A brief examination of treatment outcomes in higher levels of care for individuals with eating disorders across age groups

OBJECTIVE

Although eating disorders (EDs) occur throughout the lifespan, little research has been conducted with midlife/older adults, particularly those in higher levels of care (HLOC). The current study examined outcomes among 2009 patients with EDs receiving HLOC treatment at a large multisite facility between January 2020 and June 2022, across different age groups (ages <18, 18-25, 26-39 and ≥40). It was hypothesised that patients aged 40+ would exhibit less improvement on measures of ED psychopathology and depression than other age groups.

METHOD

Participants completed the eating disorder examination-questionnaire (EDE-Q) and the patient health questionnaire-9 (PHQ-9) at admission and discharge.

RESULTS

Changes for all outcomes from admission to discharge were statistically significant at p < 0.001 across all age groups. Changes in the EDE-Q Restraint subscale were significantly less in patients ages 26-39 than in patients ages 18-25 (p < 0.01). Changes in PHQ-9 were significantly greater in patients ages 40+ than patients ages 18-25 (p = 0.03).

CONCLUSIONS

Contrary to hypotheses, patients ages 40+ did not show worse outcomes than younger patients, and showed greater improvements in depression than young adults. The therapeutic needs of midlife/older adults with EDs may be favourably met by a HLOC regimen as described in this study.

Characterising use of recovery record among a large, transdiagnostic sample of adults with eating disorders across higher levels of care

OBJECTIVE

Smartphone applications (i.e., apps) designed to target mental health symptoms have received increasing public and empirical attention, including in eating disorder|eating disorders (EDs) treatment. While some data have begun to characterise app users in non-controlled settings, there is limited information on use of apps in higher levels of care (e.g., partial hospitalisation or residential treatment programs) for EDs.

METHOD

This study aimed to explore metrics of use while in treatment for a commonly used ED-focused mobile app (Recovery Record) among individuals enroled in intensive outpatient, partial hospitalisation, residential, or inpatient treatments (N = 2042).

RESULTS

Results indicated that older individuals and participants with binge eating disorder demonstrated more frequent app engagement compared to younger participants and other ED diagnoses, respectively. Individuals entering at intensive outpatient and partial hospitalisation levels of care, as well as those with routine discharges engaged more frequently with RR compared to individuals entering in inpatient or residential treatment, and those with non-routine discharges.

CONCLUSIONS

Our data provide initial descriptions of how RR may be used within higher levels of care for adults with EDs. Further work is needed to establish the benefit of these apps in clinical settings for EDs over and above standard treatment, better characterise for whom these apps provide benefit, and identify how best to tailor the experience to promote engagement across the full spectrum of ED patients.

Weight gain and eating disorder symptoms among individuals with atypical anorexia nervosa

OBJECTIVE

The purpose of this study was to examine the association between weight gain and eating disorder (ED) symptoms among adults receiving treatment for atypical anorexia nervosa (AAN), to determine whether those who had a higher percent of expected body weight (%EBW) at discharge exhibited lower ED symptoms than those who gained less weight, and to compare this group to a matched sample of patients with anorexia nervosa (AN).

METHOD

Participants were 96 adults receiving treatment at an ED treatment facility between December 2020 and May 2023. The Eating Disorder Examination-Questionnaire (EDE-Q) was completed at admission and discharge, and %EBW was obtained at admission and discharge.

RESULTS

All EDE-Q subscale scores improved from admission to discharge for patients with AAN and patients with AN. Neither %EBW at discharge nor weight gain were associated with EDE-Q subscale scores for those with AAN. For patients with AN, %EBW at discharge and weight gain were associated with EDE-Q Restraint at discharge.

CONCLUSIONS

Weight restoring to a higher level and gaining more weight were not associated with EDE-Q scores at discharge for AAN. Further research is needed to determine how weight restoration using intensive treatment settings affects remission and recovery in patients with AAN.

"Terminal anorexia nervosa" may not be terminal: An empirical evaluation

Gaudiani et al. (2022) presented terminal anorexia nervosa (T-AN) as a potential new specifier to the anorexia nervosa (AN) diagnosis, with criteria including (a) AN diagnosis, (b) age > 30 years, (c) previously participated in high-quality care, and (d) the clear, consistent determination by a patient with decision-making capacity that additional treatment would be futile, knowing death will result. This study's purpose was to empirically examine a subgroup of participants with AN who met the first three criteria of T-AN-and a smaller subset who also met a proxy index of the fourth criterion involving death (TD-AN)-and compare them to an adult "not terminal" anorexia nervosa (NT-AN) group and to a "not terminal" subset 30 years of age or older (NTO-AN). Patients at U.S. eating disorder treatment facilities (N = 782; T-AN: n = 51, TD-AN: n = 16, NT-AN: n = 731, NTO-AN: n = 133), all of whom met criteria for a current Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnosis of AN, were compared regarding admission, discharge, and changes from admission to discharge on physiological indices (i.e., white blood cell counts, albumin levels, aspartate aminotransferase levels, and body mass index), as well as self-report measures (i.e., eating disorder, depression, anxiety, and obsessive-compulsive symptoms). In contrast to the tight syndromal symptom interconnections of, and inevitable spiral toward death expected for, a terminal diagnosis, results suggest substantial variability within the T-AN group and TD-AN subset, and an overall trend of improvement across physiological and self-report measures. This study thus provides some empirical evidence against the specification of the T-AN diagnosis. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

An examination of adults with atypical anorexia nervosa at admission to treatment at higher levels of care: An attempt to increase diagnostic clarity

OBJECTIVE

Anorexia nervosa (AN) is a serious illness with a high mortality rate and multiple physiological complications. The vague definition of atypical AN allows for subjective interpretation. This retrospective study aimed to focus future research on the operational definition of atypical AN by examining four factors associated with atypical AN at admission to higher level of care treatment.

METHODS

Adults with atypical AN (n = 69) were examined within sample analyses among four groups: (1) >10% versus ≤10% weight loss; (2) weight loss within the previous 3 months versus >3 months; (3) engaging in purging behaviors versus absence of purging behaviors; and (4) endorsing versus not endorsing significant cognitive aspects of AN.

RESULTS

Patients with atypical AN endorsed elevated ED cognitions on the Eating Disorder Examination-Questionnaire and depressive symptoms; a lack of association was found between weight loss severity and weight loss time frame with depressive symptoms, eating concern, and restraint. Purging behavior was associated with a higher expected body weight percentage (%EBW) and dietary restraint, while greater AN cognitions were associated with a higher EBW and weight loss percentage. Few patients demonstrated bradycardia, hypophosphatemia, or amenorrhea.

DISCUSSION

This study demonstrated the severity of ED cognitions and depressive symptoms in this atypical AN sample and provided directions for future studies in the nosology of atypical AN. It may be important to distinguish between individuals with atypical AN who are purging and those who are not. Atypical AN was associated with a low frequency of physiological disturbances.

PUBLIC SIGNIFICANCE

This study provides further clarification regarding the operational definition of atypical AN; currently, a constellation of symptoms under Other Specified Feeding or Eating Disorders. This study was consistent with previous research in reporting severe eating disorder cognitions in adults with atypical AN, and noted the potential importance of distinguishing a purging distinction. A minority of patients in this study had physiological impairments.

Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures

OBJECTIVE

The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation.

METHODS

Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma).

RESULTS

MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences).

CONCLUSIONS

The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Eating disorder virtual intensive outpatient program: patient satisfaction according to age group

The COVID-19 pandemic has required a shift to telehealth services. However, not all patients are similarly satisfied with this shift, with some studies finding that midlife and older adults are less comfortable with telehealth. The current study examined patient satisfaction with a virtual intensive outpatient program (VIOP) for eating disorders (EDs) among 305 adults (ages 18-25, ages 26-39, and ages 40+), and compared adult satisfaction to satisfaction among children/adolescents (n = 33) receiving VIOP treatment between August 2020 and March 2022 from a large ED treatment facility. It was hypothesized that adults aged 40+ would report lower satisfaction than younger age groups. Patients completed several questions regarding satisfaction with treatment upon discharge, including a question about likelihood of recommending the program, which was used to calculate a Net Promoter Score (NPS). The NPS was 33.3 for children/adolescents, 33.3 for 18-25 year-olds, 57.7 for 26-39 year-olds, and 30.9 for the 40+ year age group. NPS of 31-50 = quality services; 51-70 = excellent customer experiences. Satisfaction was high, with no statistically significant differences between age groups after Bonferroni correction. The current study adds to the limited literature on the treatment experiences of midlife adults with EDs.

An open trial for adults in a residential program for binge eating spectrum disorders

The current study assessed treatment outcome for 99 adult admissions to a residential program specifically designed for binge eating spectrum disorders (BESD). Participants completed self-report measures at admission, discharge, and 12-month follow-up and were asked to complete blood draws at admission and follow-up. Primary outcomes were eating behaviors; secondary outcomes included comorbid symptoms and physiological variables. Eating behaviors improved significantly from admission to follow-up, as did most comorbid symptoms and quality of life, despite no change in body mass index. Some variables displayed a curvilinear relationship, with some worsening of symptoms from discharge to follow-up, although scores at follow-up remained well below admission values. Participation in the treatment program was associated with reduced problematic eating and comorbid symptoms and increased quality of life up to one year after discharge. Findings from this study may encourage the development of similar residential treatment programs for BESD for those who have not responded to outpatient care or mixed milieu settings, and may prompt randomized studies testing similar treatments versus usual care.

Real World Use of Anti-Obesity Medications and Weight Change in Veterans

BACKGROUND

Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss.

OBJECTIVE

To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with longer duration of use.

DESIGN

Retrospective cohort study using VA electronic health records.

PARTICIPANTS

Veterans with overweight or obesity who participated in MOVE! from 2008-2017.

MAIN MEASURES

Weight change from baseline was estimated using marginal structural models up to 24 months after MOVE! initiation. The probability of longer duration of AOM use (≥ 180 days) was estimated via a generalized linear mixed model.

RESULTS

Among MOVE! participants, 8,517 (1.6%) used an AOM within 24 months after MOVE! initiation with a median of 90 days of cumulative supply. AOM + MOVE! users achieved greater weight loss than MOVE! alone users at 6 (3.2% vs. 1.6%, p < 0.001), 12 (3.4% vs. 1.4%, p < 0.001), and 24 months (2.7% vs. 1.5%, p < 0.001), and had a greater probability of achieving ≥ 5% weight loss at 6 (38.8% vs. 26.0%, p < 0.001), 12 (43.1% vs. 28.4%, p < 0.001), and 24 months (40.4% vs. 33.3%, p < 0.001). Veterans were more likely to have ≥ 180 days of supply if they were older, exempt from medication copays, used other medications with significant weight-gain, significant weight-loss, or modest weight-loss side effects, or resided in the West North Central or Pacific regions. Veterans were less likely to have ≥ 180 days of AOM supply if they had diabetes or initiated MOVE! later in the study period.

CONCLUSIONS

AOM use following MOVE! initiation was uncommon, and exposure was time-limited. AOM + MOVE! was associated with a higher probability of achieving clinically significant weight loss than MOVE! alone.

Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients

OBJECTIVE

Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death.

DATA SOURCES, STUDY SETTING, AND STUDY DESIGN

Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models.

PRINCIPAL FINDINGS

Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures.

CONCLUSIONS

In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

A descriptive study of treatment-seeking adults with avoidant/restrictive food intake disorder at residential and inpatient levels of care

Most research on avoidant/restrictive food intake disorder (ARFID) has been with children and adolescents, while the limited research on adults with ARFID has been in the domain of outpatient treatment. This descriptive study sought to explore psychological characteristics (N = 45; measured with self-report questionnaires) and physiological characteristics (N = 66; e.g. vital signs, bloodwork) at admission for 66 adults with ARFID seeking residential and inpatient levels of care. While adults with ARFID presented with significant food restriction as well as mild depressive symptoms, high anxiety symptoms, and impaired quality of life, patients presented with mostly normal physiology, except for low bone density, and trivial abnormalities in serum creatinine and hepatic enzymes. Patients in this sample were most likely to endorse fear of aversive consequences, especially those for whom ARFID symptoms had first arisen in adulthood. These results note the psychological impairment and relative physiological normalcy of treatment-seeking adults with ARFID at the outset of residential and inpatient treatment, identifying future treatment and outcome research priorities in this understudied population.

Eating Disorder Examination-Questionnaire: Norms for Adults in Higher Levels of Care

Establishing normative data for questionnaires is essential for the accurate interpretation of scores, given that these norms can vary according to different subpopulations and treatment contexts. The purpose of this study was to establish norms for the Eating Disorder Examination-Questionnaire (EDE-Q) among adults receiving higher levels of care (HLOCs) for the treatment of eating disorders. Participants were 2,283 people receiving treatment at the inpatient, residential, partial hospitalization, or intensive outpatient levels of care. The EDE-Q was completed at admission. Patients with anorexia nervosa-restricting subtype (AN-R) had the lowest EDE-Q Global scores when compared with all other eating disorder diagnoses. When compared with intensive outpatient care, only those in residential treatment had higher EDE-Q Global scores. This study is among the first to describe norms for the EDE-Q in a large sample of adults receiving various HLOCs. Programs utilizing the EDE-Q to assess treatment outcomes can use these findings to aid people in interpreting their scores.

Association of Unmet Social Needs With Metformin Use Among Patients With Type 2 Diabetes

OBJECTIVE

To evaluate the relationship between social needs and metformin use among adults with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

In a prospective cohort study of adults with T2D (n = 722), we linked electronic health record (EHR) and Surescripts (Surescripts, LLC) prescription network data to abstract data on patient-reported social needs and to calculate metformin adherence based on expected refill frequency using a proportion of days covered methodology.

RESULTS

After adjusting for demographics and clinical complexity, two or more social needs (-0.046; 95% CI -0.089, 0.003), being uninsured (-0.052; 95% CI -0.095, -0.009) and while adjusting for other needs, being without housing (-0.069; 95% CI -0.121, -0.018) and lack of access to medicine/health care (-0.058; 95% CI -0.115, -0.000) were associated with lower use.

CONCLUSIONS

We found that overall social need burden and specific needs, particularly housing and health care access, were associated with clinically significant reductions in metformin adherence among patients with T2D.

A review of implementation intentions as a tool to benefit high-need patients and healthcare systems: U.S. veterans affairs as an exemplar

Implementation intentions (if-then plans) are an evidence-based behavior change strategy designed to translate behavioral intentions into habits [1]. Despite extensive evidence of its potential utility, this behavior change strategy is underutilized and under-researched in high-need healthcare contexts within the United States (U.S.) which face high rates of chronic conditions and barriers to care such as rurality, lack of resources, and cognitive strain from mental health and neurological conditions [2,3]. Implementation intentions have demonstrated efficacy in promoting many health behaviors proven to mitigate chronic conditions, namely physical activity, healthy diet, and substance use reduction [4-6]. In addition, the accessible, adaptable, and self-driven nature of implementation intentions allow the technique to meet many of the individual and system-level priorities of these high-need care contexts. By being patient-driven, proactive, and personalized, implementation intentions can help these patients cultivate healthy habits as part of their everyday lives. At the systems-level, implementation intentions' inexpensiveness, scalability, and compatibility with telemedicine platforms allow them to be integrated easily into existing healthcare system infrastructure [7,8]. This review describes these concepts in detail, and uses the Veterans Affairs (VA) healthcare system as an exemplar to provide concrete examples of how and where implementation intentions could be integrated in a healthcare system, within some existing programs, to benefit both the system and individual patients.

Health-related quality of life profiles in adolescents and young adults with chronic conditions

PURPOSE

To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with chronic conditions.

METHODS

AYAs (N = 872) aged 14-20 years completed NIH's Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, pain interference, fatigue, social health, depression, anxiety, and anger. Latent profile analysis (LPA) was used to group AYAs into HRQOL profiles using PROMIS T-scores. The optimal number of profiles was determined by model fit statistics, likelihood ratio test, and entropy. Multinomial logistic regression models were used to examine how LPA's HRQOL profile membership was associated with patient demographic and chronic conditions. The model prediction accuracy on profile membership was evaluated using Huberty's I index with a threshold of 0.35 for good effect.

RESULTS

A 4-profile LPA model was selected. A total of 161 (18.5%), 256 (29.4%), 364 (41.7%), and 91 (10.4%) AYAs were classified into Minimal, Mild, Moderate, and Severe HRQOL Impact profiles. AYAs in each profile had distinctive mean scores with over a half standard deviation (5-points in PROMIS T-scores) of difference between profiles across most HRQOL domains. AYAs who were female or had conditions such as mental health condition, hypertension, and self-reported chronic pain were more likely to be in the Severe HRQOL Impact profile. The Huberty's I index was 0.36.

CONCLUSIONS

Approximately half of AYAs with a chronic condition experience moderate to severe HRQOL impact. The availability of risk prediction models for HRQOL impact will help to identify AYAs who are in greatest need of closer clinical care follow-up.

Mobile health contingency management for smoking cessation among veterans experiencing homelessness: A comparative effectiveness trial

Tobacco cessation is reduced in U.S. military veterans experiencing homelessness. Mobile contingency management (mCM) is a promising treatment for tobacco use among populations experiencing homelessness, but past CM studies have largely been small, have relied on in-person follow-up, and/or lacked long-term biochemically verified abstinence measures. Veterans who smoked and were experiencing homelessness (N = 127) were randomly assigned to mCM treatment (4 weeks of mCM, 5 weeks of telehealth counseling, and the option of 12 weeks of pharmacotherapy) or VA standard care (3 biweekly group sessions and clinically appropriate pharmacotherapy), and all participants were randomly assigned to a $100 longer-term financial incentive for abstinence at 3-month follow-up. Participants were followed at 3-, 6-, and 12-months post-randomization, with the a priori main outcome designated as biochemically verified prolonged abstinence (with lapses) at 6-month follow-up. At 6-months, participants in the mCM group were significantly more likely to meet criteria for prolonged abstinence (OR = 3.1). Across time points, veterans in the mCM group had twice the odds of prolonged abstinence as those in the standard care group. However, by the 12-month follow-up, there was no statistically significant group difference in abstinence. Cost-effectiveness analysis indicated a modest increase in cost ($1,133) associated with an increase of one quality-adjusted life year saved for the intervention compared to standard care. mCM is a cost-effective approach to smoking cessation among veterans experiencing homelessness. Considering waning potency of this and other tobacco cessation interventions at 12-month follow-up, it is crucial to implement strategies to sustain abstinence for individuals experiencing homelessness.

Empirical Investigation of Different Factor Structures for the Eating Disorder Examination-Questionnaire in Adult Women With Anorexia Nervosa

The Eating Disorder Examination-Questionnaire (EDE-Q) is a widely used self-report measure of eating pathology. Despite widespread use, investigations of its factor structure have proved inconclusive and rarely supported the "original" interpretation. The current study evaluates several proposed factor solutions of the EDE-Q using latent variable analysis in a sample of adult women with anorexia nervosa (AN). A total of 804 patients from a specialist treatment center in the United States participated in the study. Confirmatory factor analysis was conducted on 22 EDE-Q items assessing attitudinal features of eating pathology. Findings suggested that three full-item versions (none of which was the "original" interpretation) fit the data adequately, with a brief, seven-item version showing excellent fit. The study is one of the first to examine this within a sample of women with AN and provides an empirical foundation for how best to use the EDE-Q among clinical and research participants with AN. Findings suggest that the "original" factor structure lacks structural validity in women with AN. Its use should generally be discouraged, and future work on screening and treatment outcomes might consider the EDE-Q7.

Videoconferencing of Movement-Based and Psychologically Informed Interventions for Chronic Pain: A Systematic Review and Horizon Scan

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic, use of telehealth technology increased dramatically. Nonpharmacological approaches to pain management may be well suited for virtual care. Yet, it is not widely understood if this treatment modality is effective when delivered via videoconferencing. This review examines the effectiveness of movement-based and psychologically informed chronic pain management interventions delivered via videoconferencing compared to in-person care. Methods: Searches of MEDLINE® (via Ovid®), Embase (via Elsevier), CINAHL Complete (via EBSCO), and Cochrane Central Register of Controlled Trials (via Ovid) were performed from inception to June 10, 2021. All articles meeting eligibility criteria were included for data abstraction. Results: Eight thousand two hundred fifty-two citations were identified, and after removing duplicates, 4,661 citations remained. One study investigating acceptance and commitment therapy met eligibility criteria. The noninferiority randomized trial found no statistically significant difference in outcomes between delivery modalities. A horizon scan was conducted to assess planned or recent studies. Horizon scan results yielded six protocols in trial databases, one pilot study, and three published protocols for ongoing studies. Discussion: Findings from this study indicate that virtually delivered pain management is a possible substitute for in-person care. Given the paucity of evidence on this topic, further comparative and adequately powered studies that assess the impact of movement-based and psychologically informed pain management delivered via videoconferencing are needed. Conclusions: Research is needed to understand patient preferences of such interventions within a variety of settings. Such evaluations will be needed to guide clinical and operations practice to optimize equitable deployment and access to high-quality health care delivered via videoconferencing.

Applying latent profile analysis to identify adolescents and young adults with chronic conditions at risk for poor health-related quality of life

The impact of chronic diseases on health-related quality of life (HRQOL) in adolescents and young adults (AYAs) is understudied. Latent profile analysis (LPA) can identify profiles of AYAs based on their HRQOL scores reflecting physical, mental, and social well-being. This paper will (1) demonstrate how to use LPA to identify profiles of AYAs based on their scores on multiple HRQOL indicators; (2) explore associations of demographic and clinical factors with LPA-identified HRQOL profiles of AYAs; and (3) provide guidance on the selection of adult or pediatric versions of Patient-Reported Outcomes Measurement Information System® (PROMIS®) in AYAs. A total of 872 AYAs with chronic conditions completed the adult and pediatric versions of PROMIS measures of anger, anxiety, depression, fatigue, pain interference, social health, and physical function. The optimal number of LPA profiles was determined by model fit statistics and clinical interpretability. Multinomial regression models examined clinical and demographic factors associated with profile membership. As a result of the LPA, AYAs were categorized into 3 profiles: Minimal, Moderate, and Severe HRQOL Impact profiles. Comparing LPA results using either the pediatric or adult PROMIS T-scores found approximately 71% of patients were placed in the same HRQOL profiles. AYAs who were female, had hypertension, mental health conditions, chronic pain, and those on medication were more likely to be placed in the Severe HRQOL Impact Profile. Our findings may facilitate clinicians to screen AYAs who may have low HRQOL due to diseases or treatments with the identified risk factors without implementing the HRQOL assessment.

BMI Trends for Veterans Up to 10 Years After VA Enrollment Following Military Discharge

BACKGROUND

Obesity (body mass index [BMI]≥30kg/m2) among US adults has tripled over the past 45 years, but it is unclear how this population-level weight change has occurred.

OBJECTIVE

We sought to identify distinct long-term BMI trajectories and examined associations with demographic and clinical characteristics.

DESIGN

The design was latent trajectory modeling over 10 years of a retrospective cohort. Subgroups were identified via latent class growth mixture models, separately by sex. Weighted multinomial logistic regressions identified factors associated with subgroup membership.

PARTICIPANTS

Participants were a retrospective cohort of 292,331 males and 62,898 females enrolled in VA.

MAIN MEASURES

The main outcome measure was 6-month average VA-measured BMI over the course of 10 years. Additional electronic health record measures on demographic, clinical, and services utilization characteristics were also used to characterize latent trajectories.

KEY RESULTS

Four trajectories were identified for men and for women, corresponding to standard BMI categories "normal weight" (BMI <25), "overweight" (BMI 25-29.99), and "with obesity" (BMI ≥30): "normal weight" and increasing (males: 28.4%; females: 22.8%), "overweight" and increasing (36.4%; 35.6%), "with obesity" and increasing (33.6%; 40.0%), and "with obesity" and stable (males: 1.6%) or decreasing (females: 1.6%). Race, ethnicity, comorbidities, mental health diagnoses, and mental health service utilization discriminated among classes.

CONCLUSIONS

BMI in the 10 years following VA enrollment increased modestly. VA should continue prioritizing weight management interventions to the large number of veterans with obesity upon VA enrollment, because the majority remain with obesity.

Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients

RESEARCH OBJECTIVE

To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients.

DATA SOURCES

Patient survey, VA, Medicare data.

STUDY DESIGN

Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death.

DATA EXTRACTION METHODS

Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims.

PRINCIPAL FINDINGS

Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good).

CONCLUSIONS

Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.

Barriers and facilitators to the implementation and adoption of improvement coaching: A qualitative evidence synthesis

BACKGROUND

Healthcare organisations and teams perform improvement activities to facilitate high-quality healthcare. The use of an improvement coach who provides support and guidance to the healthcare team may facilitate improvement activities; however, no systematic review exists on the facilitators and barriers to implementing an improvement coach.

AIMS

We conducted a qualitative evidence synthesis to examine the facilitators and barriers to the implementation of improvement coaching.

METHODS

We searched MEDLINE^® , Embase and CINAHL. The final search was in March 2021. The screening eligibility criteria included the following: interdisciplinary team receiving the coaching, improvement coaching, designs with a qualitative component and primary purpose of evaluating practice facilitation in OECD countries. An ecologically-informed consolidated framework for implementation research (CFIR) served as the framework for coding. Patterns of barriers and facilitators across domains were identified through matrix analysis. Risk of bias was assessed using Critical Appraisal Skills Program. PRISMA reporting guidelines served as a guide for reporting this review.

RESULTS

Nineteen studies with a qualitative component met the inclusion criteria. Four themes of barriers and facilitators crossed multiple CFIR domains: adaptability (e.g. making adjustments to the project; process, or approach); knowledge and skills (e.g. understanding of content and process for the project); engagement (e.g. willingness to be involved in the process) and resources (e.g. assets required to complete the improvement process).

CONCLUSION

Improvement coaching is a complex intervention that influences the context, healthcare team being coached and improvement activities. Improvement coaches should understand how to minimise barriers and promote facilitators that are unique to each improvement project across the domains. Limitations of the study are related to the nature of the intervention including potential publication bias given quality improvement focus; the variety of terms similar to improvement coaching or selection of framework.

Care utilization in eating disorders: for whom are multiple episodes of care more likely?

PURPOSE

The current study aimed to determine baseline clinical features among adults receiving varied levels of care for transdiagnostic eating disorders (N = 5206, 89.9% female, mean age 29 years old) that may be associated with increased care utilization.

METHODS

We used negative binomial regression models to evaluate associations among eating disorder diagnoses, other psychiatric features (e.g., lifetime history of comorbid disorders), and the number of episodes of care for treatment of the eating disorder.

RESULTS

Having a diagnosis of binge eating disorder (p < .001) or avoidant restrictive food intake disorder (p = .04) were associated with lower odds of readmissions. A lifetime diagnosis of major depressive disorder (p < .001) or self-injury (p < .001) was each associated with significantly higher odds of readmissions.

CONCLUSIONS

Care utilization may differ according to eating disorder diagnosis, with a likelihood of increased readmission for those with a history of mood disorder or self-injury. Identification of individuals with greater vulnerability for eating disorder care utilization holds potential in aiding treatment and discharge planning, and development.

LEVEL OF EVIDENCE

Level III: evidence obtained from well-designed cohort or case-control analytic studies.

Avoidant restrictive food intake disorder and suicidal ideation

Most DSM-5 eating disorder diagnoses are associated with elevated suicide risk; however, little is known about the relationship between Avoidant/Restrictive Food Intake Disorder (ARFID) and suicidal ideation. The aim of the current study was to examine suicidal ideation within an adult ARFID sample. Patients with eating disorders (N = 936), some of whom met criteria for a current DSM-5 diagnosis of ARFID (n = 79), completed the Beck Depression Inventory II Item 9, regarding suicidal ideation. The study was conducted within an eating disorder treatment facility that offers inpatient, residential, partial hospitalization program, and intensive outpatient levels of care. Findings suggest no significant pairwise differences in suicidal ideation prevalence between participants with ARFID and those with any other ED diagnosis. Thorough screening for suicidal thoughts and risk among those with ARFID is warranted at all levels of care. We suggest that future research expand upon this work in a larger adult ARFID sample.

Understanding non-routine discharge: Factors that are associated with premature termination from higher levels of care in adults with anorexia nervosa

This study sought to replicate and extend associations between clinical and demographic features at admission and types of premature treatment termination for adults diagnosed with anorexia nervosa (AN) in higher-level-of-care settings. Secondary data analyses examined a study population comprised of adults with AN (N = 565) who were admitted to one of two United States eating disorder treatment centers (April 2015-April 2020) for intensive outpatient, partial hospitalization, residential, or inpatient services. There were no significant differences in the type of non-routine discharge according to level of care. At admission, those with lower BMI were more likely to discharge against medical advice, and those with lower cognitive restraint and elevated binge eating were more likely to discharge against medical advice or by staff-initiated request, respectively. Discharge by parent/patient request was more likely among those who were older or who reported lower baseline desire for muscularity. Overall older age, elevated binge eating, and lower weight, desire for muscularity, and cognitive restraint may be associated with less tolerance/acceptability for AN treatment. Increased understanding of how to better support patients who admit to higher levels of care with these clinical features will contribute to better odds of completion of a full course of treatment.

Comparing eating disorder treatment outcomes of transgender and nonbinary individuals with cisgender individuals

OBJECTIVE

The purpose of this study was to compare symptom severity of eating disorders (EDs), depression and anxiety at admission and discharge for transgender and nonbinary (TNB) individuals and cisgender adult individuals receiving treatment for EDs at higher levels of care (HLOC), adding to the limited research in this area.

METHOD

Participants were 25 TNB individuals and 376 cisgender individuals admitted to a HLOC ED treatment facility. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q), Patient Health Questionnaire-9, and Beck Anxiety Inventory at admission and discharge.

RESULTS

TNB individuals showed significant improvements on EDE-Q global scores between admission and discharge (Cohen's d = 1.27), and showed similar improvements on the EDE-Q over the course of treatment (Cohen's d = 0.06) when compared to cisgender individuals. TNB individuals had more severe depression at admission (Cohen's d = 0.61). Although depression improved over the course of treatment for both groups, TNB individuals showed less improvement (Cohen's d = 0.59). Suicidality was higher for TNB individuals on admission and discharge and did not improve significantly over the course of treatment (Cohen's d = 0.38).

DISCUSSION

This study provides preliminary evidence that TNB and cisgender individuals show similar improvement in ED symptoms during HLOC treatment. However, TNB individuals have more severe depression and less improvement in depression compared to cisgender individuals, without improvement in suicidality. TNB individuals may benefit from care targeting depression and suicidality during ED treatment.

PUBLIC SIGNIFICANCE STATEMENT

TNB individuals have increased risk of EDs. Little research addresses how TNB individuals respond to ED treatment, which was traditionally created for cisgender individuals. We present one of the first studies examining ED treatment outcomes for TNB adults. TNB individuals showed improved ED symptoms with treatment, but less improvement in depression and their suicidality remained elevated. This suggests the need for targeted treatment.

Resisting vs. Persisting: Different Types of Self-Control Predict Different Outcomes Following Incarceration

Introduction: Trait self-control is one of the most robust predictors of important life outcomes. Recent evidence suggests at least two domains of self-control: inhibitory self-control (refraining from more attractive but goal-inconsistent behaviors) and initiatory self-control (engaging in and persisting in less attractive but goal-consistent behaviors). Methods: We examined longitudinal associations between these two self-control domains and subsequent post-incarceration behaviors in 492 jail inmates with a combination of self-reported questionnaires and official arrest records. Results: The two constructs were moderately associated, evidencing a similar-yet-distinct association of the same magnitude as depression and anxiety. Structural equation modeling demonstrated that inhibitory self-control uniquely predicted less recidivism and substance dependence, and better community adjustment. Initiatory self-control uniquely predicted less recidivism and better community adjustment. As expected, inhibitory self-control was a significantly better predictor of substance dependence than initiatory self-control. Discussion: These results have theoretical implications for the measurement of self-control and practical implications for the prediction of impactful post-incarceration behaviors and more precise interventions targeting specific self-control deficits.

Eating disorder behaviors as predictors of suicidal ideation among people with an eating disorder

OBJECTIVE

Suicidality is known to be elevated among people with an eating disorder. The aim of the current study was to examine whether any of three specific behavioral facets of eating disorders (i.e., purging, binge eating, restricting) would be the strongest predictors of suicidal ideation, controlling for one another, in longitudinal analyses from admission to discharge. We hypothesized that purging, above and beyond restricting or binge eating, would be the most important predictor of suicidal ideation.

METHOD

In the present study, patients with an eating disorder (N = 936), the majority of whom met criteria for a current DSM-5 diagnosis of Anorexia Nervosa (n = 560), completed the Eating Pathology Symptoms Inventory (EPSI) and the Beck Depression Inventory II-Item 9 suicidal ideation index, at admission and again at discharge. The settings were eating disorder treatment facilities offering inpatient, residential, partial hospitalization program (PHP), and intensive outpatient (IOP) levels of care. We pitted EPSI purging, EPSI restriction, and EPSI binge eating against one another in a regression framework predicting discharge suicidal ideation controlling for suicidal ideation at admission.

RESULTS

EPSI Purging significantly predicted both presence/absence of suicidal ideation (β = .22, t = 2.48, p = .01; OR = 1.25, 95% CI [1.05, 1.49]) and intensity of suicidal ideation (β = .04, t = 2.31, p = .02) at discharge, whereas neither EPSI Restricting nor EPSI Binge Eating did (p > .30).

DISCUSSION

Study results suggest that purging may have particular relevance in estimating suicide risk in patients with an eating disorder.

How can equitable video visit access be delivered in primary care? A qualitative study among rural primary care teams and patients

OBJECTIVE

The COVID-19 pandemic sparked exponential growth in video visit use in primary care. The rapid shift to virtual from in-person care exacerbated digital access disparities across racial groups and rural populations. Moving forward, it is critical to understand when and how to incorporate video visits equitably into primary care. We sought to develop a novel clinical algorithm to guide primary care clinics on how and when to employ video visits as part of care delivery.

DESIGN

Qualitative data collection: one team member conducted all patient semistructured interviews and led all focus groups with four other team members taking notes during groups.

SETTING

3 rural primary care clinics in the USA.

PARTICIPANTS

24 black veterans living in rural areas and three primary care teams caring for black veterans living in rural areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

Findings from semistructured interviews with patients and focus groups with primary care teams.

RESULTS

Key issues around appropriate use of video visits for clinical teams included having adequate technical support, encouraging engagement during video visits and using video visits for appropriate clinical situations. Patients reported challenges with broadband access, inadequate equipment, concerns about the quality of video care, the importance of visit modality choice, and preferences for in-person care experience over virtual care. We developed an algorithm that requires input from both patients and their care team to assess fit for each clinical encounter.

CONCLUSIONS

Informed matching of patients and clinical situations to the right visit modality, along with individual patient technology support could reduce virtual access disparities.

Cardiometabolic Comorbidities in Cancer Survivors

There are nearly 17 million cancer survivors in the United States, including those who are currently receiving cancer therapy with curative intent and expected to be long-term survivors, as well as those with chronic cancers such as metastatic disease or chronic lymphocytic leukemia, who will receive cancer therapy for many years. Current clinical practice guidelines focus on lifestyle interventions, such as exercise and healthy eating habits, but generally do not address management strategies for clinicians or strategies to increase adherence to medications. We discuss 3 cardiometabolic comorbidities among cancer survivors and present the prevalence of comorbidities prior to a cancer diagnosis, treatment of comorbidities during cancer therapy, and management considerations of comorbidities in long-term cancer survivors or those on chronic cancer therapy. Approaches to support medication adherence and potential methods to enhance a team approach to optimize care of the individual with cancer across the continuum of disease are discussed.

•

Cancer survivors are at increased risk for several chronic conditions, including hypertension, dyslipidemia, and diabetes.

•

Determining optimal management of comorbidities for patients with cancer is critical.

•

A multidisciplinary care approach is recommended throughout the continuum of active cancer treatment and survivorship.

•

Survivorship research should focus on medication adherence and coordination of care.

Treatment Outcome for Adults in a Residential Program for Binge Eating Spectrum Disorders: Protocol for a Prospective Pragmatic Single-Arm Trial

Background

Most studies reporting treatment outcomes for eating disorders at higher levels of care focus on anorexia nervosa and bulimia nervosa. No studies have been published with a singular focus on examining treatment outcomes for adults receiving residential programming specifically designed for the treatment of binge eating spectrum disorders (BESD), including binge eating disorder and bulimia nervosa.

Objective

The purpose of this paper is to outline the protocol of a prospective study examining treatment outcomes at discharge and 3-month, 6-month, and 12-month postdischarge follow-up, for a sample of consecutive admissions to a residential program specifically for patients with BESD.

Methods

One hundred consecutive admissions to a binge eating treatment program were enrolled in the prospective single-arm trial between January 2019 and February 2020. Data were collected at admission, discharge, and 3, 6, and 12 months postdischarge, with admission, discharge, and 12-month follow-up as the major timepoints of interest. Results across the major timepoints will be analyzed with mixed effects general linear models.

Results

The primary aim is to assess the impact of the program on eating disordered behaviors at discharge and 12-month follow-up, which are hypothesized to improve as a result of treatment. Secondary hypotheses include improvements on comorbid symptoms, including trauma, depression, and obsessive-compulsive symptoms, as well as improvements on medical indicators of health, including cholesterol and triglycerides, at discharge and 12-month follow-up.

Conclusions

This study may aid in the development of treatment guidelines for patients with BESD at higher levels of care and lend support to having specialty treatment programs for patients with BESD.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32270

Adverse childhood experiences among adults with eating disorders: comparison to a nationally representative sample and identification of trauma

BACKGROUND

Adverse childhood experiences (ACEs) are prevalent, impact long-term physical and mental health, and are associated with eating disorders (EDs) in adulthood. The primary objectives of the current study were: (1) to examine and compare ACEs between two samples: treatment-seeking adults, and a nationally representative sample of adults, (2) to characterize ACEs items and total scores across demographic and diagnostic information in adults seeking treatment for an ED, (3) to statistically classify ACEs profiles using latent class analysis, and (4) to examine associations between ACEs profiles and diagnosis.

METHODS

This cross-sectional study assessed patients with a DSM-5 ED receiving treatment between October 2018 and April 2020 at the inpatient, residential, or partial hospitalization levels of care at one of two private ED treatment facilities. ACEs were assessed with the Adverse Childhood Experiences Survey at admission. Generalized linear models and Welch's t-tests were used to compare ACEs in the current sample with national estimates. A latent class analysis was conducted to examine subgroups of ACEs responses, and differences in these classes by ED diagnoses were examined with multinomial logistic regression.

RESULTS

Patients with EDs had significantly higher ACEs scores (M = 1.95, SD = 1.90) than the nationally representative sample (M = 1.57, SD = 4.72; t = 6.42, p < .001). Within patients with EDs, four latent classes of ACEs item endorsement were identified. Patients with other specified feeding or eating disorder (OSFED) and binge eating disorder (BED) were more likely to fall into the "Household ACEs" and "Abuse ACEs" groups, respectively, compared to anorexia nervosa-restricting subtype (AN-R).

CONCLUSIONS

Patients with EDs reported more ACEs than the nationally representative sample, and differences in total ACEs and latent class membership were found across ED diagnoses. The current study can inform the development of trauma-informed care for patients with EDs.

Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review

BACKGROUND

A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy.

METHODS

We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

RESULTS

We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low.

CONCLUSION

QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources.

PROTOCOL REGISTRATION

This study was registered and followed a published protocol (PROSPERO: CRD42020165069).

Effects of Alcohol Reduction Interventions on Blood Pressure

PURPOSE OF REVIEW

Much of alcohol's purported negative impact on a population's health can be attributed to its association with increased blood pressure, rates of hypertension, and incidence of cardiovascular disease (CVD). Less attention, however, has been placed on the association of the positive impact of alcohol reduction interventions on physical health.

RECENT FINDINGS

This review delineates the evidence of blood pressure reductions as a function of alcohol reduction interventions based on current care models. The findings of this review suggest two things: (1) sufficient evidence exists for a relationship between alcohol reductions and blood pressure generally, and (2) little evidence exists for the relationship between alcohol reductions and blood pressure for any one care model currently employed in the health system. The evidence base would benefit from more studies using established alcohol reduction interventions examining the impact of these interventions on blood pressure.

Adverse childhood experiences among a treatment-seeking sample of adults with eating disorders

OBJECTIVE

The purpose of the current study was to examine the prevalence of adverse childhood experiences (ACEs) among adults with eating disorders (EDs), to assess whether experiencing a greater number of ACEs is associated with more severe ED psychopathology, and to determine whether ACEs predict treatment outcome.

METHOD

Participants were 1819 patients (88.5% female, ages 18-72) admitted to one of two treatment facilities at inpatient, residential, or partial hospitalisation levels of care. The Adverse Childhood Experiences Survey and the Eating Pathology Symptom Inventory (EPSI) were completed at admission and the EPSI at discharge.

RESULTS

Female patients reported higher ACEs than males (p = 0.03), and all diagnoses except avoidant/restrictive food intake disorder had significantly higher ACEs than patients with anorexia nervosa-restricting type (AN-R) (p's < 0.01). Across diagnoses, higher ACEs were associated with decreases in binge eating scores during treatment, but were not associated with changes in purging or restricting. Within diagnoses, higher ACEs scores were associated with decreases in purging for patients with AN-R and increases in purging for patients with binge eating disorder.

CONCLUSIONS

Results partially supported the hypothesis that higher ACEs would be associated with more severe ED psychopathology.

Expressed emotion and long-term outcome among adolescents with anorexia nervosa

OBJECTIVE

The purpose of the current study is to examine expressed emotion (EE) and long-term treatment outcome among adolescents participating in a randomized controlled trial (RCT) for treatment of anorexia nervosa (AN). It was hypothesized that patients with high EE parents at baseline would show more severe symptoms at end-of-treatment, 12-month follow-up, and 4-year follow-up than patients from low EE families.

METHOD

Secondary data analysis was conducted of original RCT data from a two-site eating disorder treatment trial conducted in the United States. Participants were 121 adolescents with AN who completed measures of EE, eating disorder psychopathology, depression, and self-esteem.

RESULTS

Generalized estimating equations showed that participants who were in the Low EE group achieved a more accelerated drop in depression scores in the context of treatment (first 12 months) than participants in the High EE group. No other significant Group × Time interactions were found.

DISCUSSION

Findings suggest that high parental EE at baseline does not indicate that adolescent patients with AN will fare poorly 4 years later.

Pilot Cohorts for Development of Concurrent Mobile Treatment for Alcohol and Tobacco Use Disorders

Alcohol and tobacco are the 2 most frequently used drugs in the United States and represent the highest co-occurrence of polysubstance use. The objective of this study was to refine an intervention combining mobile contingency management with cognitive-behavioral telephone counseling for concurrent treatment of alcohol and tobacco use disorders. Two cohorts (n = 13 total, n = 5 women) of participants were enrolled, with 10/13 completing treatment and 7/13 completing the 6-month follow-up. At enrollment, participants were drinking a mean of 28.9 drinks per week (SD = 14.1), with a mean of 14.7 heavy drinking days in the past month (SD = 9.9), and a mean of 18.1 cigarettes per day (SD = 11.7). Treatment included a mobile application that participants used to record carbon monoxide and breath alcohol content readings to bioverify abstinence. Participants received up to 4 sessions of phone cognitive-behavioral therapy and monetary reinforcement contingent on abstinence. In cohort 1, 4/6 participants reported abstinent or low-risk drinking post-monitoring. Six weeks post quit-date, 2/6 participants were CO-bioverified abstinent from tobacco use, with 2/6 in dual remission. These results were maintained at 6-months. In cohort 2, 6/7 reported abstinent or low-risk drinking post-monitoring, 5 weeks post quit-date. At the post-monitoring visit, 5/7 were CO-bioverified abstinent from smoking, with 5/7 in dual remission. At 6-months, 3/7 reporting abstinent or low-risk drinking, 1/7 had bioverified abstinence from smoking, with 1/7 in dual remission. Observations suggest that it is possible to develop a concurrent mobile treatment for alcohol and tobacco use disorders.

A real-world evaluation of a smokeless tobacco cessation text message program for veterans: Outcomes and comparison to cigarette smokers

INTRODUCTION

Smokeless tobacco (ST) use and cessation rates have remained unchanged while cigarette smoking has declined, and cessation rates have increased. Text message programs have proved effective for cigarette smokers but have not been evaluated for ST users. The Veterans Health Administration (VHA) created a ST-specific arm of its SmokefreeVET automated text message program to help veteran ST users quit.

METHODS

A retrospective evaluation was conducted on a real-world sample of veteran ST users (n=1,139) who subscribed to SmokefreeVET between 2017 and 2020. Time in program, abstinence, and nicotine replacement therapy (NRT) use were evaluated and compared to 9,764 cigarette smokers who subscribed to SmokefreeVET.

RESULTS

Younger subscribers were more likely to opt out early; 54% of ST users and 60% of cigarette smokers completed the 6-week program. ST users were more likely to report abstinence than cigarette smokers at all time points: the primary outcome, 30-day abstinence at 6 months, was 3.9% in ST users and 2.6% in cigarette smokers (p=.05) and the secondary outcome, abstinence at 3 months, was 5.3% in ST users and 3.4% in cigarette smokers (p=.03). NRT was used by 17% of ST users and was associated with a trend toward higher abstinence compared to ST users who did not use NRT.

CONCLUSION

A real-world sample of ST users were more likely to report abstinence after using the SmokefreeVET text program than cigarette smokers. Automated text message programs may be effective for increasing cessation among ST users and warrant further investigation.

IMPLICATIONS

Smokeless tobacco (ST) cessation is an important public health priority and of importance for veteran and military populations that have higher rates of ST use. There have been relatively few studies conducted investigating the effectiveness of text message interventions for ST cessation, despite the proven efficacy for cigarette smokers. This study provides evidence from a large, real-world sample that text message programs may be effective for ST users and suggests that further research into this treatment modality for ST users is needed.

Impact of financial medication assistance on medication adherence: a systematic review

BACKGROUND: The prevalence of financial medication assistance (FMA), including patient assistance programs, coupons/copayment cards, vouchers, discount cards, and programs/pharmacy services that help patients apply for such programs, has increased. The impact of FMA on medication adherence and persistence has not been synthesized. OBJECTIVE: The primary objective of this study was to review published studies evaluating the impact of FMA on the three phases of medication adherence (initiation [or primary adherence], implementation [or secondary adherence], and discontinuation) and persistence. Among these studies, the secondary objective was to report the impact of FMA on patient out-of-pocket costs and clinical outcomes. METHODS: A systematic review was performed using MEDLINE and Web of Science. RESULTS: Of 656 articles identified, eight studies met all inclusion criteria. Seven studies examined FMA for medications treating cardiovascular diseases, while one study assessed FMA for cancer medications. Among included studies, FMA had a positive impact on medication adherence or persistence, and most measured this impact over one year or less. Of the three phases of medication adherence, implementation (5 of 8) was most commonly reported, followed by discontinuation (3 of 8), and then initiation (1 of 8). Regarding implementation, users of FMA had a higher mean medication possession ratio (MPR) than nonusers, ranging from 7 to 18 percentage points higher. The percentage of patients who discontinued medication was 7 percentage points lower in users of FMA versus nonusers for cardiovascular disease states. In one cancer study, FMA had a larger impact on initiation than discontinuation, ie, compared to nonusers, users of FMA were less likely to abandon an initial prescription (risk ratio= 0.12, 95% confidence interval [CI]: 0.08-0.18), and this effect was larger than the decreased likelihood of discontinuing the medication (hazard ratio = 0.76, 95% CI: 0.66-0.88). In 3 of 8 studies reporting on medication persistence, FMA increased the odds of medication persistence for one year ranged from 11% to 47%, depending on the study. In addition to adherence, half of the studies reported on FMA impacts on patient out-of-pocket costs and 3 of 8 studies reported on clinical outcomes. Impacts on patient out-of-pocket costs were mixed; two studies reported that out-of-pocket costs were higher for users of a coupon or a voucher versus nonusers, one study reported the opposite, and one study reported null effects. Impacts on clinical outcomes were either positive or null. CONCLUSIONS: We found that FMA has positive impacts on all phases of medication adherence as well as medication persistence over one year. Future studies should assess whether FMA has differential impacts based on phase of medication adherence and report on its longer-term (ie, beyond one year) impacts on medication adherence. DISCLOSURES: This work was sponsored by a grant from Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Hung reports past employment by Blue Cross Blue Shield Association and CVS Health and a grant from PhRMA outside of the submitted work. Zullig reports research funding from Proteus Digital Health and the PhRMA Foundation. consulting fees from Novartis. Reed reports receiving research support from Abbott Vascular, AstraZeneca, Janssen Research & Development, Monteris, PhRMA Foundation, and TESARO and consulting fees from Sanofi/Regeneron, NovoNordisk, SVC Systems, and Minomic International, Inc. Bosworth reports research grants from the PhRMA Foundation, Proteus Digital Health, Otsuka, Novo Nordisk, Sanofi, Improved Patient Outcomes, Boehinger Ingelheim, NIH, and VA, as well as consulting fees from Sanofi, Novartis, Otsuka, Abbott, Xcenda, Preventric Diagnostics, and the Medicines Company. The other authors have nothing to report. This work was presented as a poster presentation at the ESPACOMP Annual Meeting in November 2020.

The association of alcohol use with all-cause and cardiovascular disease-related hospitalizations or death in older, high-risk Veterans

BACKGROUND

The prevalence of alcohol misuse among older adults has grown dramatically in the past decade, yet little is known about the association of alcohol misuse with hospitalization and death in this patient population.

METHODS

We examined the association between alcohol use (measured by a screening instrument in primary care) and rates of all-cause and cardiovascular disease (CVD)-related 6-month hospitalization or death via electronic health records (EHRs) in a nationally representative sample of older, high-risk Veterans. Models were adjusted for sociodemographic and clinical characteristics, including frailty and comorbid conditions.

RESULTS

The all-cause hospitalization or death rate at 6 months was 14.9%, and the CVD-related hospitalization or death rate was 1.8%. In adjusted analyses, all-cause hospitalization or death was higher in older Veterans who were nondrinkers or harmful use drinkers compared to moderate use drinkers, but CVD-related hospitalization or death was similar in all categories of drinking.

CONCLUSIONS

These findings suggest that the complex association between alcohol and all-cause acute healthcare utilization found in the broader population is similar in older, high-risk Veteran patients. These findings do not support an association between alcohol consumption and CVD-specific hospitalizations.

Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization

OBJECTIVE

Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death.

STUDY DESIGN AND SETTING

SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression.

RESULTS

Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14).

CONCLUSION

Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.

Motivation to recover for adolescent and adult eating disorder patients in residential treatment

OBJECTIVE

This study aimed to assess how baseline motivation to recover impacts eating disorder (ED) and comorbid symptoms at end-of-treatment (EOT) for adolescents and adults in inpatient/residential treatment.

METHOD

Two hundred and three adolescent (M = 15.90) and 395 adult (M = 25.45) patients with a Diagnostic Statistical Manual, 5th edition ED diagnosis completed the Decisional Balance Scale (DBS) at baseline, and psychosocial measures (ED symptoms, anxiety, depression, obsessive-compulsive disorder symptoms), and %body mass index (kg/m² ; BMI) or median %BMI (for adolescents) at baseline and EOT.

RESULTS

The DBS Avoidance Coping and Burdens subscales at baseline were significantly lower for adolescents than adults (p < 0.001), whereas the DBS Benefits subscale at baseline did not significantly differ between subsamples (p = 0.06). Motivation to recover via DBS subscales was a more reliable predictor of EOT outcomes for both ED and comorbid psychopathology in adults (significant predictor in 19 of 54 total analyses, and 4 significant associations post-Bonferroni correction) than adolescents (significant predictor in 5 of 54 total analyses, and 1 significant association post-Bonferroni correction).

CONCLUSIONS

Baseline motivation to recover may be an important predictor of outcome for adult patients in inpatient/residential treatment but does not appear associated with outcomes for adolescent patients.

Posttraumatic stress disorder symptoms and trauma-informed care in higher levels of care for eating disorders

OBJECTIVE

The purpose of the current study was to examine the prevalence and trajectory of posttraumatic stress disorder (PTSD) symptoms among patients with eating disorders (EDs) in higher level of ED care with trauma-informed components, but without a formal evidence-based trauma intervention.

METHOD

Participants were 613 adults diagnosed with EDs receiving treatment at inpatient, residential, or partial hospitalization levels of care. Participants completed the PTSD Checklist-5 (PCL-5) at admission and discharge.

RESULTS

Over half of patients scored above the cutoff of 33 on the PCL-5 at admission, suggestive of PTSD symptoms characteristic of a formal PTSD diagnosis. The average PCL-5 score significantly decreased for every ED diagnostic category, and there was a significant reduction in the proportion of patients above the PCL-5 cutoff score at discharge. PCL-5 subscales measuring PTSD criteria B (intrusions) and C (avoidance) improved with modest effect sizes, whereas PCL-5 subscales D (negative alterations in cognitions and mood) and E (alterations in arousal and reactivity) improved with larger effect sizes.

DISCUSSION

PTSD symptoms are prevalent among patients with EDs seeking higher levels of care. Despite not offering evidence-based trauma-specific interventions, PTSD symptoms decreased over the course of treatment. However, improvements cannot definitely be attributed to trauma-informed care.

Gender identity, race/ethnicity and eating pathology in a treatment-seeking community sample

Despite the wide-reaching impact of eating disorders (EDs), less is known about eating pathology among individuals across racial/ethnic groups whose gender identity differs from the binary categorization. Examining ED pathology both across binary and minority-gender groups, and relative to racial/ethnic identification is necessary to inform screening and culturally-sensitive intervention efforts. This study investigated patterns of ED symptomology among youth and adults (N = 13658) who telephoned treatment centers in the United States when seeking clinical support for ED symptoms. Analyses examined data from participants who completed a semi-structured clinical interview. Results indicated that Anorexia nervosa was the most common diagnosis in each gender category and for a majority of race/ethnic groups; Black individuals had elevated rates of binge eating disorder. Compared to females, males were less likely to endorse all ED symptoms (ps < .001); gender minority status was also associated with decreased report of a majority of ED symptoms. Asian and Black individuals were less likely than Whites to endorse most ED symptoms. When compared to Whites, Hispanic/Latinx and Bi/Multi-racial participants did not demonstrate significant differences in presentation across a majority of ED symptoms. Overall findings suggest individuals with female gender and White race may seek treatment from an ED treatment facility with greater frequency than other demographic groups. Noted exceptions include Hispanic/Latinx and Bi/Multi-racial individuals, for whom ED pathology may be represented comparably to Whites. While findings confirm traditional patterns in gender and racial/ethnic representation in EDs, current study findings also underscore that EDs are not culture bound.

General Behavioral Engagement and Changes in Clinical and Cognitive Outcomes of Patients with Type 2 Diabetes Using the Time2Focus Mobile App for Diabetes Education: Pilot Evaluation

Background

Type 2 diabetes affects 30 million Americans, representing a significant cause of morbidity and mortality. Self-management support is an important component of chronic illness care and is a key pillar of the chronic care model. Face-to-face teaching and patient education materials suffer from being static or incompatible with mobile lifestyles. Digital apps provide a self-management support alternative that is convenient and scalable.

Objective

This pilot study tested the real-world deployment of a self-guided mobile app for diabetes education (Time2Focus app; MicroMass Communications Inc, Cary, NC), which utilizes evidence-based content and gamification to deliver an interactive learning experience.

Methods

Primary care providers were approached for permission to invite their patients to participate. Eligible patients were 18 to 89 years of age, had a diagnosis of type 2 diabetes, hemoglobin A1c (HbA1c) ≥8% and <12% in the past 3 months, an active online patient portal account (tied to the electronic health record), and access to an iOS or Android smartphone. Interested patients were emailed a baseline survey, and once this was completed, were sent instructions for downloading the Time2Focus app. After completing all 12 levels, participants were sent a follow-up survey. The primary outcome was the change in HbA1c. Secondary outcomes included medication adherence, self-care activities, self-reporting of physical activities, diabetes self-efficacy, illness perceptions, diabetes distress scale, and users’ engagement with and rating of the app.

Results

Of 1355 potentially eligible patients screened, 201 were consented. Of these 201 patients, 101 (50.2%) did not download the app. Of the 100 participants (49.8%) who downloaded the app, 16 (16.0%) completed 0 levels, 26 (26.0%) completed 1 to 4 levels, 10 (10.0%) completed 5 to 11 levels, and 48 (48.0%) completed all 12 levels of the app and the follow-up survey. Those completing one or more levels had a mean pre/post-HbA1c change of –0.41% (compared to –0.32% among those who completed zero levels); however, the unadjusted two-tailed t test indicated no significant difference between the two groups (P=.73). Diabetes self-efficacy showed a large and significant increase during app usage for completers (mean change 1.28, P<.001, d=.83). Severity of illness perceptions showed a small but significant decrease during app usage for completers (mean change –0.51, P=.004, d=.43). Diabetes distress showed a small but significant decrease during app usage for completers (mean change –0.45, P=.006, d=.41). The net promoter score was 62.5, indicating that those who completed all levels of the app rated it highly and would recommend it to others.

Conclusions

Participants who engaged in all 12 levels of the Time2Focus mobile app showed an improvement in diabetes self-efficacy and a decrease in severity of illness perceptions. The decrease in HbA1c observed in app users relative to nonusers during this limited pilot study was not statistically significant. However, uptake and application of lessons learned from self-management support may be delayed. Further research is needed to address how to increase engagement through self-management support and to investigate if follow up over a longer period demonstrates a significant change in outcomes such as HbA1c.

Regulatory Focus and Substance Use in Adolescents: Protective Effects of Prevention Orientation

Substance use is a major risk factor for negative health and functioning outcomes among middle schoolers. The purpose of this study was to assess whether individual differences in the adolescents' goal orientation are associated with elevated or attenuated risk for substance use. Regulatory focus theory stipulates that individuals vary in their strength of orientation toward promotion goals ("making good things happen") and prevention goals ("keeping bad things from happening"). Objectives: We sought to examine the association between individual differences in regulatory focus and adolescents' reports of their own and their friends' substance use. Methods: Participants were 241 seventh grade students who completed measures of regulatory focus (promotion and prevention orientation), self-reported substance use, perceived substance use habits of peers, and demographics. Logistic regression models were used to examine adjusted odds of lifetime tobacco use, alcohol use, and marijuana use for both participants' own use and their reports of friends' use. Results: Prevention orientation was associated with lower odds of all self-reported lifetime substance use outcomes (tobacco, alcohol, and marijuana). Prevention orientation was also associated with lower odds of reporting all types of substance use among friends. Promotion orientation was not associated with any self-reported substance use outcome, and was only associated with higher odds of reporting lifetime alcohol use among friends. Conclusions: These findings underscore the importance of regulatory focus as it relates to adolescent substance use. Future research may seek to incorporate regulatory focus within interventions intended to prevent or delay initiation of substance use in adolescents.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

Background

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

Objective

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

Methods

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

Results

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

Conclusions

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Patient-Reported Social and Behavioral Determinants of Health and Estimated Risk of Hospitalization in High-Risk Veterans Affairs Patients

IMPORTANCE

Despite recognition of the association between individual social and behavioral determinants of health (SDH) and patient outcomes, little is known regarding the value of SDH in explaining variation in outcomes for high-risk patients.

OBJECTIVE

To describe SDH factors among veterans who are at high risk for hospitalization, and to determine whether adding patient-reported SDH measures to electronic health record (EHR) measures improves estimation of 90-day and 180-day all-cause hospital admission.

DESIGN, SETTING, AND PARTICIPANTS

A survey was mailed between April 16 and June 29, 2018, to a nationally representative sample of 10 000 Veterans Affairs (VA) patients whose 1-year risk of hospitalization or death was in the 75th percentile or higher based on a VA EHR-derived risk score. The survey included multiple SDH measures, such as resilience, social support, health literacy, smoking status, transportation barriers, and recent life stressors.

MAIN OUTCOMES AND MEASURES

The EHR-based characteristics of survey respondents and nonrespondents were compared using standardized differences. Estimation of 90-day and 180-day hospital admission risk was assessed for 3 logistic regression models: (1) a base model of all prespecified EHR-based covariates, (2) a restricted model of EHR-based covariates chosen via forward selection based on minimizing Akaike information criterion (AIC), and (3) a model of EHR- and survey-based covariates chosen via forward selection based on AIC minimization.

RESULTS

In total, 4685 individuals (response rate 46.9%) responded to the survey. Respondents were comparable to nonrespondents in most characteristics, but survey respondents were older (eg, >80 years old, 881 [18.8%] vs 800 [15.1%]), comprised a higher percentage of men (4391 [93.7%] vs 4794 [90.2%]), and were composed of more White non-Hispanic individuals (3366 [71.8%] vs 3259 [61.3%]). Based on AIC, the regression model with survey-based covariates and EHR-based covariates better estimated hospital admission at 90 days (AIC, 1947.7) and 180 days (AIC, 2951.9) than restricted models with only EHR-based covariates (AIC, 1980.2 at 90 days; AIC, 2981.9 at 180 days). This result was due to inclusion of self-reported measures such as marital or partner status, health-related locus of control, resilience, smoking status, health literacy, and medication insecurity.

CONCLUSIONS AND RELEVANCE

Augmenting EHR data with patient-reported social information improved estimation of 90-day and 180-day hospitalization risk, highlighting specific SDH factors that might identify individuals who are at high risk for hospitalization.