enrolled in HBPC. Care preferences and health outcome goals were documented in the medical record and communicated during HBPC team meetings. Design This was a prospective, observational study of HBPC enrollees. After the priorities identification
conversation, a three-question survey was administered to identify patients’ perceptions of the conversation and interaction with the pharmacist. Health outcome goals and care preference statements were reviewed to determine with which value domain(s) they most aligned. Descriptive statistics
were used for results analysis. Results Pharmacists led conversations with 30 participants. Average overall satisfaction with the conversation was 4.6 on a 5-point Likert scale (1 = least, 5 = most satisfied). Ninety-three percent of patients felt it was appropriate to
have a pharmacist lead these conversations. Ninety-seven percent believed it was important/very important to discuss their values and goals with their health care team. The predominant value domains represented were Managing Health (43%) and Functioning (40%). Conclusion Patients
were mostly satisfied with having PPC conversations and felt it was appropriate for a pharmacist to lead these conversations. Managing health conditions and preserving function were the most frequent value domains associated with patients’ goals and care preferences.
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Affiliation(s)
| | - Aanand D. Naik
- 2 Department of Management, Policy and Community Health, University of Texas School of Public Health, Austin, Texas
| | - Lea Kiefer
- 3 Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Casey Tak
- 5 Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | | | - Kelly Jamieson
- 7 Mountain Area Health Education Center, Asheville, North Carolina
| | | | - Tasha Woodall
- 7 Mountain Area Health Education Center, Asheville, North Carolina
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Naik AD. Measuring patient-centered care to improve hospital experiences of older adults. J Am Geriatr Soc 2022; 70:3348-3351. [PMID: 36125214 DOI: 10.1111/jgs.18048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA.,UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA.,VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Grouls A, Nwogu-Onyemkpa E, Guffey D, Chatterjee S, Herlihy JP, Naik AD. Palliative Care Impact on COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation. J Pain Symptom Manage 2022; 64:e181-e187. [PMID: 35764199 PMCID: PMC9233556 DOI: 10.1016/j.jpainsymman.2022.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022]
Abstract
CONTEXT Patients with severe respiratory failure from COVID-19 refractory to conventional therapies may be treated with extracorporeal membrane oxygenation (ECMO). ECMO requirement is associated with high mortality and prolonged hospital course. ECMO is a high-resource intervention with significant burdens placed on caregivers and families with limited data on the integration of palliative care consultation (PCC). OBJECTIVES To explore the role of standard vs. automatic PCC in the management of COVID patients on ECMO. METHODS Retrospective chart review of all COVID patients on ECMO admitted from March 2020 to May 2021 at a large volume academic medical center with subsequent analysis. RESULTS Forty-eight patients were included in the analysis. Twenty-six (54.2%) received PCC of which 42% of consults were automatically initiated. PCC at any point in admission was associated with longer duration on ECMO (24.5 vs. 37 days; P < 0.05). Automatic PCC resulted in more family meetings than standard PCC (0 vs. 3; P < 0.05) and appears to trend with reduced time on ECMO, shorter length of stay, and higher DNAR rates at death, though results were not significant. Decedents not receiving PCC had higher rates of no de-escalation of interventions at time of death (31% vs. 11%), indicating full intensive care measures continued through death. CONCLUSIONS Among patients with COVID-19 receiving ECMO, PCC may be associated with a shift to DNAR status particularly with automatic PCC. There may be a further impact on length of stay, duration of time on ECMO and care plan at end of life.
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Affiliation(s)
- Astrid Grouls
- Department of Medicine (A.G., E.N.O.), Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, USA.
| | - Eberechi Nwogu-Onyemkpa
- Department of Medicine (A.G., E.N.O.), Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research (D.G.), Baylor College of Medicine, Houston, Texas, USA
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery (S.C.), Michael E. DeBakey Department of Surgery, Baylor College Medicine, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - James P Herlihy
- Department of Medicine (J.P.H.), Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- Department of Management, Policy, and Community Health (MPACH) (A.D.N.), University of Texas School of Public Health, UTHealth Consortium on Aging; and VA Center of Innovations, DeBakey VA Medical Center, Houston, Texas USA
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Arney J, Gray C, Walling AM, Clark JA, Smith D, Melcher J, Asch S, Kanwal F, Naik AD. Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals. BMJ Open 2022; 12:e062836. [PMID: 36691142 PMCID: PMC9445787 DOI: 10.1136/bmjopen-2022-062836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/16/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD. SETTING 3 geographically dispersed United States Veterans Health Administration health systems. PARTICIPANTS 26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist. MAIN OUTCOME MEASURES We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model. RESULTS Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care. CONCLUSIONS Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care.
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Affiliation(s)
- Jennifer Arney
- Department of Sociology, University of Houston Clear Lake, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Caroline Gray
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, California, USA
| | - Jack A Clark
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Melcher
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Steven Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of General Medical Disciplines, Stanford School of Medicine, Stanford, California, USA
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- University of Texas Health Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA
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Nwogu-Onyemkpa E, Dongarwar D, Salihu HM, Akpati L, Marroquin M, Abadom M, Naik AD. Inpatient palliative care use by patients with sickle cell disease: a retrospective cross-sectional study. BMJ Open 2022; 12:e057361. [PMID: 35973707 PMCID: PMC9386219 DOI: 10.1136/bmjopen-2021-057361] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Sickle cell disease (SCD) is a highly morbid condition notable for recurrent hospitalisations due to vaso-occlusive crises and complications of end organ damage. Little is known about the use of inpatient palliative care services in adult patients with SCD. This study aims to evaluate inpatient palliative care use during SCD-related hospitalisations overall and during terminal hospitalisations. We hypothesise that use of palliative care is low in SCD hospitalisations. DESIGN A retrospective cross-sectional study using data from the National Inpatient Sample from 2008 to 2017 was conducted. SETTING US hospitals from 47 states and the District of Columbia. PARTICIPANTS Patients >18 years old hospitalised with a primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or ICD-10-CM diagnosis of SCD were included. PRIMARY AND SECONDARY OUTCOME MEASURES Palliative care service use (documented by ICD-9-CM and ICD-10-CM diagnosis codes V66.7 and Z51.5). RESULTS 987 555 SCD-related hospitalisations were identified, of which 4442 (0.45%) received palliative care service. Palliative care service use increased at a rate of 9.2% per year (95% CI 5.6 to 12.9). NH-black and Hispanic patients were 33% and 53% less likely to have palliative care services compared with NH-white patients (OR 0.67; 95% CI 0.45 to 0.99 and OR 0.47; 95% CI 0.26 to 0.84). Female patients (OR 0.40; 95% CI 0.21 to 0.76), Medicaid use (OR 0.40; 95% CI 0.21 to 0.78), rural (OR 0.47; 95% CI 0.28 to 0.79) and urban non-teaching hospitals (OR 0.61; 95% CI 0.47 to 0.80) each had a lower likelihood of palliative care services use. CONCLUSION Use of palliative care during SCD-related hospitalisations is increasing but remains low. Disparities associated with race and gender exist for use of palliative care services during SCD-related hospitalisation. Further studies are needed to guide evidence-based palliative care interventions for more comprehensive and equitable care of adult patients with SCD.
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Affiliation(s)
- Eberechi Nwogu-Onyemkpa
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Lois Akpati
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Maricarmen Marroquin
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Megan Abadom
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- UTHealth Consortium on Aging; Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, Texas, USA
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
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Affiliation(s)
| | - Aanand D Naik
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth Houston)
- Michael E. DeBakey VA Medical Center, Houston, Texas
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Chary A, Liu SW, Southerland L, Cameron-Comasco L, Ouchi K, Carpenter CR, Boyer EW, Naik AD, Kennedy M. Emergency Department Policies to Improve Care Experiences for Older Adults During the COVID-19 Pandemic. J Geriatr Emerg Med 2022; 3:10.17294/2694-4715.1031. [PMID: 36111131 PMCID: PMC9473422 DOI: 10.17294/2694-4715.1031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Anita Chary
- Section of Health Services Research, Dept. of Medicine; Dept. of Emergency Medicine; Center for Innovations in Quality, Effectiveness and Safety; Baylor College of Medicine
| | - Shan W Liu
- Dept. of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School
| | | | - Lauren Cameron-Comasco
- Dept. of Emergency Medicine, Beaumont Hospital-Royal Oak, Oakland University William Beaumont School of Medicine
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Dana Farber Cancer Institute
| | - Christopher R Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, Washington University School of Medicine
| | - Edward W Boyer
- Department of Emergency Medicine, Ohio State University, Harvard Medical School
| | - Aanand D Naik
- Department of Management, Policy, and Community Health, UT School of Public Health and UT Health Consortium on Aging
| | - Maura Kennedy
- Dept. of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School
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Naik AD, Walling AM. Getting patients ready for "in the moment" decisions. J Am Geriatr Soc 2022; 70:2474-2477. [PMID: 35781226 DOI: 10.1111/jgs.17935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA.,UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA.,VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Texas, USA.,VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Gray C, Arney J, Clark JA, Walling AM, Kanwal F, Naik AD. The chosen and the unchosen: How eligibility for liver transplant influences the lived experiences of patients with advanced liver disease. Soc Sci Med 2022; 305:115113. [PMID: 35690034 DOI: 10.1016/j.socscimed.2022.115113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 02/07/2023]
Abstract
Advanced liver disease is often uncurable and fatal. Liver transplant is the only curative option for patients with advanced, irreversible liver disease, but the need for new livers far exceeds the supply. Patients with the greatest need as well as the greatest likelihood of benefit, based on a complex array of biomedical and psychosocial considerations, are prioritized for transplant. The opportunity to receive a life-saving surgery no doubt has enormous consequences for patients and their healthcare providers, as does the absence of that opportunity. But these consequences are poorly characterized, especially for patients deemed poor candidates for liver transplant. Through in-depth interviews with patients living with advanced liver disease and the providers who care for them, we explore how eligibility status affects illness experiences, including patients' interactions with clinicians, knowledge about their disease, expectations for the future, and efforts to come to terms with a life-limiting illness. We describe how the clinical and social requirements needed to secure eligibility for liver transplant lend themselves to a clinical and cultural logic that delineates "worthy" and "unworthy" patients. We describe how providers and candidates discuss the possibility of moral redemption for such patients through transplant surgeries, a discourse notably absent among patients not eligible for transplant.
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Affiliation(s)
- Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Jennifer Arney
- Department of Sociology, University of Houston-Clear Lake, 2700 Bay Area Boulevard, Houston, TX, 77058, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA.
| | - Jack A Clark
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Anne M Walling
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA; Department of Medicine, Division of General Internal Medicine and Health Services Research University of California at Los Angeles, 1100 Glendon Ave STE 850, Los Angeles, CA, 90024, USA.
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Health Services Research and Gastroenterology and Hepatology, Baylor College of Medicine, 7200 Cambridge St., Houston, TX, 77030, USA.
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd Suite 01Y, Houston, TX, 77021, USA; Department of Medicine, Department of Health Services Research, Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, TX 7200 Cambridge St., Houston, TX, 77030, USA.
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Grigoryan L, Naik AD, Lichtenberger P, Graber CJ, Patel PK, Drekonja DM, Gauthier TP, Shukla B, Sales AE, Krein SL, Van JN, Dillon LM, Hysong SJ, Kramer JR, Walder A, Ramsey D, Trautner BW. Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2222530. [PMID: 35877123 PMCID: PMC9315417 DOI: 10.1001/jamanetworkopen.2022.22530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. OBJECTIVE To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. INTERVENTION Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. MAIN OUTCOMES AND MEASURES Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. RESULTS Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. CONCLUSIONS AND RELEVANCE The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Paola Lichtenberger
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Christopher J. Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Medicine, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor
| | - Dimitri M. Drekonja
- Division of Infectious Diseases and International Medicine, University of Minnesota Medical School and Minneapolis VA Health Care System, Minneapolis
| | | | - Bhavarth Shukla
- Department of Medicine, University of Miami Miller School of Medicine and the Miami VA Healthcare System, University of Miami, Miami, Florida
| | - Anne E. Sales
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John N. Van
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Laura M. Dillon
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
| | - Sylvia J. Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Annette Walder
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Samper-Ternent R, Tinetti M, Jennings LA, Wong R, Arney J, Naik AD. Better care for older Hispanics: Identifying priorities and harmonizing care. J Am Geriatr Soc 2022; 70:1889-1894. [PMID: 35319787 PMCID: PMC9228737 DOI: 10.1111/jgs.17748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/26/2022] [Accepted: 03/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Lee A. Jennings
- Section of Geriatric Medicine, University of Oklahoma Health Sciences Center
| | | | - Jennifer Arney
- University of Houston Clear Lake
- Houston VA HSR Center of Innovation, Michael E. DeBakey VA Medical Center
| | - Aanand D. Naik
- University of Texas Health Science Center, Houston, Texas
- Houston VA HSR Center of Innovation, Michael E. DeBakey VA Medical Center
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Woodard L, Amspoker AB, Hundt NE, Gordon HS, Hertz B, Odom E, Utech A, Razjouyan J, Rajan SS, Kamdar N, Lindo J, Kiefer L, Mehta P, Naik AD. Comparison of Collaborative Goal Setting With Enhanced Education for Managing Diabetes-Associated Distress and Hemoglobin A1c Levels: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e229975. [PMID: 35507345 PMCID: PMC9069258 DOI: 10.1001/jamanetworkopen.2022.9975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Type 2 diabetes is a prevalent and morbid condition. Poor engagement with self-management can contribute to diabetes-associated distress and hinder diabetes control. OBJECTIVE To evaluate the implementation and effectiveness of Empowering Patients in Chronic Care (EPICC), an evidence-based intervention to improve diabetes-associated distress and hemoglobin A1c (HbA1c) levels after the intervention and after 6-month maintenance. DESIGN, SETTING, AND PARTICIPANTS This hybrid (implementation-effectiveness) randomized clinical trial was performed in Veterans Affairs clinics across Illinois, Indiana, and Texas from July 1, 2015, to June 30, 2017. Participants included adults with uncontrolled type 2 diabetes (HbA1c level >8.0%) who received primary care during the prior year in participating clinics. Data collection was completed on November 30, 2018, and data analysis was completed on June 30, 2020. All analyses were based on intention to treat. INTERVENTIONS Participants in EPICC attended 6 group sessions based on a collaborative goal-setting theory led by health care professionals. Clinicians conducted individual motivational interviewing sessions after each group. Usual care was enhanced (EUC) with diabetes education. MAIN OUTCOMES AND MEASURES The primary outcome consisted of changes in HbA1c levels after the intervention and during maintenance. Secondary outcomes included the Diabetes Distress Scale (DDS), Morisky Medication Adherence Scale, and Lorig Self-efficacy Scale. Secondary implementation outcomes included reach, adoption, and implementation (number of sessions attended per patient). RESULTS A total of 280 participants with type 2 diabetes (mean [SD] age, 67.2 [8.4] years; 264 men [94.3]; 134 non-Hispanic White individuals [47.9%]) were equally randomized to EPICC or EUC. Participants receiving EPICC had significant postintervention improvements in HbA1c levels (F1, 252 = 9.12, Cohen d = 0.36 [95% CI, 0.12-0.59]; P = .003) and DDS (F1, 245 = 9.06, Cohen d = 0.37 [95% CI, 0.13-0.60]; P = .003) compared with EUC. During maintenance, differences between the EUC and EPICC groups remained significant for DDS score (F1, 245 = 8.94, Cohen d = 0.36 [95% CI, 0.12-0.59]; P = .003) but not for HbA1c levels (F1, 252 = 0.29, Cohen d = 0.06 [95% CI, -0.17 to 0.30]; P = .60). Improvements in DDS scores were modest. There were no differences between EPICC and EUC in improvements after intervention or maintenance for either adherence or self-efficacy. Among all 4002 eligible patients, 280 (7.0%) enrolled in the study (reach). Each clinic conducted all planned EPICC sessions and cohorts (100% adoption). The EPICC group participants attended a mean (SD) of 4.34 (1.98) sessions, with 54 (38.6%) receiving all 6 sessions. CONCLUSIONS AND RELEVANCE A patient-empowerment approach using longitudinal collaborative goal setting and motivational interviewing is feasible in primary care. Improvements in HbA1c levels after the intervention were not sustained after maintenance. Modest improvements in diabetes-associated distress after the intervention were sustained after maintenance. Innovations to expand reach (eg, telemedicine-enabled shared appointments) and sustainability are needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01876485.
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Affiliation(s)
- LeChauncy Woodard
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Humana Integrated Health System Sciences Institute, University of Houston, Houston, Texas
- Department of Health Systems and Population Health Sciences, University of Houston College of Medicine, Houston, Texas
| | - Amber B. Amspoker
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Natalie E. Hundt
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Howard S. Gordon
- Jesse Brown Veterans Affairs Medical Center, VA Center of Innovation for Complex Chronic Healthcare, Chicago, Illinois
- Section of Academic Internal Medicine, Department of Medicine, University of Illinois Chicago
- Institute for Health Research and Policy, University of Illinois Chicago
| | - Brian Hertz
- Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Chicago, Illinois
- Division of Internal Medicine, Hines Veterans Affairs Hospital, Hines, Illinois
- Office of Veterans Access to Care, US Department of Veterans Affairs, Washington, DC
| | - Edward Odom
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anne Utech
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Nutrition and Food Services, US Department of Veterans Affairs, Washington, DC
| | - Javad Razjouyan
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Big Data Scientist Training Enhancement Program (BD-STEP), VA Office of Research and Development, Washington, DC
| | - Suja S. Rajan
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston
| | - Nipa Kamdar
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jasmin Lindo
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Lea Kiefer
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Praveen Mehta
- Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Chicago, Illinois
- Veterans Integrated Network 16 (Great Lakes VA Health System), Chicago, Illinois
| | - Aanand D. Naik
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. Debakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Big Data Scientist Training Enhancement Program (BD-STEP), VA Office of Research and Development, Washington, DC
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston
- Consortium on Aging, University of Texas Health Science Center, Houston
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Howard C, Amspoker AB, Morgan CK, Kuo D, Esquivel A, Rosen T, Razjouyan J, Siddique MA, Herlihy JP, Naik AD. Implementation of automated early warning decision support to detect acute decompensation in the emergency department improves hospital mortality. BMJ Open Qual 2022; 11:bmjoq-2021-001653. [PMID: 35396254 PMCID: PMC8996043 DOI: 10.1136/bmjoq-2021-001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/06/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Amber B Amspoker
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Dick Kuo
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Adol Esquivel
- Baylor St Luke's Medical Center (BSLMC), Houston, Texas, USA
| | - Tracey Rosen
- Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Javad Razjouyan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | | | - James P Herlihy
- Baylor St Luke's Medical Center (BSLMC), Houston, Texas, USA
| | - Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA.,Management, Policy, and Community Health, University of Texas School of Public Health, Houston, Texas, USA
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Godwin KM, Horstman MJ, Chao S, Dolansky M, Al Mohajer M, Naik AD. Developing an Interprofessional Health Care Improvement Portfolio: Results From a Consensus Panel Process. Acad Med 2022; 97:503-509. [PMID: 34647921 DOI: 10.1097/acm.0000000000004448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The increased focus on professional-led, continuous health care improvement has not produced formalized processes for identifying, recognizing, and rewarding excellence in quality improvement. Moreover, the team-based nature of improvement requires a mechanism to document interprofessional contributions. In 2018, the authors created a health care improvement portfolio to document and demonstrate individual impact for the purpose of promotion. A draft portfolio was developed from a review of the literature and publicly available quality improvement and educational portfolios. The portfolio was further refined through a 2-round, modified Delphi consensus process with a panel of interprofessional experts across North America. In the first round, 35 panelists gave feedback through open-ended comments on the design and content of the portfolio. In the second round, 34 panelists rated the comprehensiveness and clarity of the portfolio on a scale of 1-9 (1 = lowest, 9 = highest) and provided comments. Consensus was defined as an average score over 8.0. Panelists in the second round achieved consensus, with average scores of 8.4 in comprehensiveness and 8.3 in clarity (range, 6-9). The finalized portfolio includes the following sections: personal statement; health care improvement training and certification; leadership and administrative roles; health care improvement project activities; health care improvement coaching, teaching, and curricular activities; health care improvement honors, awards, and recognitions; and supporting documents. The portfolio facilitates the documentation of health care professionals' contributions to and impact in health care improvement and covers the breadth of interprofessional health care improvement (i.e., projects, leadership, education, scholarship). The portfolio can be tailored to an individual's area of specific expertise. While this portfolio was originally developed for interprofessional faculty at academic institutions, the content and structure of the portfolio are easily adapted for health care providers in other health care settings.
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Affiliation(s)
- Kyler M Godwin
- K.M. Godwin is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, director, VA Quality Scholars Coordinating Center, and assistant professor, Department of Medicine, Baylor College of Medicine, Houston, Texas; ORCID: https://orcid.org/0000-0002-6286-1899
| | - Molly J Horstman
- M.J. Horstman is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, core faculty, VA Quality Scholars Coordinating Center, and assistant professor, Department of Medicine, Baylor College of Medicine, Houston, Texas; ORCID: https://orcid.org/0000-0003-3936-8112
| | - Samantha Chao
- S. Chao is a Health, Humanism, and Society Scholars Program undergraduate student, Rice University, Houston, Texas
| | - Mary Dolansky
- M. Dolansky is Sarah C. Hirsh professor and director, Quality and Safety Education for Nurses Institute, Frances Payne Bolton School of Nursing, and associate professor, Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, and senior advisor, VA Quality Scholars program; ORCID: https://orcid.org/000-0002-6472-1275
| | - Mayar Al Mohajer
- M. Al Mohajer is associate professor, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Aanand D Naik
- A.D. Naik is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, senior advisor, VA Quality Scholars program, and professor and Luchi Chair in geriatric medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas; https://orcid.org/0000-0001-6936-7984
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Arney J, Gray C, Clark JA, Smith D, Swank A, Matlock DD, Melcher J, Kanwal F, Naik AD. Prognosis conversations in advanced liver disease: A qualitative interview study with health professionals and patients. PLoS One 2022; 17:e0263874. [PMID: 35180233 PMCID: PMC8856527 DOI: 10.1371/journal.pone.0263874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 01/31/2022] [Indexed: 12/16/2022] Open
Abstract
Advanced Liver Disease (AdvLD) is common, morbid, and associated with high likelihood of death. Patients may not fully understand their prognosis and are often unprepared for the course of illness. Little is known about how and when to deliver prognosis-related information to patients with AdvLD, who should participate, and what should be discussed. We conducted in-depth interviews with a multi-profession sample of Hepatology clinicians and patients with AdvLD. Participants were drawn from three geographically diverse facilities (New England, Texas, California). We used inductive and deductive qualitative data analysis approaches to identify themes related to AdvLD prognosis discussions. Thematic analysis focused on content, timing, and participants’ roles in prognosis discussions. In total, 31 patients with AdvLD and 26 multi-profession clinicians completed interviews. Most participants provided a broad conceptualization of prognosis beyond predictions of survival, including expectations about illness course, ways to manage or avoid complications and a need to address patients’ emotions. Patients favored initiating discussions early in the AdvLD course and welcomed a multi-profession approach to conducting discussions. Clinicians favored a larger role for specialty physicians. All participants recognized that AdvLD prognosis discussions occur infrequently and favored a structured, standardized approach to broadly discussing prognosis. Patients with AdvLD and their clinicians favored a multifaceted approach to prognosis conversations including discussions of life expectancy, predictions about likely course of liver disease, and expected changes in function and capabilities over time. Structured and early prognosis discussions should be part of routine AdvLD care.
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Affiliation(s)
- Jennifer Arney
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Donna Smith
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Annie Swank
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Daniel D. Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, Colorado
| | - Jennifer Melcher
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Fasiha Kanwal
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aanand D. Naik
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, Colorado
- * E-mail:
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Vaughan EM, Cully JA, Petersen NJ, Hundt NE, Kunik ME, Zeno DD, Naik AD. Testing the Impact of a Collaborative, Goal-Setting, and Behavioral Telehealth Intervention on Diabetes Distress: A Randomized Clinical Trial. Telemed J E Health 2022; 28:84-92. [PMID: 33728989 PMCID: PMC8785757 DOI: 10.1089/tmj.2020.0533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background:Diabetes distress is underrecognized and associated with poor outcomes. This study tested whether a 12-month collaborative, goal-setting, and behavioral telehealth intervention reduced diabetes distress levels.Methods:This is a secondary analysis of the Healthy Outcomes through Patient Empowerment (HOPE) study that included individuals (N = 225) with uncontrolled diabetes and depression living at least 20 miles from a Veteran's Affairs medical center. Participants were randomized to HOPE (intervention) or Enhanced Usual Care (EUC) with education. We evaluated diabetes distress levels as measured by the Problem Areas in Diabetes (PAID) Questionnaire and its four subscales (emotional, diabetes management, social, and treatment distress) at baseline, 6, and 12 months.Results:Between-group analysis revealed greater improvements in HOPE versus EUC for: 6-month PAID total score (p = 0.04), emotional (p = 0.03), and social (p = 0.04) subscales; 12-month PAID total score (p = 0.07) and emotional subscale (p = 0.07). Within-group comparisons showed larger effect sizes for HOPE compared with EUC: 12-month PAID total scores (0.82 vs. 0.54), 6-month emotional burden (0.54 vs. 0.31), and 6-month (0.32 vs. 0.08) and 12-month (0.41 vs. 0.12) social burdens. Repeated-measures analysis evaluating treatment group and time trended toward improvement in PAID overall for HOPE compared with EUC participants, but was not statistically significant (β = 6.96; SE = 4.35; p = 0.13).Discussion:Clinically meaningful reductions in PAID overall and the emotional and social subscales were observed in HOPE compared with EUC participants.Conclusion:Further evaluation of diabetes telehealth interventions that include other facets related to diabetes distress, including treatment, diabetes management, social, and emotional burdens, is warranted. Clinical Trial Number. NCT01572389; Clinical Trial Registry. https://clinicaltrials.gov/ct2/show/NCT01572389.
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Affiliation(s)
- Elizabeth M. Vaughan
- Baylor College of Medicine, Houston, Texas, USA.,Address correspondence to: Elizabeth M. Vaughan, DO, MPH, Department of Medicine, 1504 Taub Loop, 2 RM-81-001 a-f. BCM 285, Houston, TX 77030, USA
| | - Jeffrey A. Cully
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Nancy J. Petersen
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Natalie E. Hundt
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Mark E. Kunik
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Darrell D. Zeno
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
| | - Aanand D. Naik
- Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA
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Zhou H, Park C, Shahbazi M, York MK, Kunik ME, Naik AD, Najafi B. Digital Biomarkers of Cognitive Frailty: The Value of Detailed Gait Assessment Beyond Gait Speed. Gerontology 2022; 68:224-233. [PMID: 33971647 PMCID: PMC8578566 DOI: 10.1159/000515939] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/16/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cognitive frailty (CF), defined as the simultaneous presence of cognitive impairment and physical frailty, is a clinical symptom in early-stage dementia with promise in assessing the risk of dementia. The purpose of this study was to use wearables to determine the most sensitive digital gait biomarkers to identify CF. METHODS Of 121 older adults (age = 78.9 ± 8.2 years, body mass index = 26.6 ± 5.5 kg/m2) who were evaluated with a comprehensive neurological exam and the Fried frailty criteria, 41 participants (34%) were identified with CF and 80 participants (66%) were identified without CF. Gait performance of participants was assessed under single task (walking without cognitive distraction) and dual task (walking while counting backward from a random number) using a validated wearable platform. Participants walked at habitual speed over a distance of 10 m. A validated algorithm was used to determine steady-state walking. Gait parameters of interest include steady-state gait speed, stride length, gait cycle time, double support, and gait unsteadiness. In addition, speed and stride length were normalized by height. RESULTS Our results suggest that compared to the group without CF, the CF group had deteriorated gait performances in both single-task and dual-task walking (Cohen's effect size d = 0.42-0.97, p < 0.050). The largest effect size was observed in normalized dual-task gait speed (d = 0.97, p < 0.001). The use of dual-task gait speed improved the area under the curve (AUC) to distinguish CF cases to 0.76 from 0.73 observed for the single-task gait speed. Adding both single-task and dual-task gait speeds did not noticeably change AUC. However, when additional gait parameters such as gait unsteadiness, stride length, and double support were included in the model, AUC was improved to 0.87. CONCLUSIONS This study suggests that gait performances measured by wearable sensors are potential digital biomarkers of CF among older adults. Dual-task gait and other detailed gait metrics provide value for identifying CF above gait speed alone. Future studies need to examine the potential benefits of gait performances for early diagnosis of CF and/or tracking its severity over time.
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Affiliation(s)
- He Zhou
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA,BioSensics LLC, Newton, MA, USA
| | - Catherine Park
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohammad Shahbazi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Michele K. York
- Neurology and Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Mark E. Kunik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA,VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA,Geriatrics and Palliative Medicine Section, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D. Naik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA,VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA,Geriatrics and Palliative Medicine Section, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA,Geriatrics and Palliative Medicine Section, Baylor College of Medicine, Houston, TX, USA
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Chary A, Joshi C, Castilla-Ojo N, Santangelo I, Ouchi K, Naik AD, Carpenter CR, Liu SW, Kennedy M. Emergency Clinicians’ Perceptions of Communication Tools to Establish the Mental Baseline of Older Adults: A Qualitative Study. Cureus 2021; 13:e20616. [PMID: 35103191 PMCID: PMC8782497 DOI: 10.7759/cureus.20616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/05/2022] Open
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Chary AN, Castilla-Ojo N, Joshi C, Santangelo I, Carpenter CR, Ouchi K, Naik AD, Liu SW, Kennedy M. Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians. J Am Geriatr Soc 2021; 70:341-351. [PMID: 34796476 PMCID: PMC9200057 DOI: 10.1111/jgs.17581] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic. METHODS From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared. RESULTS Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic. CONCLUSION Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Christopher Joshi
- School of Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, St. Louis, Missouri, USA.,Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,School of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,School of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Ouellet JA, Mecca MC, Tinetti ME, Dindo L, Kiefer L, Nguyen AC, Omer ZB, Naik AD, Catic AG. Education outcomes of a multisite, virtual, interprofessional training in patient priorities aligned care. J Am Geriatr Soc 2021; 70:E5-E7. [PMID: 34741462 DOI: 10.1111/jgs.17544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/09/2021] [Accepted: 10/09/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Jennifer A Ouellet
- Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, Connecticut, USA
| | - Marcia C Mecca
- Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine (Geriatrics), VA Connecticut, West Haven, Connecticut, USA
| | - Mary E Tinetti
- Department of Internal Medicine (Geriatrics), Yale School of Medicine, New Haven, Connecticut, USA
| | - Lilian Dindo
- Department of Internal Medicine (Geriatrics), Baylor College of Medicine, Houston, Texas, USA.,Department of Internal Medicine (Geriatrics), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Lea Kiefer
- Department of Internal Medicine (Geriatrics), Baylor College of Medicine, Houston, Texas, USA.,Department of Internal Medicine (Geriatrics), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Aaron C Nguyen
- Department of Internal Medicine (Geriatrics), Baylor College of Medicine, Houston, Texas, USA
| | - Zehra B Omer
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aanand D Naik
- Department of Internal Medicine (Geriatrics), Baylor College of Medicine, Houston, Texas, USA.,Department of Internal Medicine (Geriatrics), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Angela G Catic
- Department of Internal Medicine (Geriatrics), Baylor College of Medicine, Houston, Texas, USA.,Department of Internal Medicine (Geriatrics), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Auguste EJ, Weiskittle RE, Sohl SJ, Danhauer SC, Doherty K, Naik AD, Moye J. Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga. Fed Pract 2021; 38:450-458. [PMID: 34733065 DOI: 10.12788/fp.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds. Methods We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga. Results In study 1, interest in yoga increased from 5.5 to 31.8% (χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample. Conclusions A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.
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Affiliation(s)
- Elizabeth J Auguste
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Rachel E Weiskittle
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Stephanie J Sohl
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Suzanne C Danhauer
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Kelly Doherty
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Aanand D Naik
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
| | - Jennifer Moye
- is a Research Assistant; is an Advanced Fellow; is a Health Science Specialist; and is Associate Director for Education and Evaluation; all at US Department of Veterans Affairs (VA) New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System in Massachusetts. is a Assistant Professor, and is a Professor and Director of Faculty Well-Being & Resilience, both at the Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine in Winston Salem, North Carolina. is Chief of Implementation Science at the VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center and a Professor and Robert Luchi, MD Chair in Geriatric Medicine at the Baylor College of Medicine in Houston, Texas. Rachel Weiskittle is a Research Fellow and Jennifer Moye is a Professor, both at the Department of Psychiatry, Harvard Medical School
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Godwin KM, Narayanan A, Arredondo K, Miltner RS, Bowen ME, Gilman S, Shirks A, Eng JA, Naik AD, Hysong SJ. Value of Interprofessional Education: The VA Quality Scholars Program. J Healthc Qual 2021; 43:304-311. [PMID: 34029295 DOI: 10.1097/jhq.0000000000000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Interprofessional collaboration (IPC) has been shown to improve healthcare quality and patient safety; however, formal interprofessional education (IPE) training is insufficient. The VA Quality Scholars (VAQS) program exists to develop interprofessional leaders and scholars in healthcare improvement. The purpose of this study was to examine the impact of integrating interprofessional healthcare learners and designing an interprofessional curriculum for the national VAQS program. VAQS alumni (graduates from 2001 to 2017) across eight national sites (n = 102 [53.1%]) completed a web-based survey to assess alumni perceptions of IPC skill development during the program and IPC skill utilization in their careers. Alumni from 2009 and earlier were physicians; alumni after 2009 came from diverse health professional backgrounds. Overall, IPC and teamwork was identified as the most used skill (n = 82, 70%) during their career. When comparing the pre-IPE period and the post-IPE period, post-IPE alumni identified IPC and teamwork as the area of greatest skill development (n = 38). Integrating interprofessional trainees and robust IPE curricula enhanced an established and successful quality improvement (QI) training program. VAQS alumni endorsed the importance of IPC skills during their careers. The VAQS program is an example of how health professionals can successfully learn IPC skills in healthcare QI.
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Major AB, Naik AD, Farrell TW. Finding a Voice for the Accidentally Unbefriended. JAMA Intern Med 2021; 181:1159-1160. [PMID: 34228048 DOI: 10.1001/jamainternmed.2021.2956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anita B Major
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas.,House Call Program, Ben Taub General Hospital, Harris Health System, Houston, Texas
| | - Aanand D Naik
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Timothy W Farrell
- Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.,VA Salt Lake City Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah
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Vaughan EM, Naik AD, Amspoker AB, Johnston CA, Landrum JD, Balasubramanyam A, Virani SS, Ballantyne CM, Foreyt JP. Mentored implementation to initiate a diabetes program in an underserved community: a pilot study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002320. [PMID: 34385148 PMCID: PMC8362735 DOI: 10.1136/bmjdrc-2021-002320] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/18/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Community clinics often face pragmatic barriers, hindering program initiation and replication of controlled research trial results. Mentoring is a potential strategy to overcome these barriers. We piloted an in-person and telehealth mentoring strategy to implement the Telehealth-supported, Integrated Community Health Workers (CHWs), Medication-access, group visit Education (TIME) program in a community clinic. RESEARCH DESIGN AND METHODS Participants (n=55) were low-income Latino(a)s with type 2 diabetes. The study occurred in two, 6-month phases. Phase I provided proof-of-concept and an observational experience for the clinic team; participants (n=37) were randomized to the intervention (TIME) or control (usual care), and the research team conducted TIME while the clinic team observed. Phase II provided mentorship to implement TIME, and the research team mentored the clinic team as they conducted TIME for a new single-arm cohort of participants (n=18) with no previous exposure to the program. Analyses included baseline to 6-month comparisons of diabetes outcomes (primary outcome: hemoglobin A1c (HbA1c)): phase I intervention versus control, phase II (within group), and research-run (phase I intervention) versus clinic-run (phase II) arms. We also evaluated baseline to 6-month CHW knowledge changes. RESULTS Phase I: compared with the control, intervention participants had superior baseline to 6-month improvements for HbA1c (mean change: intervention: -0.73% vs control: 0.08%, p=0.016), weight (p=0.044), target HbA1c (p=0.035), hypoglycemia (p=0.021), medication non-adherence (p=0.0003), and five of six American Diabetes Association (ADA) measures (p<0.001-0.002). Phase II: participants had significant reductions in HbA1c (mean change: -0.78%, p=0.006), diastolic blood pressure (p=0.004), body mass index (0.012), weight (p=0.010), medication non-adherence (p<0.001), and six ADA measures (p=0.007-0.005). Phase I intervention versus phase II outcomes were comparable. CHWs improved knowledge from pre-test to post-tests (p<0.001). CONCLUSIONS A novel, mentored approach to implement TIME into a community clinic resulted in improved diabetes outcomes. Larger studies of longer duration are needed to fully evaluate the potential of mentoring community clinics.
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Affiliation(s)
| | - Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA
| | - Amber B Amspoker
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA
| | - Craig A Johnston
- Department of Health and Human Performance, University of Houston, Houston, Texas, USA
| | - Joshua D Landrum
- School of Health Professions, Baylor College of Medicine, Houston, Texas, USA
| | | | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas, USA
| | | | - John P Foreyt
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Chary AN, Naik AD, Kennedy M. Visitor policies and health equity in emergency care of older adults. J Am Geriatr Soc 2021; 70:376-378. [PMID: 34310690 DOI: 10.1111/jgs.17392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 06/30/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- Houston Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Objectives: Unbefriended older adults are those who lack the capacity to make medical decisions and do not have a completed advance directive that can guide treatment decisions or a surrogate decision maker. Adult orphans are those who retain medical decision-making capacity but are at risk of becoming unbefriended due to lack of a completed advance health care directive and lack of a surrogate decision maker. In a follow-up to the 2016 American Geriatrics Society (AGS) position statement on unbefriended older adults, we examined clinicians' experiences in caring for unbefriended older adults and adult orphans.Methods: Clinicians recruited through the AGS (N = 122) completed an online survey about their experiences with unbefriended older adults regarding the perceived frequency of contact, clinical concerns, practice strategies, and terminology; and also with adult orphans regarding the perceived frequency of contact, methods of identification, and terminology.Results: Almost all inpatient (95.9%) and outpatient (86.4%) clinicians in this sample encounter unbefriended older adults at least quarterly and 92.2% of outpatient clinicians encounter adult orphans at least quarterly. Concerns about safety (95.9%), medication self-management (90.4%), and advance care planning (86.3%) bring unbefriended older adults to outpatient clinicians' attention "sometimes" to "frequently." Prolonged hospital stays (87.7%) and delays in transitioning to end-of-life care (85.7%) bring unbefriended older adults to inpatient clinicians' attention "sometimes" to "frequently." Clinicians apply a wide range of practice strategies to these populations. Participants suggested alternative terminology to replace "unbefriended" and "adult orphan."Conclusions: This study suggests that unbefriended older adults are frequently encountered in geriatrics practice, both in the inpatient and outpatient settings, and that there is widespread awareness of adult orphans in the outpatient setting. Clinicians' awareness of both groups suggests avenues for intervention and prevention.Clinical Implications: Health care professionals in geriatric settings will likely encounter older adults in need of advocates. Clinicians, attorneys, and policymakers should collaborate to improve early detection and to meet the needs of this vulnerable population.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,VA Salt Lake City Geriatric Research, Education, and Clinical Center, Salt Lake City, UT, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, UT, USA
| | - Casey Catlin
- Boston VA Research Institute, Inc, Boston, MA, USA
| | - Anna H Chodos
- Division of Geriatrics, UCSF Department of Medicine, San Francisco, CA, USA
| | - Aanand D Naik
- Houston Center for Innovations in Quality, Safety, and Effectiveness (IQuESt) at the Michael DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric Widera
- Division of Geriatrics, UCSF Department of Medicine, San Francisco, CA, USA
| | - Jennifer Moye
- VA New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Kanwal F, Hernaez R, Liu Y, Taylor TJ, Rana A, Kramer JR, Naik AD, Smith D, Taddei T, Asch SM. Factors Associated With Access to and Receipt of Liver Transplantation in Veterans With End-stage Liver Disease. JAMA Intern Med 2021; 181:949-959. [PMID: 34028505 PMCID: PMC8145153 DOI: 10.1001/jamainternmed.2021.2051] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy. OBJECTIVE To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021. EXPOSURES Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated. MAIN OUTCOMES AND MEASURES Referral, wait-listing, and liver transplantation. RESULTS Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral. CONCLUSIONS AND RELEVANCE In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.
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Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Yan Liu
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Thomas J Taylor
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jennifer R Kramer
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aanand D Naik
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Donna Smith
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Tamar Taddei
- Veterans Administration Connecticut Healthcare System, New Haven.,Department of Medicine, Yale University, New Haven, Connecticut
| | - Steven M Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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