A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans

BACKGROUND

Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic.

MATERIALS AND METHODS

Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes.

RESULTS

Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01).

CONCLUSIONS

TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

Covariates of alcohol consumption among career firefighters

BACKGROUND

Little is known about rates of alcohol consumption in career firefighters.

AIMS

To assess the quantity and frequency of alcohol consumption among career firefighters and the covariates that influence consumption levels.

METHODS

A convenience sample of career firefighters completed an online, self-administered, health assessment survey. Hierarchical binary logistic regression assessed the ability of several covariates to predict binge drinking status.

RESULTS

The majority of the sample (n = 160) consumed alcohol (89%), with approximately one-third (34%) having a drinking binge in the past 30 days. The regression model explained 13-18% of the variance in binge drinking status and correctly classified 71% of cases. Race (P < 0.05) and time of service (P < 0.01) were the only covariates that made a statistically significant contribution to the model. After controlling for other factors in the model, white respondents were ~4.5 times more likely to binge drink than non-white respondents (95% CI: 1.15-17.4). For each additional year of service, firefighters were 1.08 times less likely to binge drink (95% CI: 0.87-0.97).

CONCLUSIONS

Drinking levels observed in this study exceed those of the general adult population, including college students. Thus, it appears that firefighters represent an at-risk drinking group. Further investigations addressing reasons for alcohol use and abuse among firefighters are warranted. This study and subsequent research will provide information necessary for the development and testing of tailored interventions aimed at reducing firefighter alcohol consumption.

Predictors of primary care management of depression in the Veterans Affairs healthcare system

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.

Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care

OBJECTIVE Family involvement and social support are associated with recovery from mental disorders. This project explored how family involvement in health care and social support among depressed veterans in primary care related to medication adherence and depression outcomes. METHODS During a longitudinal telephone survey, 761 Veterans Affairs (VA) primary care patients (mean age=60 years) with probable major depression were asked about depression symptoms, self-reported health, medication adherence, social support, family involvement with care, and satisfaction with clinicians' efforts to involve the patients' families in their care. Follow-up interviews at seven and 18 months assessed depression severity and medication adherence. RESULTS Most participants lived with others (71%) and reported moderately high social support. Most participants (62%) reported being very likely to discuss treatment of a major medical condition with family, but 64% reported that VA providers had not involved the participants' family in their care within the prior six months. In multivariate regression analyses, lower depression severity and better medication adherence over time were significantly linked to higher satisfaction with limited efforts by clinicians to involve families in care. Neither social support nor the extent of family involvement by itself was associated with outcomes. CONCLUSIONS The results suggested a link between patient satisfaction with family involvement by clinicians and clinical outcomes among depressed veterans. In addition, clinician responsiveness to patient wishes may be more important than the amount of family involvement per se. Further research is needed to clarify when and how clinicians should involve a patient's family in depression treatment in primary care.

Developing effective collaboration between primary care and mental health providers

OBJECTIVE

Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices.

METHOD

Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures.

RESULTS

The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation.

CONCLUSION

By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.

Human subjects protection issues in QUERI implementation research: QUERI Series

BACKGROUND

Human Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.

METHODS

In 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.

RESULTS

There are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.

DISCUSSION

Specific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.

Time allocation and caseload capacity in telephone depression care management

OBJECTIVE

To document time allocated to care management activities and care manager workload capacity using data collected for studies of telephone care management of depression.

STUDY DESIGN

Cross-sectional, descriptive analysis of depression care manager (DCM) activities and workload in 2 collaborative depression care interventions (1 implementation study and 1 effectiveness study) at Department of Veterans Affairs primary care facilities.

METHODS

Each intervention tracked specific care management activities for 4 weeks, recording the number of events for each activity type and length of time for each activity. Patient workload data were obtained from the patient tracking systems for the 2 projects. We calculated the average time for each activity type, the average total time required to complete an initial assessment call and follow-up call, and the maximum patient panel for both projects.

RESULTS

The total time per successful initial assessment was 75 to 95 minutes, and the total time per successful follow-up call was 51 to 60 minutes, with more time spent on ancillary activities (precall preparation, postcall documentation, and provider communication) than on direct patient contact. A significant amount of time was spent in unsuccessful call attempts, requiring 9 to 11 minutes for each attempt. The maximum panel size per care manager per quarter was in the range of 143 to 165 patients.

CONCLUSIONS

The study found similar DCM time allocations and panel sizes across 2 studies and 3 regions with full-time DCMs. Reductions in DCM time spent on ancillary activities may be achievable through improved informatics and other support for panel management.

Teaching systems-based practice to primary care physicians to foster routine implementation of evidence-based depression care

Although health care organizations seeking to improve quality often must change the system for delivering care, there is little available evidence on how to educate staff and providers about this change. As part of a 2002-2003 Veterans Health Administration multisite project using collaborative care to improve the management of depression, the authors implemented the Translating Initiatives for Depression into Effective Solutions (TIDES) program. Five steps were followed for teaching systems-based practice: (1) determine providers' educational needs (through administrative data, expert opinion, and provider discussion), (2) develop educational materials (based on needs assessed), (3) help each of seven sites develop an educational intervention, (4) implement the intervention, and (5) monitor the intervention's effectiveness. Sites relied primarily on passive educational strategies. There was variable implementation of the different components (e.g., lecture, educational outreach). No site chose to write up its education plan, as was suggested. The authors thus suggest that the educational model was successful at identifying providers' needs and creating appropriate materials, because the program was not advertised in other ways and because almost all providers referred patients to the program. However, the educational model was only partially successful at getting sites to develop and implement an educational plan, although provider behavior did change. Overall, the program was somewhat effective at teaching systems-based practice. The authors believe the best way to enhance effectiveness is to build education into the system rather than rely on a separate system for education.

Informatics systems to promote improved care for chronic illness: a literature review

OBJECTIVE

To understand information systems components important in supporting team-based care of chronic illness through a literature search.

DESIGN

Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness.

MEASUREMENTS

The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated.

RESULTS

In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

Family member ride-alongs during interfacility transport

INTRODUCTION

A significant portion of the Air Med Team (AMT) flight missions involves interfacility transport of the ill or injured to receiving facilities with comprehensive resources available for their care. In an effort to help meet the psychologic needs of our patients and their families, AMT developed a Family Member Ride-Along program that allows family members or significant others to accompany patients during interfacility transport. The purpose of this study was to evaluate the ride-along program from the perspective of the family member passenger (FMP) who has accompanied a patient during transport.

METHODS

Thirty-one family member ride-alongs responded to a 10-item questionnaire using a scaled response. Questions were designed to evaluate the benefit of the ride-along program to patients and family members from the FMP perspective.

RESULTS

All FMPs surveyed thought the program was beneficial to either themselves or the patients. Several benefits described by FMPs included the ability to offer emotional support to the patient, provide patient information to receiving physicians, and sign releases for medical treatment. During interfacility transports, FMPs did not hinder either patient care or transport safety.

CONCLUSION

Our study shows that allowing FMPs to accompany patients during transport benefits both patients and family members.

The role of cadherin endocytosis in endothelial barrier regulation: involvement of protein kinase C and actin-cadherin interactions

We have previously reported that exposure of endothelial monolayers to low (0.12 mM) extracellular calcium significantly decreased the endothelial solute barrier, and that this effect was reversed by restoring 'normal' (1.2 mM) calcium (1). This effect was shown to be dependent on cadherins, however the molecular mechanisms through which barrier was altered by low calcium were not characterized. Here we investigated the mechanism of increased endothelial permeability produced by low calcium exposure. Endothelial permeability was significantly increased by exposure to low (0.12 mM) calcium; this effect was attenuated by pre-treatment with the protein kinase C (PKC) inhibitor, staurosporine (2 x 10(-7) M) for 30 min. Cell border retraction and gap formation produced by low calcium was also prevented by staurosporine. Treatment of monolayers with 0.12 mM calcium also stimulated the endocytosis of endothelial cadherins. This low calcium mediated cadherin endocytosis was also prevented by pretreatment with staurosporine. Low calcium mediated endocytosis was also prevented by the actin filament toxin, cytochalasin D (1 ug/ml, 30 min). We conclude that the mechanism of low calcium mediated loss of endothelial barrier function is mediated in part by a PKC dependent endocytosis of endothelial cadherins, which may involve interactions with the actin cytoskeleton. Physiological regulation of the in vivo endothelial barrier may also involve PKC dependent-actin mediated endocytosis of cadherin junctional elements.

Role of cadherin internalization in hydrogen peroxide-mediated endothelial permeability

Exposure of endothelial monolayers to hydrogen peroxide results in increased solute permeability in a time- and dose-dependent fashion. This effect is prevented by either staurosporine, an inhibitor of PKC, or by Gö6976, an inhibitor of "classical" PKC isoforms. Immunohistochemistry of peroxide-treated monolayers illustrates a loss of cadherin staining at cell junctions and gap formation predominantly at tri-cellular junctions. Both staurosporine and Gö6976 prevented peroxide-induced gap formation. Peroxide also stimulated internalization of cadherins as measured by the trypsin protection assay, which was not blocked by staurosporine or Gö6976. These data suggest that peroxide causes: 1) a time- and dose-dependent increase in permeability and dose-dependent increase in gap formation, both of which are PKC dependent; and 2) promotes PKC-independent cadherin internalization. These data indicate that cadherin internalization may be part of the mechanism through which oxidants regulate solute permeability.

Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors

OBJECTIVES

Opiates are commonly used to treat patients with chronic nonmalignant pain. There is much controversy over the definition, incidence, and risk factors of prescription opiate abuse in chronic pain treatment. The present study, done at the Seattle VA Medical Center, was designed to create opiate abuse criteria, test inter-rater reliability of the criteria, apply the criteria to a group of chronic pain patients, and correlate the risk of opiate abuse with the results of alcohol and drug testing.

DESIGN/OUTCOME MEASURES

A committee of experienced pain providers designed a five-point prescription opiate abuse checklist based on DSM-III-R parameters. The criteria were then applied to patients enrolled in the pain clinic. The reliability of the criteria were determined using two providers who were familiar with every patient in the clinic. Drug, alcohol, and psychosocial testing were correlated with the risk of opiate abuse.

RESULTS

A total of 19% (76/403) of all pain clinic patients were using chronic opiates. Thirty-four percent (26/76) met one, and 27.6% (21/76) met three or more of the abuse criteria. The criteria had an inter-rater reliability of > 0.9. There were no differences between chronic opiate users (n = 76) and opiate abusers (n = 21) for a history of drug or alcohol abuse or on psychosocial testing.

CONCLUSIONS

Prescription opiate abuse criteria for use in patients with chronic nonmalignant pain were designed. The criteria had good reliability and can be applied during normal clinic interactions. The percentage of chronic opiate users who become opiate abusers in pain treatment is within the range reported by others. Past opiate or alcohol abuse or psychosocial testing on clinic admission failed to predict who would become an opiate abuser. The criteria can be used to identify patients who will subsequently require more intensive treatment or intervention or can be used as an outcome to measure to test the effectiveness of treatment strategies.

The use of oral mexiletine for the treatment of pain after peripheral nerve injury

Neuropathic pain is often a difficult condition to treat. Clinical and laboratory studies using intravenously administered local anesthetics or antiarrhythmic agents support the use of these drugs for the treatment of neuropathic pain. The availability of the oral antiarrhythmic medication, mexiletine, has made it possible to study the effects of an orally administered medication on chronic neuropathic pain. The study used a double-blind placebo-controlled design to examine 11 subjects in whom treatment with conventional pain medications had been unsuccessful. Subjects had a history of peripheral nerve injury or dysfunction, and all complained of symptoms consistent with neuropathic pain. After baseline pain measurements, mexiletine or placebo was given in gradually increasing doses to a maximum daily dose of 750 mg mexiletine. After 1 month at steady state, the subject received the alternative medication. Mexiletine was found to produce a statistically significant reduction in reported pain when compared to baseline or placebo. Pain scores were rated on a scale from 0 (no pain) to 10 (unbearable pain). Median pain scores prior to mexiletine were 7, after placebo treatment 7, and while receiving mexiletine (750 mg/day) 4. Side effects were mild and well-tolerated. Mexiletine may be effective in reducing neuropathic pain for patients in whom alternative pain medications have been unsatisfactory.

Canine anatomy as assessed by computerized tomography

Computerized tomographic studies of normal canine anatomy were obtained, using a whole body scanner. The regions of interest were head and neck, thorax, and abdomen and pelvis. Scans were compared with gross transverse sections from one euthanatized dog. Identification and labeling of anatomic structures were aided by reference to recognized texts of canine anatomy.