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Duffy RA, Jeffreys AS, Coffman CJ, Alexopoulos AS, Tarkington PE, Bosworth H, Edelman D, Crowley MJ. Evaluating Therapeutic Inertia in Two Telehealth Interventions for Type 2 Diabetes: Secondary Analyses of a Randomized Trial. Telemed J E Health 2024. [PMID: 38377570 DOI: 10.1089/tmj.2023.0453] [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] [Indexed: 02/22/2024] Open
Abstract
Introduction: Although therapeutic inertia is a known driver of suboptimal type 2 diabetes control, little is known about how to combat this phenomenon. We analyzed randomized trial data to determine whether a comprehensive telehealth intervention was more effective than a less structured telehealth approach (telemonitoring and care coordination) at promoting treatment intensification in poorly controlled diabetes. Methods: Patients with poorly controlled type 2 diabetes were randomized 1:1 to telemonitoring/care coordination or a comprehensive telehealth intervention, which included an active, study provider-guided medication management component. Prospectively collected medication lists were used to determine whether treatment intensification occurred for each patient during 3-month intervals throughout the study period. To examine between-arm differences in treatment intensification over time, we fit a generalized estimation equation model. In each arm, hemoglobin A1c levels at the beginning and end of each 3-month interval were used to distinguish between therapeutic inertia and potentially appropriate nonintensification of treatment. Results: The mean, model-estimated likelihood of treatment intensification during 3-month intervals was 61.3% in the comprehensive telehealth group versus 48.6% for telemonitoring/care coordination (odds ratio 1.7, 95% confidence interval 1.2-2.2; p = 0.0007), with no evidence that treatment effect varied over time (p = 0.54). Treatment intervals with observed therapeutic inertia were more common in the telemonitoring/care coordination arm than the comprehensive telehealth arm (116/300, 39% vs. 57/275, 21%). Conclusions: A comprehensive telehealth approach that integrated protocol-guided medication management increased treatment intensification and reduced therapeutic inertia compared with a less structured telehealth approach. The studied approaches may serve as examples of how systems might use telehealth to combat therapeutic inertia. Clinical Trial Registration: ClinicalTrials.gov NCT03520413.
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Affiliation(s)
- Ryan A Duffy
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Phillip E Tarkington
- Central Virginia VA Health Care System, Department of Veterans Affairs, Richmond, Virginia, USA
| | - Hayden Bosworth
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Edelman
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; USA
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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Glynn S, Calhoun P, Ackland PE, Bokhour B, Edelman D, Falkovic M, Weidenbacher HJ, Eldridge MR, Lanford T, Swinkels C, Dedert E, Wells S, Ruffin R, Van Houtven CH. Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study. Psychol Trauma 2024:2024-44916-001. [PMID: 38236230 DOI: 10.1037/tra0001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System. METHOD This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework. RESULTS Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care. CONCLUSIONS Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | - Abigail Shapiro
- Health Services Research and Development, Durham VA Health Care System
| | | | | | - Patrick Calhoun
- Health Services Research and Development, Durham VA Health Care System
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
| | - David Edelman
- Health Services Research and Development, Durham VA Health Care System
| | - Margaret Falkovic
- Health Services Research and Development, Durham VA Health Care System
| | | | | | - Tiera Lanford
- Health Services Research and Development, Durham VA Health Care System
| | - Cindy Swinkels
- Health Services Research and Development, Durham VA Health Care System
| | - Eric Dedert
- Health Services Research and Development, Durham VA Health Care System
| | - Stephanie Wells
- Health Services Research and Development, Durham VA Health Care System
| | - Rachel Ruffin
- Health Services Research and Development, Durham VA Health Care System
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Gass JC, Maisto SA, Edelman D, Funderburk JS. Brief conjoint visits between an embedded behavioral health provider and primary care team member: When are they used and what are the barriers and facilitators? Fam Syst Health 2023; 41:488-501. [PMID: 37471048 DOI: 10.1037/fsh0000817] [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] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Conjoint visits utilize the expertise of primary care providers (PCPs) and behavioral health providers (BHPs) to address complex comorbidities in patients. The objectives were to describe the use and features of conjoint visits and identify barriers and facilitators as described by BHPs in integrated settings. METHOD Three hundred and forty-five BHPs who worked in integrated primary care, a majority identifying as female and white, completed an online survey between October 2018 and July 2019. RESULTS Results indicated common reasons for conjoint visits were for mental or behavioral health concerns. Though they reported high comfort using conjoint visits (M = 4.3/5), 56.5% of BHPs participated in them less than monthly or never. Using a constant comparison approach, qualitative data were coded to reveal six categories of barriers and five categories of facilitators to conjoint visits. The most common barriers were a result of a lack of systemic support, such as 73.5% reporting lack of time, while the most common facilitators were coordination (60.7%) and interprofessional communication (39.3%). DISCUSSION Although conjoint visits are used infrequently, findings suggest it is not because they are unhelpful as providers generally found this type of appointment favorable. Rather, they and their teams lack time, training, and support needed for implementation. This research provides an introduction for researchers or clinicians to better understand the use of conjoint visits for patients with high needs and complexities. Future work focused on addressing barriers cited by providers regarding conjoint visits would increase providers' ability to use this form of care when it is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Julie C Gass
- VA Center for Integrated Healthcare, Western NY VA Medical Center
| | | | - David Edelman
- ADAPT Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System
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Shepherd-Banigan M, Shapiro A, Sheahan KL, Ackland PE, Meis LA, Thompson-Hollands J, Edelman D, Calhoun PS, Weidenbacher H, Van Houtven CH. Mental health therapy for veterans with PTSD as a family affair: A qualitative inquiry into how family support and social norms influence veteran engagement in care. Psychol Serv 2023; 20:839-848. [PMID: 36780280 PMCID: PMC10423295 DOI: 10.1037/ser0000742] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Social support is important for posttraumatic stress disorder (PTSD) recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 U.S. military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran's personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should be engaged early in mental health therapy and to the extent desired by the patient and family member. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Kate L. Sheahan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Princess E. Ackland
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Laura A. Meis
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Johanna Thompson-Hollands
- Behavioral Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Boston University School of Medicine, Department of Psychiatry, 720 Harrison Ave, Boston, MA 02118
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 W Main St, Durham, NC, 27701, USA
| | | | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Sheahan KL, Ackland PE, Smith VA, Bokhour BG, Glynn SM, Calhoun PS, Edelman D, Weidenbacher HJ, Eldridge MR, Van Houtven CH. Exploring the importance of predisposing, enabling, and need factors for promoting Veteran engagement in mental health therapy for post-traumatic stress: a multiple methods study. BMC Psychiatry 2023; 23:372. [PMID: 37237261 DOI: 10.1186/s12888-023-04840-7] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. Despite efforts by the Department of Veterans Affairs (VA) to increase mental health care access, the proportion of Veterans with PTSD who engage in PTSD therapy remains low. Support for therapy from family members and friends could improve Veteran therapy use. METHODS We applied a multiple methods approach using data from VA administrative data and semi-structured individual interviews with Veterans and their support partners who applied to the VA Caregiver Support Program. We integrated findings from a machine learning analysis of quantitative data with findings from a qualitative analysis of the semi-structured interviews. RESULTS In quantitative models, Veteran medical need for health care use most influenced treatment initiation and retention. However, qualitative data suggested mental health symptoms combined with positive Veteran and support partner treatment attitudes motivated treatment engagement. Veterans indicated their motivation to seek treatment increased when family members perceived treatment to be of high value. Veterans who experienced poor continuity of VA care, group, and virtual treatment modalities expressed less care satisfaction. Prior marital therapy use emerged as a potentially new facilitator of PTSD treatment engagement that warrants more exploration. CONCLUSIONS Our multiple methods findings represent Veteran and support partner perspectives and show that amid Veteran and organizational barriers to care, attitudes and support of family members and friends still matter. Family-oriented services and intervention could be a gateway to increase Veteran PTSD therapy engagement.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
| | | | - Kate L Sheahan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Valerie A Smith
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA, 01605, USA
| | - Shirley M Glynn
- UCLA Semel Institute of Neuroscience and Human Behavior, VA Greater Los Angeles Healthcare System at West Los Angeles, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073, USA
| | - Patrick S Calhoun
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | | | - Courtney H Van Houtven
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
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German J, Kobe EA, Lewinski AA, Jeffreys AS, Coffman C, Edelman D, Batch BC, Crowley MJ. Factors Associated With Diabetes Distress Among Patients With Poorly Controlled Type 2 Diabetes. J Endocr Soc 2023; 7:bvad031. [PMID: 36926446 PMCID: PMC10011876 DOI: 10.1210/jendso/bvad031] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 03/06/2023] Open
Abstract
Objective Examine factors associated with increased diabetes distress (DD) among patients with type 2 diabetes with DD assessed by Diabetes Distress Scale (DDS) total and subscale scores (emotional burden, physician-related distress, regimen-related distress, and interpersonal distress). Methods Cross-sectional analysis of data from veterans with persistently poorly controlled diabetes mellitus. Multivariable linear regression models included baseline patient characteristics (independent variables) and DDS total and subscale scores (dependent variable). Results The cohort's (N = 248) mean age was 58 years (SD 8.3); 21% were female, 79% were non-White, and 5% were Hispanic/Latinx. Mean hemoglobin A1c (HbA1c) was 9.8%, and 37.5% had moderate to high DD. Hispanic/Latinx ethnicity (β=0.41; 95% CI 0.01, 0.80), baseline HbA1c (0.07; 95% CI 0.01,0.13), and higher Personal Health Questionnaire-8 (PHQ-8) scores (0.07; 95% CI 0.05, 0.09) were associated with higher total DD. Hispanic/Latinx ethnicity (0.79; 95% CI 0.25, 1.34) and higher PHQ-8 (0.05; 95% CI 0.03, 0.08) were associated with higher interpersonal-related distress. Higher HbA1c (0.15; 95% CI 0.06, 0.23) and higher PHQ-8 scores (0.10; 95% CI 0.07, 0.13) were associated with higher regimen-related distress. The use of basal insulin (0.28; 95% CI 0.001, 0.56) and higher PHQ-8 (0.02; 95% CI 0.001, 0.05) were associated with higher physician-related distress. Higher PHQ-8 (0.10; 95% CI 0.07, 0.12) was associated with higher emotional burden. Conclusion Hispanic/Latinx ethnicity, depressive symptoms, uncontrolled hyperglycemia, and insulin use were associated with higher risk for DD. Future research should explore these relationships, and interventions designed to reduce diabetes distress should consider accounting for these factors.
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Affiliation(s)
- Jashalynn German
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, Duke University, Durham, NC 27710, USA
| | - Elizabeth A Kobe
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Allison A Lewinski
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA.,Duke University School of Nursing, Durham, NC 27710, USA
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
| | - Cynthia Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC 27710, USA
| | - David Edelman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
| | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, Duke University, Durham, NC 27710, USA
| | - Matthew J Crowley
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, Duke University, Durham, NC 27710, USA.,Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27705, USA
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Alexopoulos AS, Soliman D, Lewinski AA, Strawbridge E, Steinhauser K, Edelman D, Crowley MJ. Simplifying therapy to assure glycemic control and engagement (STAGE) in poorly-controlled diabetes: A pilot study. J Diabetes Complications 2023; 37:108364. [PMID: 36525906 PMCID: PMC9839589 DOI: 10.1016/j.jdiacomp.2022.108364] [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: 08/08/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
In this single-arm pilot study, we demonstrated feasibility and acceptability of an insulin simplification intervention in patients with persistent, poorly-controlled type 2 diabetes on complex insulin regimens. While not powered to assess clinical outcomes, we observed neither worsened glycemic control nor increased hypoglycemia.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States.
| | - Diana Soliman
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; School of Nursing, Duke University, Durham, NC 27710, United States
| | - Elizabeth Strawbridge
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States
| | - Karen Steinhauser
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Population Health Sciences, Duke University, Durham, NC 27710, United States
| | - David Edelman
- Department of Population Health Sciences, Duke University, Durham, NC 27710, United States; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, United States
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States
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Shepherd-Banigan M, Wells SY, Falkovic M, Ackland PE, Swinkels C, Dedert E, Ruffin R, Van Houtven CH, Calhoun PS, Edelman D, Weidenbacher HJ, Shapiro A, Glynn S. Adapting a family-involved intervention to increase initiation and completion of evidenced-based psychotherapy for posttraumatic stress disorder. SSM Ment Health 2022; 2:100114. [PMID: 35979411 PMCID: PMC9376943 DOI: 10.1016/j.ssmmh.2022.100114] [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] [Indexed: 11/24/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is disabling condition among United States Veterans. Training programs for evidenced-based therapies have been rolled out nationally in the Veterans Health Administration (VHA), but provider adoption of these treatments is limited and rates of Veteran dropout are high. Increasing support for mental health therapy within the Veteran's social network would improve treatment engagement. We discuss the adaptation of Recovery-Oriented Decisions for Relatives' Support (REORDER)-a family-based intervention for individuals with serious mental illness- to create Family Support in Mental Health Recovery (FAMILIAR), an intervention that seeks to strengthen support partners' abilities to help Veterans engage in therapy. Our goal was to apply modifications to meet the needs of Veterans with PTSD and their support partners. We used input from Veterans, support partners, clinicians and VA system leaders to inform the modifications. Then, a multi-disciplinary intervention development team met to determine which modifications would be applied and how. We used the domains from the Framework for Adaptations and Modification (FRAME) to systematically track and describe modifications. Adaptations made to REORDER included changes in content, structure, and delivery format. The resulting intervention, FAMILIAR, was a 3-4 session intervention beginning prior to EBP initiation and continuing through sessions 3, 4 or 5 of the EBP. Sessions were designed for maximum flexibility and could be offered either in-person or virtually, and sessions involve interactions between the interventionist with the Veteran and support partner alone and together. We learned the importance of including diverse stakeholder perspectives to develop a comprehensive understanding of the needs of the target population and the health system. While feasibility and effectiveness testing is needed, we applied a proactive adaptation approach that we anticipate will make FAMILIAR successful in addressing patient, clinical, and system considerations of a family approach to increase Veteran engagement in PTSD treatment.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | | | - Margaret Falkovic
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Cindy Swinkels
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Eric Dedert
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - Rachel Ruffin
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Shirley Glynn
- Semel Institute of Neuroscience and Human Behavior, Greater LA VA Health Care System/UCLA, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073 USA
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Tarras S, White MT, Toloff K, Cooley D, Edelman D. Just Do It: Participation in Structured Online Curricula Reliably Improves Low ABSITE Scores. J Surg Educ 2022; 79:e166-e172. [PMID: 35902350 DOI: 10.1016/j.jsurg.2022.07.011] [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] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/03/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We hypothesized residents enrolled in an Accelerated Clinical Education in Surgery (ACES) program would improve their scores to above the 30th percentile. We analyzed which components of ACES correlated with improvement. DESIGN AND SETTING A retrospective review of three academic cycles (2018-2021) at an academic general surgery residency. PARTICIPANTS Residents scoring ≤30th percentile on the ABSITE were enrolled in ACES. Baseline demographics including STEP scores were collected. ACES included: (1) SCORE and DeckerMed assignments (2) Weekly faculty review sessions and (3) Monthly meeting with assigned mentor. Data were analyzed by Student's t-test, one-way ANOVA and Fisher's exact test. RESULTS Twenty-six surgical residents enrolled in ACES. Compared to residents not in ACES, there was no significant difference females (15 vs. 15; p = 0.19) and STEP 2 scores (241 vs. 246; p = 0.06). Residents in ACES had significantly lower STEP 1 (225 vs. 237; p < 0.001) and STEP 3 (212 vs. 223; p < 0.001) scores. Demographics of ACES residents who subsequently scored >30th percentile were similar to those who didn't, except for STEP 3 scores (216 vs. 204; p = 0.008). For residents in ACES, the completion of assignments between July and January was significantly higher for those who subsequently achieved an ABSITE score >30th percentile: TWIS, 77% vs. 53% (p = 0.022), Decker WC, 80% vs. 49% (p = 0.009) and Decker MR, 53% vs. 29% (p = 0.016). Completion of an online practice exam prior to ABSITE also correlated with score >30th percentile (57% vs. 13%, p = 0.007). There was also no correlation between the number of faculty review sessions and ABSITE (11.5 vs.11.9, p = 0.931). CONCLUSIONS Participation in a structured online program of reading and quizzes was durably effective in improving ABSITE scores >30th percentile. Completion of online assignments, rather than scores on practice tests or review sessions, appeared to be the most important factor for success.
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Affiliation(s)
- Samantha Tarras
- The Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, Michigan.
| | - Michael T White
- The Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, Michigan
| | - Katelyn Toloff
- The Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, Michigan
| | - Dana Cooley
- The Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, Michigan
| | - David Edelman
- The Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, Michigan
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10
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Kobe EA, Lewinski AA, Jeffreys AS, Smith VA, Coffman CJ, Danus SM, Sidoli E, Greck BD, Horne L, Saxon DR, Shook S, Aguirre LE, Esquibel MG, Evenson C, Elizagaray C, Nelson V, Zeek A, Weppner WG, Scodellaro S, Perdew CJ, Jackson GL, Steinhauser K, Bosworth HB, Edelman D, Crowley MJ. Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes. J Gen Intern Med 2022; 37:3080-3088. [PMID: 34981358 PMCID: PMC8722663 DOI: 10.1007/s11606-021-07281-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/12/2021] [Accepted: 11/10/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging. OBJECTIVE To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas. DESIGN Mixed-methods implementation study. PARTICIPANTS 230 patients with clinic-refractory, uncontrolled T2D. INTERVENTION ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period. MAIN MEASURES Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c). KEY RESULTS From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (- 1.43%, 95% CI: - 1.64, - 1.21; P < .001). Benefits persisted at 12 (- 1.26%, 95% CI: - 1.48, - 1.05; P < .001) and 18 months (- 1.08%, 95% CI - 1.35, - 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years. CONCLUSIONS When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population.
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Affiliation(s)
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- School of Nursing, Duke University School of Medicine, Durham, NC, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Susanne M Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Elisabeth Sidoli
- Western North Carolina Veteran Affairs Health Care System, Asheville, NC, USA
| | - Beth D Greck
- Western North Carolina Veteran Affairs Health Care System, Asheville, NC, USA
| | - Leanne Horne
- VISN 19 Rocky Mountain Regional, Denver, CO, USA
| | - David R Saxon
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Endocrinology, Rocky Mountain Veterans Affairs Medical Center, Aurora, CO, USA
| | - Susan Shook
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Lina E Aguirre
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Mary G Esquibel
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Clarene Evenson
- Montana Veteran Affairs Health Care System, Kalispell, MT, USA
| | | | - Vivian Nelson
- Veterans Affairs Central Ohio Healthcare System, Columbus, OH, USA
| | - Amanda Zeek
- Veterans Affairs Central Ohio Healthcare System, Columbus, OH, USA
| | - William G Weppner
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Boise Veteran Affairs Medical Center, Boise, ID, USA
| | | | | | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Karen Steinhauser
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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11
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Crowley MJ, Tarkington PE, Bosworth HB, Jeffreys AS, Coffman CJ, Maciejewski ML, Steinhauser K, Smith VA, Dar MS, Fredrickson SK, Mundy AC, Strawbridge EM, Marcano TJ, Overby DL, Majette Elliott NT, Danus S, Edelman D. Effect of a Comprehensive Telehealth Intervention vs Telemonitoring and Care Coordination in Patients With Persistently Poor Type 2 Diabetes Control: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:943-952. [PMID: 35877092 PMCID: PMC9315987 DOI: 10.1001/jamainternmed.2022.2947] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 11/14/2022]
Abstract
IMPORTANCE Persistently poorly controlled type 2 diabetes (PPDM) is common and causes poor outcomes. Comprehensive telehealth interventions could help address PPDM, but effectiveness is uncertain, and barriers impede use in clinical practice. OBJECTIVE To address evidence gaps preventing use of comprehensive telehealth for PPDM by comparing a practical, comprehensive telehealth intervention to a simpler telehealth approach. DESIGN, SETTING, AND PARTICIPANTS This active-comparator, parallel-arm, randomized clinical trial was conducted in 2 Veterans Affairs health care systems. From December 2018 to January 2020, 1128 outpatients with PPDM were assessed for eligibility and 200 were randomized; PPDM was defined as maintenance of hemoglobin A1c (HbA1c) level of 8.5% or higher for 1 year or longer despite engagement with clinic-based primary care and/or diabetes specialty care. Data analyses were preformed between March 2021 and May 2022. INTERVENTIONS Each 12-month intervention was nurse-delivered and used only clinical staffing/resources. The comprehensive telehealth group (n = 101) received telemonitoring, self-management support, diet/activity support, medication management, and depression support. Patients assigned to the simpler intervention (n = 99) received telemonitoring and care coordination. MAIN OUTCOMES AND MEASURES Primary (HbA1c) and secondary outcomes (diabetes distress, diabetes self-care, self-efficacy, body mass index, depression symptoms) were analyzed over 12 months using intent-to-treat linear mixed longitudinal models. Sensitivity analyses with multiple imputation and inclusion of clinical data examined the impact of missing HbA1c measurements. Adverse events and intervention costs were examined. RESULTS The population (n = 200) had a mean (SD) age of 57.8 (8.2) years; 45 (22.5%) were women, 144 (72.0%) were of Black race, and 11 (5.5%) were of Hispanic/Latinx ethnicity. From baseline to 12 months, HbA1c change was -1.59% (10.17% to 8.58%) in the comprehensive telehealth group and -0.98% (10.17% to 9.19%) in the telemonitoring/care coordination group, for an estimated mean difference of -0.61% (95% CI, -1.12% to -0.11%; P = .02). Sensitivity analyses showed similar results. At 12 months, patients receiving comprehensive telehealth had significantly greater improvements in diabetes distress, diabetes self-care, and self-efficacy; no differences in body mass index or depression were seen. Adverse events were similar between groups. Comprehensive telehealth cost an additional $1519 per patient per year to deliver. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that compared with telemonitoring/care coordination, comprehensive telehealth improved multiple outcomes in patients with PPDM at a reasonable additional cost. This study supports consideration of comprehensive telehealth implementation for PPDM in systems with appropriate infrastructure and may enhance the value of telehealth during the COVID-19 pandemic and beyond. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03520413.
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Affiliation(s)
- Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Hayden B Bosworth
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew L Maciejewski
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina
| | - Karen Steinhauser
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Valerie A Smith
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Moahad S Dar
- Greenville VA Health Care Center, Greenville, North Carolina.,Division of Endocrinology, Department of Medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | | | - Amy C Mundy
- Central Virginia Veterans Affairs Health Care System, Richmond
| | - Elizabeth M Strawbridge
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | | | - Donna L Overby
- Central Virginia Veterans Affairs Health Care System, Richmond
| | - Nadya T Majette Elliott
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - Susanne Danus
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - David Edelman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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12
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Sagalla N, Yancy WS, Edelman D, Jeffreys AS, Coffman CJ, Voils CI, Alexopoulos AS, Maciejewski ML, Dar M, Crowley MJ. Factors associated with non-adherence to insulin and non-insulin medications in patients with poorly controlled diabetes. Chronic Illn 2022; 18:398-409. [PMID: 33100020 PMCID: PMC8995079 DOI: 10.1177/1742395320968627] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate differences in factors associated with self-reported medication non-adherence to insulin and non-insulin medications in patients with uncontrolled type 2 diabetes. METHODS In this secondary analysis of a randomized trial in patients with obesity and uncontrolled type 2 diabetes, multivariable logistic regression was used to evaluate associations between several clinical factors (measured with survey questionnaires at study baseline) and self-reported non-adherence to insulin and non-insulin medications. RESULTS Among 263 patients, reported non-adherence was 62% (52% for insulin, 55% for non-insulin medications). Reported non-adherence to non-insulin medications was less likely in white versus non-white patients (odds ratio (OR) = 0.42; 95%CI: 0.22,0.80) and with each additional medication taken (OR = 0.75; 95%CI: 0.61,0.93). Non-adherence to non-insulin medications was more likely with each point increase in a measure of diabetes medication intensity (OR = 1.43; 95%CI: 1.01,2.03), the Problem Areas in Diabetes (PAID) score (OR = 1.06; 95%CI: 1.02,1.12), and in men versus women (OR = 3.03; 95%CI: 1.06,8.65). For insulin, reporting non-adherence was more likely (OR = 1.02; 95%CI: 1.00,1.04) with each point increase in the PAID. DISCUSSION Despite similar overall rates of reported non-adherence to insulin and non-insulin medications, factors associated with reported non-adherence to each medication type differed. These findings may help tailor approaches to supporting adherence in patients using different types of diabetes medications.
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Affiliation(s)
- Nicole Sagalla
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
| | - William S Yancy
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA.,Duke Diet and Fitness Center, Durham, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, USA.,Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, USA
| | - Moahad Dar
- Division of Endocrinology and Metabolism, East Carolina University, Greenville, USA.,Greenville Veterans Affairs Health Care Center, Greenville, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
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13
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Drake C, Snyderman R, Cannady M, Batchelder H, Lian T, Wedda B, Clipper C, Edelman D. Personalized Medical Group Visits: A Novel Approach for the Care of Prediabetes. Diabetes Spectr 2022; 35:504-511. [PMID: 36545257 PMCID: PMC9668724 DOI: 10.2337/ds21-0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
- Corresponding author: Connor Drake,
| | - Ralph Snyderman
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Meagan Cannady
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - Heather Batchelder
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Christie Clipper
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - David Edelman
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Durham VA Healthcare System, Durham, NC
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14
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Sancheznieto F, Sorkness CA, Attia J, Buettner K, Edelman D, Hobbs S, McIntosh S, McManus LM, Sandberg K, Schnaper HW, Scholl L, Umans JG, Weavers K, Windebank A, McCormack WT. Clinical and translational science award T32/TL1 training programs: program goals and mentorship practices. J Clin Transl Sci 2021; 6:e13. [PMID: 35211339 PMCID: PMC8826009 DOI: 10.1017/cts.2021.884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/17/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION A national survey characterized training and career development for translational researchers through Clinical and Translational Science Award (CTSA) T32/TL1 programs. This report summarizes program goals, trainee characteristics, and mentorship practices. METHODS A web link to a voluntary survey was emailed to 51 active TL1 program directors and administrators. Descriptive analyses were performed on aggregate data. Qualitative data analysis used open coding of text followed by an axial coding strategy based on the grounded theory approach. RESULTS Fifty out of 51 (98%) invited CTSA hubs responded. Training program goals were aligned with the CTSA mission. The trainee population consisted of predoctoral students (50%), postdoctoral fellows (30%), and health professional students in short-term (11%) or year-out (9%) research training. Forty percent of TL1 programs support both predoctoral and postdoctoral trainees. Trainees are diverse by academic affiliation, mostly from medicine, engineering, public health, non-health sciences, pharmacy, and nursing. Mentor training is offered by most programs, but mandatory at less than one-third of them. Most mentoring teams consist of two or more mentors. CONCLUSIONS CTSA TL1 programs are distinct from other NIH-funded training programs in their focus on clinical and translational research, cross-disciplinary approaches, emphasis on team science, and integration of multiple trainee types. Trainees in nearly all TL1 programs were engaged in all phases of translational research (preclinical, clinical, implementation, public health), suggesting that the CTSA TL1 program is meeting the mandate of NCATS to provide training to develop the clinical and translational research workforce.
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Affiliation(s)
- Fátima Sancheznieto
- University of Wisconsin Institute for Clinical and Translational Research, Madison, WI, USA
| | - Christine A. Sorkness
- University of Wisconsin Institute for Clinical and Translational Research, Madison, WI, USA
| | - Jacqueline Attia
- Center for Leading Innovation and Collaboration, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Kathryn Buettner
- Center for Leading Innovation and Collaboration, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - David Edelman
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Stuart Hobbs
- The Ohio State University, Center for Clinical and Translational Science, Columbus, OH, USA
| | - Scott McIntosh
- Center for Leading Innovation and Collaboration, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kathryn Sandberg
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | - H. William Schnaper
- Northwestern University Clinical and Translational Sciences Institute, Northwestern University, Chicago, IL, USA
| | | | - Jason G. Umans
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | | | | | - Wayne T. McCormack
- Clinical & Translational Science Institute, Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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15
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Alexopoulos AS, Yancy WS, Edelman D, Coffman CJ, Jeffreys AS, Maciejewski ML, Voils CI, Sagalla N, Barton Bradley A, Dar M, Mayer SB, Crowley MJ. Clinical associations of an updated medication effect score for measuring diabetes treatment intensity. Chronic Illn 2021; 17:451-462. [PMID: 31653175 PMCID: PMC7182482 DOI: 10.1177/1742395319884096] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The medication effect score reflects overall intensity of a diabetes regimen by consolidating dosage and potency of agents used. Little is understood regarding how medication intensity relates to clinical factors. We updated the medication effect score to account for newer agents and explored associations between medication effect score and patient-level clinical factors. METHODS Cross-sectional analysis of baseline data from a randomized controlled trial involving 263 Veterans with type 2 diabetes and hemoglobin A1c levels ≥8.0% (≥7.5% if under age 50). Medication effect score was calculated for all patients at baseline, alongside additional measures including demographics, comorbid illnesses, hemoglobin A1c, and self-reported psychosocial factors. We used multivariable regression to explore associations between baseline medication effect score and patient-level clinical factors. RESULTS Our sample had a mean age of 60.7 (SD = 8.2) years, was 89.4% male, and 57.4% non-White. Older age and younger onset of diabetes were associated with a higher medication effect score, as was higher body mass index. Higher medication effect score was significantly associated with medication nonadherence, although not with hemoglobin A1c, self-reported hypoglycemia, diabetes-related distress, or depression. DISCUSSION We observed several expected associations between an updated medication effect score and patient-level clinical factors. These associations support the medication effect score as an appropriate measure of diabetes regimen intensity in clinical and research contexts.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - William S Yancy
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Diet and Fitness Center, Durham, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Nicole Sagalla
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - Anna Barton Bradley
- Richmond Diabetes and Endocrinology, Bon Secours Medical Group, Richmond, VA, USA
| | - Moahad Dar
- Division of Endocrinology and Metabolism, East Carolina University, Greenville NC, USA.,Greenville Veterans Affairs Health Care Center, Greenville, NC, USA
| | - Stéphanie B Mayer
- Hunter Holmes McGuire Veterans Affairs Medical Center, Division of Endocrinology and Metabolism, Richmond, VA, USA.,Virginia Commonwealth University, Division of Endocrinology and Metabolism, Richmond, VA, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
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Mitzel LD, Funderburk JS, Buckheit KA, Gass JC, Shepardson RL, Edelman D. Virtual integrated primary care teams: Recommendations for team-based care. Fam Syst Health 2021; 39:638-643. [PMID: 34735210 DOI: 10.1037/fsh0000655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Integrated primary care teams are increasingly relying upon virtual care, including both telehealth and team members who are teleworking, due to the COVID-19 pandemic. This shift to virtual care can present challenges for the coordination and provision of team-based care in primary care. The current report uses extant literature on teams to provide recommendations to support integrated primary care teams, including behavioral health providers, in adapting to and sustaining virtual team-based care. METHOD We used the Seven C's framework by Salas and colleagues (2015) to organize our findings and recommendations, focusing on coordination, cooperation, cognition, and communication. RESULTS Integrated primary care teams may benefit from tending to both implicit and explicit forms of coordination and the use of debriefs to improve team coordination. Given the potential challenge of trust in a virtual team, documentation of care coordination and reexamination of how feedback is provided to primary care providers may benefit team cooperation. Sharing team goals and crosstraining on specific aspects of team processes, such as communicating essential information to behavioral health providers for a warm handoff, may improve the cognition of the team. Teams may also benefit by findings ways to incorporate informal communication into the workflow and using closed-loop communication to decrease missed communications. DISCUSSION This report provides initial recommendations based on extant team literature to support integrated primary care teams in adapting to virtual care. Future work should build off this report by examining virtual integrated primary care teams and providing evidence-based recommendations to optimize virtual care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Luke D Mitzel
- VA Center for Integrated Healthcare, Syracuse VA Medical Center
| | | | | | - Julie C Gass
- VA Center for Integrated Healthcare, Western NY VA Medical Center
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Kobe EA, Crowley MJ, Jeffreys AS, Yancy WS, Zervakis J, Edelman D, Voils CI, Maciejewski ML, Coffman CJ. Heterogeneity of Treatment Effects Among Patients With Type 2 Diabetes and Elevated Body Mass Index in a Study Comparing Group Medical Visits Focused on Weight Management and Medication Intensification. Med Care 2021; 59:1031-1038. [PMID: 34510104 PMCID: PMC8516740 DOI: 10.1097/mlr.0000000000001642] [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: 11/25/2022]
Abstract
BACKGROUND Illuminating heterogeneity of treatment effect (HTE) within trials is important for identifying target populations for implementation. OBJECTIVE The aim of this study was to examine HTE in a trial of group medical visits (GMVs) for patients with type 2 diabetes and elevated body mass index. RESEARCH DESIGN AND MEASURES Participants (n=263) were randomized to GMV-based medication management plus low carbohydrate diet-focused weight management (WM/GMV; n=127) or GMV-based medication management alone (GMV; n=136) for diabetes control. We used QUalitative INteraction Trees, a tree-based clustering method, to identify subgroups with greater improvement in hemoglobin A1c (HbA1c) and weight from either WM/GMV or GMV. Subgroup predictors included 32 baseline demographic, clinical, and psychosocial factors. Internal validation was conducted to estimate bias in the range of mean outcome differences between arms. RESULTS QUalitative INteraction Trees analyses indicated that for patients who had not previously attempted weight loss, WM/GMV resulted in better glycemic control than GMV (mean difference in HbA1c improvement=1.48%). For patients who had previously attempted weight loss and had lower cholesterol and blood urea nitrogen, GMV was better than WM/GMV (mean difference in HbA1c improvement=1.51%). No treatment-subgroup effects were identified for weight. Internal validation resulted in moderate corrections in mean HbA1c differences between arms; however, differences remained in the clinically significant range. CONCLUSION This work represents a novel step toward targeting care approaches for patients to maximize benefit based on individual patient characteristics.
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Affiliation(s)
| | - Matthew J. Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
- Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Amy S. Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
| | - William S. Yancy
- Duke University School of Medicine, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
- Duke Lifestyle and Weight Management Center, Durham, NC
| | - Jennifer Zervakis
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
| | - David Edelman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Corrine I. Voils
- William S Middleton Memorial Veterans Hospital, Madison, WI
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Matthew L. Maciejewski
- Duke University School of Medicine, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Cynthia J. Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
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18
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Drake C, Batchelder H, Lian T, Cannady M, Weinberger M, Eisenson H, Esmaili E, Lewinski A, Zullig LL, Haley A, Edelman D, Shea CM. Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework. BMC Health Serv Res 2021; 21:975. [PMID: 34530826 PMCID: PMC8445654 DOI: 10.1186/s12913-021-06991-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. METHODS Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. RESULTS Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach. CONCLUSION Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA.
| | - Heather Batchelder
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Meagan Cannady
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Emily Esmaili
- Lincoln Community Health Center, Durham, NC, USA.,Global Health Institute, Duke University, Durham, NC, USA
| | - Allison Lewinski
- Duke University School of Nursing, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA
| | - Amber Haley
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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19
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Drake C, Lian T, Trogdon JG, Edelman D, Eisenson H, Weinberger M, Reiter K, Shea CM. Evaluating the association of social needs assessment data with cardiometabolic health status in a federally qualified community health center patient population. BMC Cardiovasc Disord 2021; 21:342. [PMID: 34261446 PMCID: PMC8278633 DOI: 10.1186/s12872-021-02149-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients' clinical condition. METHODS In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management. RESULTS Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950). CONCLUSIONS Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA.
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA.
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - David Edelman
- Department of Medicine, Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27705, USA
- Durham VA Healthcare System, 508 Fulton St, Durham, NC, 27705, USA
| | - Howard Eisenson
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC, 27707, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, DUMC 2914, Durham, NC, 27710, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - Kristin Reiter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA
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20
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Dong R, Leung C, Naert MN, Naanyu V, Kiptoo P, Matelong W, Matini E, Orango V, Bloomfield GS, Edelman D, Fuster V, Manyara S, Menya D, Pastakia SD, Valente T, Kamano J, Horowitz CR, Vedanthan R. Chronic disease stigma, skepticism of the health system, and socio-economic fragility: Qualitative assessment of factors impacting receptiveness to group medical visits and microfinance for non-communicable disease care in rural Kenya. PLoS One 2021; 16:e0248496. [PMID: 34097700 PMCID: PMC8183981 DOI: 10.1371/journal.pone.0248496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/13/2020] [Accepted: 02/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known. METHODS Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes. RESULTS We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. In the context of poverty and previous experiences with the health system, participants described challenges to NCD care across three themes: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility. However, they also outlined windows of opportunity and facilitators of group medical visits and microfinance to address those challenges. DISCUSSION Our qualitative study revealed actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also described opportunities to address and mitigate the impact of these factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.
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Affiliation(s)
- Rae Dong
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Claudia Leung
- Duke University Medical Center, Durham, North Carolina, United States of America
| | - Mackenzie N. Naert
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Violet Naanyu
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Peninah Kiptoo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Winnie Matelong
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Esther Matini
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Gerald S. Bloomfield
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - David Edelman
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Simon Manyara
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Diana Menya
- School of Public Health, Moi University, Eldoret, Kenya
| | - Sonak D. Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, West Lafayette, Indiana, United States of America
| | - Tom Valente
- Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Jemima Kamano
- College of Health Sciences, Moi University, Eldoret, Kenya
| | - Carol R. Horowitz
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Rajesh Vedanthan
- NYU Grossman School of Medicine, New York, NY, United States of America
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21
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Vedanthan R, Kamano JH, Chrysanthopoulou SA, Mugo R, Andama B, Bloomfield GS, Chesoli CW, DeLong AK, Edelman D, Finkelstein EA, Horowitz CR, Manyara S, Menya D, Naanyu V, Orango V, Pastakia SD, Valente TW, Hogan JW, Fuster V. Group Medical Visit and Microfinance Intervention for Patients With Diabetes or Hypertension in Kenya. J Am Coll Cardiol 2021; 77:2007-2018. [PMID: 33888251 PMCID: PMC8065205 DOI: 10.1016/j.jacc.2021.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 02/12/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Incorporating social determinants of health into care delivery for chronic diseases is a priority. OBJECTIVES The goal of this study was to evaluate the impact of group medical visits and/or microfinance on blood pressure reduction. METHODS The authors conducted a cluster randomized trial with 4 arms and 24 clusters: 1) usual care (UC); 2) usual care plus microfinance (MF); 3) group medical visits (GMVs); and 4) GMV integrated into MF (GMV-MF). The primary outcome was 1-year change in systolic blood pressure (SBP). Mixed-effects intention-to-treat models were used to evaluate the outcomes. RESULTS A total of 2,890 individuals (69.9% women) were enrolled (708 UC, 709 MF, 740 GMV, and 733 GMV-MF). Average baseline SBP was 157.5 mm Hg. Mean SBP declined -11.4, -14.8, -14.7, and -16.4 mm Hg in UC, MF, GMV, and GMV-MF, respectively. Adjusted estimates and multiplicity-adjusted 98.3% confidence intervals showed that, relative to UC, SBP reduction was 3.9 mm Hg (-8.5 to 0.7), 3.3 mm Hg (-7.8 to 1.2), and 2.3 mm Hg (-7.0 to 2.4) greater in GMV-MF, GMV, and MF, respectively. GMV and GMV-MF tended to benefit women, and MF and GMV-MF tended to benefit poorer individuals. Active participation in GMV-MF was associated with greater benefit. CONCLUSIONS A strategy combining GMV and MF for individuals with diabetes or hypertension in Kenya led to clinically meaningful SBP reductions associated with cardiovascular benefit. Although the significance threshold was not met in pairwise comparison hypothesis testing, confidence intervals for GMV-MF were consistent with impacts ranging from substantive benefit to neutral effect relative to UC. Incorporating social determinants of health into care delivery for chronic diseases has potential to improve outcomes. (Bridging Income Generation With Group Integrated Care [BIGPIC]; NCT02501746).
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Affiliation(s)
- Rajesh Vedanthan
- New York University Grossman School of Medicine, New York, New York, USA.
| | - Jemima H Kamano
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | | | | | | | - Eric A Finkelstein
- Duke University, Durham, North Carolina, USA; Duke-National University of Singapore Medical School, Singapore
| | - Carol R Horowitz
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Simon Manyara
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Diana Menya
- School of Public Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Violet Naanyu
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | | | | | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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22
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Diebel LN, Marinica AL, Edelman D, Liberati D. The effect of perturbations of the glycocalyx on microvascular perfusion in the obese trauma population: an in vitro study. Trauma Surg Acute Care Open 2021; 6:e000711. [PMID: 33981861 PMCID: PMC8076937 DOI: 10.1136/tsaco-2021-000711] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives Patients with morbid obesity have impaired responses to resuscitation following severe injury, which may contribute to adverse outcomes. Obesity is associated with microvascular dysfunction and metabolic changes associated with altered hemorheological profiles. These include decreased red blood cell (RBC) deformity associated with increased aggregation and adhesion. These RBC changes may be impacted by the glycocalyx layer of the endothelial cell (EC) and RBC. Degradation of either or both glycocalyx layers may impair microvascular perfusion. This was studied from blood obtained from patients with obesity and in an in vitro microfluidic device to mimic the microvascular environment. Methods RBCs were obtained from fresh whole blood from normal controls and patients with obesity (body mass index 37.6–60.0). RBC glycocalyx was indexed by fluorescent intensity and shedding of EC glycocalyx components into the serum was determined by measurement of syndecan-1 and hyaluronic acid. In a second set of experiments, human umbilical vein endothelial cell monolayers (HUVEC) were perfused with RBC suspensions from control and patients with obesity using a microfluidic device and RBC adherence under normoxic or shock conditions (hypoxia+epinephrine) was determined using confocal microscopy. HUVEC glycocalyx thickness and shedding were also measured. Results Microfluidic studies demonstrated that RBC obtained from subjects with obesity had increased adhesion to the endothelial layer, which was more profound under shock conditions versus normal subjects. This appeared to be related to increased shedding of the endothelial glycocalyx following shock as well as a diminished RBC glycocalyx layer in the obese population. Conclusion Blood from patients with obesity have decreased RBC glycocalyx thickness accompanied by evidence of increased EC glycocalyx shedding. In vitro adhesion to the endothelium was more pronounced with RBC from patients with obesity and was significantly greater under ‘shock conditions’. Hemorheological properties of RBC from patients with obesity may account for failure of standard resuscitation procedures in the trauma patient. Level of evidence
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Affiliation(s)
- Lawrence N Diebel
- Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - David Edelman
- Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Liberati
- Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction is an established surgical technique to restore UCL deficiency, especially in the overhead throwing athlete. Over the past decade, the number of patients requiring UCL reconstruction has increased significantly, particularly in the adolescent patient population. Return-to-play rates after UCL reconstruction reported in the literature have ranged from 33% to 92%, and a recent systematic review noted a return-to-play rate of 89.40% in all high school athletes. PURPOSE To evaluate the outcomes, particularly return-to-play rates and subjective outcome scores, of UCL reconstruction of the elbow in adolescent throwing athletes. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was conducted via the electronic databases Embase, PubMed, and Cochrane. Studies that reported on outcomes, particularly return-to-play rates, in adolescent throwing athletes met the inclusion criteria and were included in our analysis. Studies that did not report on adolescent throwing athletes and studies that reported on adolescent throwing athletes but did not specify the return-to-play outcomes for these athletes were excluded from our analysis. RESULTS Nine studies met the inclusion criteria and were included in this review. There were 404 baseball players and 10 javelin throwers included in our analysis. A total of 349 of the 414 patients (84.30%) were successfully able to return to play at the same level of competition or higher. Successful rates of return to prior performance ranged from 66.67% to 91.49% in our analysis. Javelin throwers had a mean 80.00% rate of return to prior performance, while baseball players had a mean return-to-play rate of 84.40%. Complications were evaluated for 8 (88.9%) studies and 283 (68.4%) patients. There were 11 (3.9%) reported complications and 5 (1.8%) reoperations. CONCLUSION The findings of this systematic review revealed that adolescent patients are generally able to return to their preinjury level of performance or higher with limited complications. Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes.
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Affiliation(s)
| | - David Edelman
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alfonso Arevalo
- Philadelphia College of Osteopathic Medicine-Orthopedic Surgery, Philadelphia, Pennsylvania, USA
| | - Nimit Patel
- Orthopedic Partners, North Franklin, Connecticut, USA
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Drake C, Reiter K, Weinberger M, Eisenson H, Edelman D, Trogdon JG, Shea CM. The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings. J Health Care Poor Underserved 2021; 32:1872-1888. [PMID: 34803048 PMCID: PMC9996544 DOI: 10.1353/hpu.2021.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Social determinants of health, including food insecurity, housing instability, social isolation, and unemployment are important drivers of health outcomes and utilization. To inform implementation of social needs screening and response protocols, there is a need to identify the associated costs in routine primary care encounters. METHODS We interviewed key stakeholders in four diverse community health centers that had adopted a widely used social needs screening and response protocol. We evaluated costs using an activity-based costing tool across both the initial implementation phase and ongoing maintenance phase. RESULTS Clinic costs were associated with workforce development, planning, and electronic health record integration. These initial implementation costs varied by site ($6,644-$49,087). On a per-patient basis, ongoing maintenance costs ranged from $9.76 to $47.98. CONCLUSION Our findings can aid in designing reimbursement mechanisms tied to social needs screening and response to accelerate translational efforts and promote health equity.
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Leung CL, Naert M, Andama B, Dong R, Edelman D, Horowitz C, Kiptoo P, Manyara S, Matelong W, Matini E, Naanyu V, Nyariki S, Pastakia S, Valente T, Fuster V, Bloomfield GS, Kamano J, Vedanthan R. Correction to: Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res 2020; 20:738. [PMID: 32787850 PMCID: PMC7422549 DOI: 10.1186/s12913-020-05345-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
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Grilo SA, Catallozzi M, Desai U, Sein AS, Quinteros-Baumgart C, Timmins G, Edelman D, Amiel J. Columbia COVID-19 Student Service Corps: Harnessing Student Skills and Galvanizing the Power of Service Learning. FASEB Bioadv 2020; 3:166-174. [PMID: 33363269 PMCID: PMC7753454 DOI: 10.1096/fba.2020-00105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/11/2022] Open
Abstract
The COVID‐19 pandemic in New York City led to the forced rapid transformation of the medical school curriculum as well as increased critical needs to the health system. In response, a group of faculty and student leaders at CUIMC developed the COVID‐19 Student Service Corps (Columbia CSSC). The CSSC is an interprofessional service‐learning organization that galvanizes the skills and expertise of faculty and students from over 12 schools and programs in the response to the COVID‐19 pandemic, and is agile enough to shift and respond to future public health and medical emergencies. Since March 2020, over 30 projects have been developed and implemented supporting needs identified by the health system, providers, faculty, staff, and students as well as the larger community. The development of the CSSC also provided critical virtual educational opportunities in the form of service learning for students who were unable to have any in‐person instruction. The CSSC model has been shared nationally and nine additional chapters have started at academic institutions across the country.
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Affiliation(s)
- S A Grilo
- Columbia University Mailman School of Public Health Heilbrunn Department of Population and Family Health 60 Haven Avenue, B-2-221 New York NY 10032 USA
| | - M Catallozzi
- Columbia University Medical Center Department of Pediatrics Vagelos College of Physicians and Surgeons Heilbrunn Department of Population and Family Health 650 W 168th Street, PH 520 New York NY 10032 USA
| | - U Desai
- Columbia University Medical Center Department of Family Medicine Vagelos College of Physicians and Surgeons 650 W 168th Street New York NY 10032 USA
| | - A Swan Sein
- Center for Education Research and Evaluation Columbia University Medical Center 100 Haven Avenue, Tower 3 Room L3A-01 New York NY 10032 USA
| | - C Quinteros-Baumgart
- Columbia University Vagelos College of Physicians and Surgeons M.D. Candidate Class of 2022
| | - G Timmins
- Columbia University Mailman School of Public Health MPH Candidate Class of 2021
| | - D Edelman
- Primary Care/Social Internal medicine Resident at Montefiore Health System
| | - J Amiel
- Interim Co-Vice Dean for Education and Senior Associate Dean for Curricular Affairs Columbia University Vagelos College of Physicians and Surgeons
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Kieseler ML, Maechler M, Hoffman Z, Dhanoa N, Fang J, Giess S, McHugh III J, Ram M, Edelman D, Missal M, Tse P. Octopus bimaculoides can learn to use a mirror to find food not in the line of sight. J Vis 2020. [DOI: 10.1167/jov.20.11.551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kobe EA, Edelman D, Tarkington PE, Bosworth HB, Maciejewski ML, Steinhauser K, Jeffreys AS, Coffman CJ, Smith VA, Strawbridge EM, Szabo ST, Desai S, Garrett MP, Wilmot TC, Marcano TJ, Overby DL, Tisdale GA, Durkee M, Bullard S, Dar MS, Mundy AC, Hiner J, Fredrickson SK, Majette Elliott NT, Howard T, Jeter DH, Danus S, Crowley MJ. Practical telehealth to improve control and engagement for patients with clinic-refractory diabetes mellitus (PRACTICE-DM): Protocol and baseline data for a randomized trial. Contemp Clin Trials 2020; 98:106157. [PMID: 32971277 PMCID: PMC7505207 DOI: 10.1016/j.cct.2020.106157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
Background Persistent poorly-controlled type 2 diabetes mellitus (PPDM), or maintenance of a hemoglobin A1c (HbA1c) ≥8.5% despite receiving clinic-based diabetes care, contributes disproportionately to the national diabetes burden. Comprehensive telehealth interventions may help ameliorate PPDM, but existing approaches have rarely been designed with clinical implementation in mind, limiting use in routine practice. We describe a study testing a novel telehealth intervention that comprehensively targets clinic-refractory PPDM, and was explicitly developed for practical delivery using existing Veterans Health Administration (VHA) clinical infrastructure. Methods Practical Telehealth to Improve Control and Engagement for Patients with Clinic-Refractory Diabetes Mellitus (PRACTICE-DM) is an ongoing randomized controlled trial comparing two 12-month interventions: 1) standard VHA Home Telehealth (HT) telemonitoring/care coordination; or 2) the PRACTICE-DM intervention, a comprehensive HT-delivered intervention combining telemonitoring, self-management support, diet/activity support, medication management, and depression management. The primary outcome is HbA1c. Secondary outcomes include diabetes distress, self-care, self-efficacy, weight, depressive symptoms, implementation barriers/facilitators, and costs. We hypothesize that the PRACTICE-DM intervention will reduce HbA1c by >0.6% versus standard HT over 12 months. Results Enrollment for this ongoing trial concluded in January 2020; 200 patients were randomized (99 to standard HT and 101 to the PRACTICE-DM intervention). The cohort has a mean age of 58 and is 23% female and 72% African American. Mean baseline HbA1c and BMI were 10.2% and 34.8 kg/m2. Conclusions Because it comprehensively targets factors underlying PPDM using existing clinical infrastructure, the PRACTICE-DM intervention may be well suited to lower the complications and costs of PPDM in routine practice.
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Affiliation(s)
- Elizabeth A Kobe
- Duke University School of Medicine, Durham, NC, United States of America
| | - David Edelman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Phillip E Tarkington
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Hayden B Bosworth
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Matthew L Maciejewski
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Karen Steinhauser
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
| | - Valerie A Smith
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Elizabeth M Strawbridge
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Steven T Szabo
- Durham Veterans Affairs Health Care System, Durham, NC, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States of America; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center, Durham, NC, United States of America
| | - Shivan Desai
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Mary P Garrett
- Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Theresa C Wilmot
- Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Teresa J Marcano
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Donna L Overby
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Glenda A Tisdale
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Melissa Durkee
- Department of Pharmacy, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Susan Bullard
- Department of Pharmacy, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Moahad S Dar
- Greenville VA Health Care Center, Greenville, NC, United States of America; Division of Endocrinology, Department of Medicine, Brody School of Medicine at East Carolina University, Greenville, NC, United States of America
| | - Amy C Mundy
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Janette Hiner
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Sonja K Fredrickson
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Nadya T Majette Elliott
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Teresa Howard
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Deborah H Jeter
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, United States of America
| | - Susanne Danus
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America
| | - Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT), Durham, NC, United States of America; Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America.
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Olsen MK, Stechuchak KM, Hung A, Oddone EZ, Damschroder LJ, Edelman D, Maciejewski ML. A data-driven examination of which patients follow trial protocol. Contemp Clin Trials Commun 2020; 19:100631. [PMID: 32913914 PMCID: PMC7471618 DOI: 10.1016/j.conctc.2020.100631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/24/2020] [Accepted: 08/02/2020] [Indexed: 11/25/2022] Open
Abstract
Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2–4 subgroups based on splits of 1–3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact. Trial registration ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226.
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Affiliation(s)
- Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Anna Hung
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,DCRI, Duke University, Durham, NC, USA
| | - Eugene Z Oddone
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Laura J Damschroder
- Ann Arbor VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA.,VA PROVE QUERI, Ann Arbor, MI, USA
| | - David Edelman
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA
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Chatterjee R, Davenport CA, Kwee L, D'Alessio D, Svetkey LP, Lin PH, Slentz CA, Ilkayeva O, Johnson J, Edelman D, Shah SH. Preliminary evidence of effects of potassium chloride on a metabolomic path to diabetes and cardiovascular disease. Metabolomics 2020; 16:75. [PMID: 32556595 PMCID: PMC8053254 DOI: 10.1007/s11306-020-01696-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/28/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Low potassium intake can affect cardiovascular disease (CVD) risk and cardiometabolic risk factors. OBJECTIVE We hypothesize that potassium chloride (KCl) supplementation can improve cardiovascular risk metabolomic profile. METHODS In this secondary analysis of a pilot randomized clinical trial (RCT) of 26 participants with prediabetes randomized to KCl or placebo, we performed targeted mass-spectrometry-based metabolomic profiling on baseline and 12-week (end-of-study) plasma samples. Principal component analysis (PCA) was used to reduce the many correlated metabolites into fewer, independent factors that retain most of the information in the original data. RESULTS Those taking KCl had significant reductions (corresponding to lower cardiovascular risk) in the branched-chain amino acids (BCAA) factor (P = 0.004) and in valine levels (P = 0.02); and non-significant reductions in short-chain acylcarnitines (SCA) factor (P = 0.11). CONCLUSIONS KCl supplementation may improve circulating BCAA levels, which may reflect improvements in overall cardiometabolic risk profile. CLINICAL TRIALS REGISTRY Clinicaltrials.gov identifier: NCT02236598; https://clinicaltrials.gov/ct2/show/NCT02236598.
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Affiliation(s)
- Ranee Chatterjee
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA.
| | - Clemontina A Davenport
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Lydia Kwee
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - David D'Alessio
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Laura P Svetkey
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
| | - Pao-Hwa Lin
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
| | - Cris A Slentz
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Olga Ilkayeva
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Johanna Johnson
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - David Edelman
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
| | - Svati H Shah
- Department of Medicine, Duke University, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
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Chatterjee R, Davenport C, Kwee L, D'Alessio D, Svetkey L, Lin PH, Slentz C, Ilkayeva O, Johnson J, Edelman D, Shah S. Effects of Potassium Chloride on a Metabolomic Path to Cardiovascular Disease and Diabetes. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa067_011] [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: 11/13/2022] Open
Abstract
Abstract
Objectives
Metabolomic profiling is used to identify biological pathways and biomarkers for cardiovascular disease (CVD) and diabetes. Thus, metabolomics could be used to identify metabolic effects and demonstrate short-term efficacy of interventions designed to reduce longer-term risk of these conditions. Low potassium (K) intake has been linked to high blood pressure and increased CVD and diabetes risk. The effects of increasing K intake on metabolomic measures related to CVD and diabetes risk are not known. In this ancillary study, we tested the hypothesis that potassium chloride (KCl) supplementation would be associated with improvements in metabolomic biomarkers, such as branched-chain amino acids (BCAA) which are associated with CVD and diabetes risk.
Methods
We performed targeted mass-spectrometry-based metabolomic profiling of 60 metabolites on baseline and 12-week (end-of-study) plasma samples from 26 African-American participants with prediabetes randomized to KCl supplements vs. placebo. Principal component analysis (PCA) was used for dimensionality reduction. Univariate and multivariable analyses were used to assess differences between the two intervention arms in the changes in metabolomic factor scores and individual metabolites.
Results
In univariate comparisons, compared to placebo, a PCA factor composed of long-chain acylcarnitines (LCA) increased in the KCl arm (P = 0.02). In multivariable models adjusted for baseline factor score, age, and sex, this association with the LCA factor was no longer significant; but those taking KCl had significant reductions in the BCAA factor (P = 0.004) and in valine levels (P = 0.02).
Conclusions
These results suggest that KCl supplementation may be associated with improvements in BCAA metabolism. Further studies among a larger population and with longer-term follow-up are warranted to verify these results and to determine if KCl supplementation may be an effective intervention for CVD and diabetes prevention.
Funding Sources
NIH/Duke CTSA.
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Leung CL, Naert M, Andama B, Dong R, Edelman D, Horowitz C, Kiptoo P, Manyara S, Matelong W, Matini E, Naanyu V, Nyariki S, Pastakia S, Valente T, Fuster V, Bloomfield GS, Kamano J, Vedanthan R. Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res 2020; 20:415. [PMID: 32398131 PMCID: PMC7218487 DOI: 10.1186/s12913-020-05199-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/07/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs. METHODS We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members. RESULTS Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context. CONCLUSIONS Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings. TRIAL REGISTRATION Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.
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Affiliation(s)
- Claudia L. Leung
- Duke University Medical Center, 10 Duke Medicine Circle, Durham, NC 27710 USA
- Division of General Internal Medicine, Duke University School of Medicine, 200 Morris St. 3rd floor, Durham, NC 27701 USA
| | - Mackenzie Naert
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Rae Dong
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - David Edelman
- Division of General Internal Medicine, Duke University School of Medicine, 200 Morris St. 3rd floor, Durham, NC 27701 USA
| | - Carol Horowitz
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Peninah Kiptoo
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Simon Manyara
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Winnie Matelong
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Esther Matini
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Violet Naanyu
- Department of Behavioral Sciences, School of Medicine, College of Health Science, Moi University College of Health Sciences, Eldoret, Kenya
| | - Sarah Nyariki
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Sonak Pastakia
- Purdue University, Purdue University College of Pharmacy, Purdue-Kenya Partnership, West Lafayette, IN, PO Box 5760, Eldoret, 30100 Kenya
| | - Thomas Valente
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Gerald S. Bloomfield
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Jemima Kamano
- Department of Behavioral Sciences, School of Medicine, College of Health Science, Moi University College of Health Sciences, Eldoret, Kenya
| | - Rajesh Vedanthan
- New York University Grossman School of Medicine, 180 Madison Avenue, 8th Floor, New York, NY 10016 USA
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Maoz M, Devir M, Inbar M, Inbar-Daniel Z, Sherill-Rofe D, Bloch I, Meir K, Edelman D, Azzam S, Nechushtan H, Maimon O, Uziely B, Kadouri L, Sonnenblick A, Eden A, Peretz T, Zick A. Author Correction: Clinical Implications of Sub-grouping HER2 Positive Tumors by Amplicon Structure and Co-amplified Genes. Sci Rep 2020; 10:3941. [PMID: 32109238 PMCID: PMC7046641 DOI: 10.1038/s41598-020-60492-7] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Myriam Maoz
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Michal Devir
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Michal Inbar
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ziva Inbar-Daniel
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Dana Sherill-Rofe
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Idit Bloch
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Karen Meir
- Department of Pathology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - David Edelman
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Salah Azzam
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Hovav Nechushtan
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ofra Maimon
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Beatrice Uziely
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Luna Kadouri
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Amir Sonnenblick
- The Oncology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Amir Eden
- Department of Cell & Developmental Biology, Institute of Life Sciences, The Hebrew University of Jerusalem, Edmond J. Safra Campus, Givat Ram, Jerusalem, Israel
| | - Tamar Peretz
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Aviad Zick
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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Yancy WS, Crowley MJ, Dar MS, Coffman CJ, Jeffreys AS, Maciejewski ML, Voils CI, Bradley AB, Edelman D. Comparison of Group Medical Visits Combined With Intensive Weight Management vs Group Medical Visits Alone for Glycemia in Patients With Type 2 Diabetes: A Noninferiority Randomized Clinical Trial. JAMA Intern Med 2020; 180:70-79. [PMID: 31682682 PMCID: PMC6830502 DOI: 10.1001/jamainternmed.2019.4802] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 01/08/2023]
Abstract
IMPORTANCE Traditionally, group medical visits (GMVs) for persons with diabetes improved glycemia by intensifying medications, which infrequently led to weight loss. Incorporating GMVs with intensive dietary change could enable weight loss and improve glycemia while decreasing medication intensity. OBJECTIVE To examine whether a program of GMVs combined with intensive weight management (WM) is noninferior to GMVs alone for change in glycated hemoglobin (HbA1c) level at 48 weeks (prespecified margin of 0.5%) and superior to GMVs alone for hypoglycemic events, diabetes medication intensity, and weight loss. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial identified via the electronic medical record 2814 outpatients with type 2 diabetes, uncontrolled HbA1c, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 27 or higher from Veterans Affairs Medical Center clinics in Durham and Greenville, North Carolina. Between January 12, 2015, and May 30, 2017, 263 outpatients started the intervention. INTERVENTIONS Participants randomized to the GMV group (n = 136) received counseling about diabetes-related topics with medication optimization every 4 weeks for 16 weeks, then every 8 weeks (9 visits). Participants randomized to the WM/GMV group (n = 127) received low-carbohydrate diet counseling with baseline medication reduction and subsequent medication optimization every 2 weeks for 16 weeks followed by an abbreviated GMV intervention every 8 weeks (13 visits). MAIN OUTCOMES AND MEASURES Outcomes included HbA1c level, hypoglycemic events, diabetes medication effect score, and weight at 48 weeks analyzed using hierarchical generalized mixed models to account for clustering within group sessions. RESULTS Among 263 participants (mean [SD] age, 60.7 [8.2] years; 235 [89.4%] men; 143 [54.4%] black), baseline HbA1c level was 9.1% (1.3%) and BMI was 35.3 (5.1). At 48 weeks, HbA1c level was improved in both study arms (8.2% in the WM/GMV arm and 8.3% in the GMV arm; mean difference, -0.1%; 95% CI, -0.5% to 0.2%; upper 95% CI, <0.5% threshold; P = .44). The WM/GMV arm had lower diabetes medication use (mean difference in medication effect score, -0.5; 95% CI, -0.6 to -0.3; P < .001) and greater weight loss (mean difference, -3.7 kg; 95% CI, -5.5 to -1.9 kg; P < .001) than did the GMV arm at 48 weeks and approximately 50% fewer hypoglycemic events (incidence rate ratio, 0.49; 95% CI, 0.27 to 0.71; P < .001) during the 48-week period. CONCLUSIONS AND RELEVANCE In GMVs for diabetes, addition of WM using a low-carbohydrate diet was noninferior for lowering HbA1c levels compared with conventional medication management and showed advantages in other clinically important outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01973972.
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Affiliation(s)
- William S Yancy
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Diet and Fitness Center, Durham, North Carolina
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina.,Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Moahad S Dar
- Greenville Health Care Center, Department of Veterans Affairs, Greenville, North Carolina.,Brody School of Medicine, Greenville, North Carolina
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison
| | | | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Department of Veterans Affairs, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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35
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Sandrowski K, Edelman D, Rivlin M, Jones C, Wang M, Gallant G, Beredjiklian PK. A Prospective Evaluation of Adverse Reactions to Single-Dose Intravenous Antibiotic Prophylaxis During Outpatient Hand Surgery. Hand (N Y) 2020; 15:41-44. [PMID: 30009635 PMCID: PMC6966299 DOI: 10.1177/1558944718787264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: While it is established that routine prophylactic antibiotics are not needed for all hand surgery, some cases do require it. The purpose of this study was to determine the rate of adverse reactions resulting from prophylactic antibiotic administration on patients undergoing outpatient hand and upper extremity surgical procedures. We hypothesize that the rate of complications resulting from the use of antibiotic prophylaxis is smaller than that reported in the currently referenced literature. Methods: We prospectively evaluated 570 consecutive patients undergoing outpatient upper extremity surgery. Patients were excluded if they were on antibiotics prior to surgery, were discharged on antibiotics, or if they wished to be excluded. Nineteen patients were excluded, resulting in a study cohort of 551 patients. Patients were monitored perioperatively, 2 to 3 days postoperatively, during the first postoperative visit and 1 month postoperatively for adverse reactions. The type and timing of the adverse reaction was recorded. Results: Five hundred fifty-one patients were included for evaluation and 8 patients (1.5%) developed an adverse reaction to antibiotics. Five patients (0.9%) reported a rash and 3 patients (0.5%) reported diarrhea within 3 days of surgery. There were no anaphylactic reactions or complications necessitating hospital transfer or admission in the postoperative period. Conclusion: This study represents a prospective investigation designed to determine the rate of adverse reactions to single-dose antibiotics given during outpatient hand surgery. We conclude that the use of intravenous, single-dose prophylactic antibiotic is safe in the outpatient setting for cases that require it.
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Affiliation(s)
| | | | | | | | - Mark Wang
- Rothman Institute, Philadelphia, PA,
USA
| | | | - Pedro K. Beredjiklian
- Rothman Institute, Philadelphia, PA,
USA,Pedro K. Beredjiklian, Rothman Institute,
1025 Chestnut Street, Philadelphia, PA 19107, USA.
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36
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Maoz M, Devir M, Inbar M, Inbar-Daniel Z, Sherill-Rofe D, Bloch I, Meir K, Edelman D, Azzam S, Nechushtan H, Maimon O, Uziely B, Kadouri L, Sonnenblick A, Eden A, Peretz T, Zick A. Clinical Implications of Sub-grouping HER2 Positive Tumors by Amplicon Structure and Co-amplified Genes. Sci Rep 2019; 9:18795. [PMID: 31827209 PMCID: PMC6906288 DOI: 10.1038/s41598-019-55455-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/27/2019] [Indexed: 12/18/2022] Open
Abstract
ERBB2 amplification is a prognostic marker for aggressive tumors and a predictive marker for prolonged survival following treatment with HER2 inhibitors. We attempt to sub-group HER2+ tumors based on amplicon structures and co-amplified genes. We examined five HER2+ cell lines, three HER2+ xenographs and 57 HER2+ tumor tissues. ERBB2 amplification was analyzed using digital droplet PCR and low coverage whole genome sequencing. In some HER2+ tumors PPM1D, that encodes WIP1, is co-amplified. Cell lines were treated with HER2 and WIP1 inhibitors. We find that inverted duplication is the amplicon structure in the majority of HER2+ tumors. In patients suffering from an early stage disease the ERBB2 amplicon is composed of a single segment while in patients suffering from advanced cancer the amplicon is composed of several different segments. We find robust WIP1 inhibition in some HER2+ PPM1D amplified cell lines. Sub-grouping HER2+ tumors using low coverage whole genome sequencing identifies inverted duplications as the main amplicon structure and based on the number of segments, differentiates between local and advanced tumors. In addition, we found that we could determine if a tumor is a recurrent tumor or second primary tumor and identify co-amplified oncogenes that may serve as targets for therapy.
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Affiliation(s)
- Myriam Maoz
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Michal Devir
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Michal Inbar
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ziva Inbar-Daniel
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Dana Sherill-Rofe
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Idit Bloch
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Karen Meir
- Department of Pathology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - David Edelman
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Salah Azzam
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Hovav Nechushtan
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ofra Maimon
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Beatrice Uziely
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Luna Kadouri
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Amir Sonnenblick
- The Oncology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Amir Eden
- Department of Cell & Developmental Biology, Institute of Life Sciences, The Hebrew University of Jerusalem, Edmond J. Safra Campus, Givat Ram, Jerusalem, Israel
| | - Tamar Peretz
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Aviad Zick
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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Abstract
Background: Fusion of the thumb metacarpophalangeal joint (MPJ) can be performed using tension band wiring (TBW) or plate and screw (PS) fixation. This study evaluated results and complications using these techniques. Methods: A retrospective review of patients who underwent thumb MPJ fusion at our institution from 2010 to 2016 was performed. Patients with >1 year follow-up were included. Demographic information, indication for fusion, time to fusion, and complications were collected. Final radiographs were examined and alignment measured. Results: There were 56 thumbs in 53 patients (42 women and 11 men) including 12 TBW and 44 PS. The mean age was 60.9 years, and follow-up was 32.4 months. Twenty-eight of 44 plates were nonlocking, and 16 were locking. Of the locking plates, 7 of 26 used all locking screws, and 9 of 26 had a combination of locked and nonlocked screws. The mean flexion angle for TBW was 16.5° and PS was 12.8°. The mean coronal angle for TBW patients was 4.0° ulnar and PS was 2.5° ulnar. The overall union rate was 95%. There were 12 complications, 9 in the PS group. The TBW complications were painful hardware requiring removal. Eight complications in the PS group occurred in patients with locked plates. Five of the delayed or nonunions occurred in patients with locked plates and 4 of these were in plates with all screws locked. Conclusion: Complications using PS or TBW are not infrequent. Alignment with both techniques is similar, but use of locked plates specifically increases the rate of delayed or nonunions. We do not recommend routine use of locked plates for fusion of the thumb MPJ.
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Affiliation(s)
- Kevin F. Lutsky
- Thomas Jefferson University,
Philadelphia, PA, USA,Kevin F. Lutsky, Department of Hand &
Upper Extremity Surgery, The Rothman Institute, Thomas Jefferson University, 925
Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
| | | | - Cory Lebowitz
- Rowan University School of Medicine,
Philadelphia, PA, USA
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Drake C, Kirk JK, Buse JB, Edelman D, Shea CM, Spratt S, Young LA, Kahkoska AR. Characteristics and Delivery of Diabetes Shared Medical Appointments in North Carolina. N C Med J 2019; 80:261-268. [PMID: 31471505 DOI: 10.18043/ncm.80.5.261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Successful diabetes care requires patient engagement and health self-management. Diabetes shared medical appointments (SMAs) are an evidence-based approach that enables peer support, diabetes group education, and medication management to improve outcomes. The purpose of this study is to learn how diabetes SMAs are being delivered in North Carolina, including the characteristics of diabetes SMAs across the state.METHOD Twelve health systems in the state of North Carolina were contacted to explore clinical workflow and intervention characteristics with a member of the SMA care delivery team. Surveys were used to assess intervention characteristics and delivery.RESULTS Diabetes SMAs were offered in 10 clinics in 5 of the 12 health systems contacted with considerable heterogeneity across sites. The majority of SMAs were open cohorts (80%), offered monthly (60%) for 1.5 hours (60%). SMAs included a mean of 7.5 ± 3.4 patients with a maximum of 11.2 ± 2.7 patients. Survey data revealed barriers (cost-sharing and provider buy-in) to, and facilitators (leadership support and clinical champions) of, clinical adoption and sustained implementation.LIMITATIONS External validity is limited due to the small sample size and geographic clustering.CONCLUSION There is significant heterogeneity in the delivery and characteristics of diabetes SMAs in North Carolina with only modest uptake across the health systems. Further research to determine best practices and effectiveness in diverse, real-world clinical settings is required to inform implementation and dissemination efforts.
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Affiliation(s)
- Connor Drake
- research program director, Duke Center for Personalized Health Care, Duke University School of Medicine, Durham, North Carolina; PhD candidate, Department of Health Policy and Management Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Julienne K Kirk
- professor, Department of Family and Community Medicine, Wake Foprofessor, Department of Family and Community Medicine, Wake Forest School of medicine, Winston-Salem, North Carolina; certified diabetes educator, Diabetes and Endocrinology Center, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - John B Buse
- Verne S. Caviness distinguished professor, Division of Endocrinology & Metabolism, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David Edelman
- professor, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; research associate, Center for Innovation, Durham VA Health Care System, Durham, North Carolina
| | - Christopher M Shea
- associate professor, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan Spratt
- associate professor, Division of Endocrinology, Department of Medicine, Metabolism, and Nutrition, Duke University School of Medicine, Durham, North Carolina
| | - Laura A Young
- assistant professor, Division of Endocrinology & Metabolism, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anna R Kahkoska
- MD/PhD candidate, Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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39
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Abstract
Objective To assess the impact of a group medical clinic designed for patient with type 2 diabetes mellitus and hypertension on body mass index. Methods Using data from a randomized trial of 239 veterans with type 2 diabetes mellitus, we performed a secondary analysis using analysis of covariance mixed models to explore the effect of a 12-month group medical clinic intervention on change in body mass index vs. usual care. In an exploratory subgroup analysis, we compared change in body mass index between treatment arms stratified by whether patients had >0.5% reduction in hemoglobin A1c at 12 months. Results Baseline body mass index was 33.5 kg/m2. At 12 months, there was no significant difference in change in body mass index between treatment arms (estimate=−0.02, 95% CI −0.51 to 5.05; P = 0.94); body mass index increased by approximately 0.20 points in both groups. There was also no significant difference in change in body mass index between treatment arms by whether or not patients had >0.5% reduction in hemoglobin A1c (estimate=−0.14, 95% CI −1.21 to −0.92; P = 0.79). Discussion Improved glycemic control was not associated with improved body mass index in the group medical clinic intervention. Given their positive effects on other outcomes, group medical clinics for patients with type 2 diabetes mellitus may be more beneficial if focus is shifted towards weight loss.
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Affiliation(s)
- Adva Eisenberg
- 1 Department of Medicine, Duke University Medical Center, Durham, USA
| | - Matthew J Crowley
- 1 Department of Medicine, Duke University Medical Center, Durham, USA.,2 Health Services Research and Development Service, Durham VA Medical Center, Durham, USA
| | - Cynthia Coffman
- 2 Health Services Research and Development Service, Durham VA Medical Center, Durham, USA.,3 Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, USA
| | - David Edelman
- 1 Department of Medicine, Duke University Medical Center, Durham, USA.,2 Health Services Research and Development Service, Durham VA Medical Center, Durham, USA
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40
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Jackson GL, Smith VA, Edelman D, Hendrix CC, Morgan PA. Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants. Ann Intern Med 2019; 171:145. [PMID: 31307081 DOI: 10.7326/l19-0200] [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: 11/22/2022] Open
Affiliation(s)
- George L Jackson
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Valerie A Smith
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - David Edelman
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Cristina C Hendrix
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
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41
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Morgan PA, Smith VA, Berkowitz TSZ, Edelman D, Van Houtven CH, Woolson SL, Hendrix CC, Everett CM, White BS, Jackson GL. Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients. Health Aff (Millwood) 2019; 38:1028-1036. [DOI: 10.1377/hlthaff.2019.00014] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Perri A. Morgan
- Perri A. Morgan is a professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine, in Durham, North Carolina
| | - Valerie A. Smith
- Valerie A. Smith is an assistant professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs (VA) Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
| | - Theodore S. Z. Berkowitz
- Theodore S. Z. Berkowitz is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - David Edelman
- David Edelman is a professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Division of General Internal Medicine, Duke University School of Medicine
| | - Courtney H. Van Houtven
- Courtney H. Van Houtven is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences, Duke University School of Medicine
| | - Sandra L. Woolson
- Sandra L. Woolson is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Cristina C. Hendrix
- Cristina C. Hendrix is an associate professor in the Geriatric Research, Education, and Clinical Center, Durham VA Health Care System and Duke University School of Nursing
| | - Christine M. Everett
- Christine M. Everett is an associate professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine
| | - Brandolyn S. White
- Brandolyn S. White is a research health science specialist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - George L. Jackson
- George L. Jackson is an associate professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
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Alexopoulos AS, Jackson GL, Edelman D, Smith VA, Berkowitz TSZ, Woolson SL, Bosworth HB, Crowley MJ. Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study. PLoS One 2019; 14:e0214679. [PMID: 30925177 PMCID: PMC6440639 DOI: 10.1371/journal.pone.0214679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Patients with persistent poorly-controlled diabetes mellitus (PPDM) despite engagement in clinic-based care are at particularly high risk for diabetes complications and costs. Understanding this population's demographics, comorbidities and care utilization could guide strategies to address PPDM. We characterized factors associated with PPDM in a large sample of Veterans with type 2 diabetes. METHODS We identified a cohort of Veterans with medically treated type 2 diabetes, who received Veterans Health Administration primary care during fiscal years 2012 and 2013. PPDM was defined by hemoglobin A1c levels uniformly >8.5% during fiscal year (FY) 2012, despite engagement with care during this period. We used FY 2012 demographic, comorbidity and medication data to describe PPDM in relation to better-controlled diabetes patients and created multivariable models to examine associations between clinical factors and PPDM. We also constructed multivariable models to explore the association between PPDM and FY 2013 care utilization. RESULTS In our cohort of diabetes patients (n = 435,820), 12% met criteria for PPDM. Patients with PPDM were younger than better-controlled patients, less often married, and more often Black/African-American and Hispanic or Latino/Latina. Of included comorbidities, only retinopathy (OR 1.68, 95% confidence interval (CI): 1.63,1.73) and nephropathy (OR 1.26, 95% CI: 1.19,1.34) demonstrated clinically significant associations with PPDM. Complex insulin regimens such as premixed (OR 10.80, 95% CI: 10.11,11.54) and prandial-containing regimens (OR 18.74, 95% CI: 17.73,19.81) were strongly associated with PPDM. Patients with PPDM had higher care utilization, particularly endocrinology care (RR 3.56, 95% CI: 3.47,3.66); although only 26.4% of patients saw endocrinology overall. CONCLUSION PPDM is strongly associated with complex diabetes regimens, although heterogeneity in care utilization exists. While there is evidence of underutilization, inadequacy of available care may also contribute to PPDM. Our findings should inform tailored approaches to meet the needs of PPDM, who are among the highest-risk, highest-cost patients with diabetes.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
| | - George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Sandra L. Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
- Department of Psychiatry & Behavioral Sciences, Duke University, Durham NC, United States of America
| | - Matthew J. Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
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Warshaw H, Edelman D. Building Bridges Through Collaboration and Consensus: Expanding Awareness and Use of Peer Support and Peer Support Communities Among People With Diabetes, Caregivers, and Health Care Providers. J Diabetes Sci Technol 2019; 13:206-212. [PMID: 30394789 PMCID: PMC6399793 DOI: 10.1177/1932296818807689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetes, regardless of type, is a complex disease. Successful management to achieve both short- and long-term health goals and outcomes is highly dependent on learning, mastery, and regular implementation and execution of self-care behaviors. The importance of a positive mental outlook and minimization of psychosocial barriers to care is increasingly identified as important in managing the whole person with diabetes and, as appropriate, the caregivers. Ongoing support from HCP and increasingly ongoing support from peers are critical elements of quality diabetes care. With the availability of virtually accessible technologies for social media and networking, the volume of peer support among people with diabetes and their caregivers has increased exponentially and will likely continue to do so. With the value of ongoing peer support recognized as an important element in diabetes health, a growing number of peer support communities and increasing engagement in these communities among some diabetes educators, the American Association of Diabetes Educators (AADE) embarked on an initiative to more formally work with diabetes peer support communities and their leaders. To initiate this effort AADE held and supported a consensus meeting in 2017. This article reviews the history and goals of this effort and details the meeting outcomes. It also discusses the collaborations completed since the initial meeting along with plans for the near future. This collaboration is unique and presents a model for similar endeavors in diabetes or other chronic diseases.
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Affiliation(s)
- Hope Warshaw
- Hope Warshaw Associates, LLC, Asheville, NC, USA
- Co-conveners for American Association of Diabetes Educators for AADE and Peer Support Communities Collaboration
- Hope Warshaw, MMSc, RD, CDE, BC-ADM, Hope Warshaw Associates, LLC, 70 Blackwood Rd, Asheville, NC 28804, USA.
| | - David Edelman
- Co-conveners for American Association of Diabetes Educators for AADE and Peer Support Communities Collaboration
- Diabetes Daily, Cleveland, OH, USA
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44
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Jackson GL, Smith VA, Edelman D, Woolson SL, Hendrix CC, Everett CM, Berkowitz TS, White BS, Morgan PA. Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study. Ann Intern Med 2018; 169:825-835. [PMID: 30458506 DOI: 10.7326/m17-1987] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 11/22/2022] Open
Abstract
BACKGROUND Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. OBJECTIVE To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). DESIGN Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. SETTING 568 VA primary care facilities. PATIENTS 368 481 adult patients with diabetes treated pharmaceutically. MEASUREMENTS The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. RESULTS The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. LIMITATION Most VA patients are men who receive treatment in a staff-model health care system. CONCLUSION No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. PRIMARY FUNDING SOURCE VA Health Services Research and Development.
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Affiliation(s)
- George L Jackson
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Valerie A Smith
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - David Edelman
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Sandra L Woolson
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Cristina C Hendrix
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | | | - Theodore S Berkowitz
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Brandolyn S White
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Perri A Morgan
- Duke University, Durham, North Carolina (C.M.E., P.A.M.)
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Wang V, Coffman CJ, Stechuchak KM, Berkowitz TSZ, Hebert PL, Edelman D, O'Hare AM, Crowley ST, Weidenbacher HJ, Maciejewski ML. Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings. J Am Soc Nephrol 2018; 30:159-168. [PMID: 30530657 DOI: 10.1681/asn.2018050521] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/17/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. METHODS We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. RESULTS Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings. CONCLUSIONS Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina; .,Department of Population Health Sciences.,Division of General Internal Medicine, Department of Medicine, and
| | - Cynthia J Coffman
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Karen M Stechuchak
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Theodore S Z Berkowitz
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Paul L Hebert
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, School of Public Health and
| | - David Edelman
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, and
| | - Ann M O'Hare
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Susan T Crowley
- Renal Section, Medical Services, Veterans Affairs Connecticut Health Care System, West Haven, Connecticut; and.,Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hollis J Weidenbacher
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Matthew L Maciejewski
- Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences.,Division of General Internal Medicine, Department of Medicine, and
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Jackson GL, Stechuchak KM, Weinberger M, Bosworth HB, Coffman CJ, Kirshner MA, Edelman D. How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity. Mil Med 2018; 183:e583-e588. [PMID: 29672720 DOI: 10.1093/milmed/usx111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/30/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM). MATERIALS AND METHODS A cross-sectional analysis of the results of the Patient Assessment of Chronic Illness Care (PACIC), which measured components of the care system suggested by the CCM and was completed at baseline by participants in a hypertension disease management clinical trial. Participants had a recent history of uncontrolled systolic blood pressure. RESULTS Among 377 patients, non-Hispanic African American veterans had almost twice the odds of indicating that their primary care experience is consistent with CCM features when compared with non-Hispanic White patients (odds ratio (OR) = 1.86; 95% confidence interval (CI) = 1.16-2.98). Similar statistically significant associations were observed for follow-up care (OR = 2.59; 95% CI = 1.49-4.50), patient activation (OR = 1.80; 95% CI = 1.13-2.87), goal setting (OR = 1.65; 95% CI = 1.03-2.64), and help with problem solving (OR = 1.62; 95% CI = 1.00-2.60). CONCLUSIONS Non-Hispanic African Americans with pharmaceutically treated hypertension report that the primary care system more closely approximates the Wagner CCM than non-Hispanic White patients.
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Affiliation(s)
- George L Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Karen M Stechuchak
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC
| | - Morris Weinberger
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, CB #7411, Chapel Hill, NC
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Cynthia J Coffman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Miriam A Kirshner
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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Chatterjee R, Davenport CA, Raffield LM, Maruthur N, Lange L, Selvin E, Butler K, Yeh HC, Wilson JG, Correa A, Edelman D, Hauser E. KCNJ11 variants and their effect on the association between serum potassium and diabetes risk in the Atherosclerosis Risk in Communities (ARIC) Study and Jackson Heart Study (JHS) cohorts. PLoS One 2018; 13:e0203213. [PMID: 30169531 PMCID: PMC6118367 DOI: 10.1371/journal.pone.0203213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/15/2018] [Accepted: 08/16/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In the Atherosclerosis Risk in Communities (ARIC) Study and Jackson Heart Study (JHS) cohorts, serum potassium (K) is an independent predictor of diabetes risk, particularly among African-American participants. Experimental studies show that serum K levels affects insulin secretion. The KCNJ11 gene encodes for a K channel that regulates insulin secretion and whose function is affected by serum K levels. Variants in KCNJ11 are associated with increased diabetes risk. We hypothesized that there could be a gene-by-environment interaction between KCNJ11 variation and serum K on diabetes risk. METHODS Evaluating a combined cohort of ARIC and JHS participants, we sought to determine if KCNJ11 variants are risk factors for diabetes; and if KCNJ11 variants modify the association between serum K and diabetes risk. Among participants without diabetes at baseline, we performed multivariable logistic regression to determine the effect of serum K, KCNJ11 variants, and their interactions on the odds of incident diabetes mellitus over 8-9 years in the entire cohort and by race. RESULTS Of 11,812 participants, 3220 (27%) participants developed diabetes. 48% and 47% had 1 or 2 diabetes risk alleles of rs5215 and rs5219, respectively. Caucasians had higher proportions of these risk alleles compared to African Americans (60% vs 17% for rs5215 and 60% vs 13% for rs5219, p<0.01). Serum K was a significant independent predictor of incident diabetes. Neither rs5215 nor rs5219 was associated with incident diabetes. In multivariable models, we found no statistically significant interactions between race and either rs5215 or rs5219 (P-values 0.493 and 0.496, respectively); nor between serum K and either rs5215 or rs5219 on odds of incident diabetes (P-values 0.534 and 0.687, respectively). CONCLUSION In this cohort, rs5215 and rs5219 of KCNJ11 were not significant predictors of incident diabetes nor effect modifiers of the association between serum K and incident diabetes.
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Affiliation(s)
| | | | - Laura M. Raffield
- University of North Carolina, Chapel Hill, NC, United States of America
| | - Nisa Maruthur
- Johns Hopkins University,Baltimore, MD, United States of America
| | - Leslie Lange
- University of Colorado, Denver,CO, United States of America
| | - Elizabeth Selvin
- Johns Hopkins University,Baltimore, MD, United States of America
| | - Kenneth Butler
- University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Hsin-Chieh Yeh
- Johns Hopkins University,Baltimore, MD, United States of America
| | - James G. Wilson
- University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Adolfo Correa
- University of Mississippi Medical Center, Jackson, MS, United States of America
| | - David Edelman
- Duke University, Durham, NC, United States of America
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48
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Wang V, Coffman CJ, Stechuchak KM, Berkowitz TSZ, Hebert PL, Edelman D, O'Hare AM, Weidenbacher HJ, Maciejewski ML. Comparative Assessment of Utilization and Hospital Outcomes of Veterans Receiving VA and Non-VA Outpatient Dialysis. Health Serv Res 2018; 53 Suppl 3:5309-5330. [PMID: 30094837 DOI: 10.1111/1475-6773.13022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 12/01/2022] Open
Abstract
OBJECTIVE Growing demand for VA dialysis exceeds its supply and travel distances prohibit many Veterans from receiving dialysis in a VA facility, leading to increased use of dialysis from non-VA providers. This study compared utilization and hospitalization outcomes among Veterans receiving chronic dialysis in VA and non-VA settings in 2008-2013. DATA SOURCES VA, Medicare, and national disease registry data. STUDY DESIGN National cohort of 27,301 Veterans initiating dialysis, observed for a period of 2 years after treatment initiation. We used multinomial logistic regression to examine associations between patient characteristics and dialysis use in VA, non-VA community settings via VA Purchased Care (VA-PC), community settings via Medicare, or Dual settings. Zero-inflated negative binomial regression was used to compare risk of hospitalization and days spent in the hospital across dialysis settings. PRINCIPAL FINDINGS Sixty-seven percent of Veterans obtained community-based dialysis exclusively via Medicare, 11 percent in the community via VA-PC, 4 percent in VA, and 18 percent in Dual settings. Financial and geographic access factors were important predictors of dialysis setting, but days spent in the hospital and risk of hospitalization did not differ meaningfully across settings. CONCLUSIONS Most Veterans obtained dialysis in the community. Dialysis setting appeared to have little impact on risk of hospitalization among Veterans.
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Affiliation(s)
- Virginia Wang
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Cynthia J Coffman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Karen M Stechuchak
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC
| | - Theodore S Z Berkowitz
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC
| | - Paul L Hebert
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, WA.,Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Ann M O'Hare
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - Hollis J Weidenbacher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC
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Everett CM, Morgan P, Smith VA, Woolson S, Edelman D, Hendrix CC, Berkowitz T, White B, Jackson GL. Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data. BMC Fam Pract 2018; 19:132. [PMID: 30060736 PMCID: PMC6066924 DOI: 10.1186/s12875-018-0823-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022]
Abstract
Background Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran’s Health Administration (VHA) primary care patients with diabetes. Methods This patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a “home” VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations. Results Among VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75–0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07–0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69–0.97; reference least restrictive regulation). Conclusions ICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.
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Affiliation(s)
- Christine M Everett
- Duke University School of Medicine, Physician Assistant Program
- , 800 South Duke Street, Durham, NC, 27701, USA.
| | - Perri Morgan
- Duke University School of Medicine, Physician Assistant Program
- , 800 South Duke Street, Durham, NC, 27701, USA
| | - Valerie A Smith
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sandra Woolson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Cristina C Hendrix
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Clinical Health Systems & Analytics Division, Duke University School of Nursing, Durham, NC, USA
| | - Theodore Berkowitz
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Brandolyn White
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - George L Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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50
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Edelman D, Ilyas AM. Triceps Tendon Anatomic Repair Utilizing the "Suture Bridge" Technique. J Hand Microsurg 2018; 10:166-171. [PMID: 30483027 DOI: 10.1055/s-0038-1636729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/11/2017] [Accepted: 01/20/2018] [Indexed: 01/17/2023] Open
Abstract
Triceps tendon ruptures are uncommon injuries, but they typically require surgical repair. Multiple primary repair techniques are available, including transosseous, suture anchor, and anatomic repairs. The technique described here, the "suture bridge" repair, provides an anatomic repair of the distal triceps tendon to its footprint. It has the potential advantages of increased load to failure, better footprint coverage, higher load resistance, and allows for early motion.
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Affiliation(s)
- David Edelman
- Sidney Kimmel Medical College of the Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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