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Johnson EM, Oddone EZ, Van Treese K, Gierisch JM, Dollar KM, Dundon M, Zaugg T, McCant F, White-Clark C, Khan S, Wray LO. Implementing evidence-based telephone coaching for health behavior program enrollment: A quality improvement project. Fam Syst Health 2023; 41:229-234. [PMID: 36395050 PMCID: PMC10188648 DOI: 10.1037/fsh0000758] [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] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
INTRODUCTION This program evaluation describes the use of implementation facilitation to support uptake of a telephone-based engagement coaching intervention, ACTIVATE, using paraprofessional staff, to support health behavior program enrollment. METHOD The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework guided the formative evaluation. A mixed-methods approach was used to integrate qualitative (i.e., rapid analysis approach) and quantitative (i.e., descriptive statistics, chi-square test of independence, logistic regression) analyses for each outcome. RESULTS Most patients (95%; 319 of 335) were offered ACTIVATE, and 82 patients completed ACTIVATE. Delivery with paraprofessional staff was feasible with adaptations for translation from research to a clinical setting, which are described. External facilitation (a form of implementation facilitation) was associated with higher reach. DISCUSSION Delivery of telephone-based coaching by paraprofessional staff to support health behavior program enrollment was feasible. External facilitation was important to the translation of ACTIVATE from research to clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | - Eugene Z. Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
- Department of Medicine, Duke University School of Medicine
| | - Katharine Van Treese
- VA VISN2 Behavioral Telehealth Center
- VA Center for Integrated Healthcare (CIH), VA Western NY Healthcare System
| | - Jennifer M. Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
- Department of Population Health Sciences & Department of Medicine, Duke University School of Medicine
| | | | - Margaret Dundon
- VHA National Center for Health Promotion and Disease Prevention (NCP), Durham, NC
| | - Tara Zaugg
- National Center for Rehabilitative Auditory Research (NCRAR), VA Portland Healthcare System
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Saima Khan
- VA Center for Integrated Healthcare (CIH), Syracuse VAMC
| | - Laura O. Wray
- VA Center for Integrated Healthcare (CIH), VA Western NY Healthcare System
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo WORD COUNT: 1500
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Goldstein KM, Voils CI, Bastian LA, Heisler M, Olsen MK, Woolson S, White-Clark C, Zervakis J, Oddone EZ. An Innovation to Expand the Reach of Peer Support: A Feasibility and Acceptability Study. Mil Med 2022; 188:usac295. [PMID: 36226850 DOI: 10.1093/milmed/usac295] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Peer support is a well-established part of veteran care and a cost-effective way to support individuals pursuing health behavior change. Common models of peer support, peer coaching, and mutual peer support have limitations that could be minimized by building on the strengths of each to increase the overall reach and effectiveness. We conducted a 12-week, proof-of-concept study to test the acceptability and feasibility of a hybrid model of peer support which supplements dyadic mutual peer support with as-needed peer coaching. MATERIALS AND METHODS We tested our novel peer support model within the context of cardiovascular disease (CVD) risk reduction as a support mechanism for the promotion of heart-healthy diet and exercise behaviors. We recruited peer buddies (participants who would be matched with each other to provide mutual support) with at least one uncontrolled CVD risk factor (i.e., blood pressure, weight, or diabetes) and peer coaches (individuals who would provide additional, as-needed support for peer buddies) with a recent history of CVD health behavior improvement. We aimed for 50% of peer buddies to be women to assess for potential gender differences in intervention engagement. Participants received didactic instruction during three group sessions, and peer dyads were instructed to communicate weekly with their peer buddy to problem-solve around action plans and behavioral goals. We tracked frequency of dyadic communication and conducted semi-structured interviews at the intervention's end to assess acceptability. RESULTS We recruited three peer coaches and 12 peer buddies. Ten buddies (five dyads) met at the first group session, and all were still in weekly contact with each other at week 12. Peer buddies had a mean of 8.75 out of 12 possible weekly peer buddy communications (range 6-15 in total). Peer coaches provided additional support to four participants over 12 weeks. Participants reported liking the intervention, including mixed-gender groups. Clarity and expectation setting around the role of peer coaches were important. CONCLUSIONS The supplementation of mutual peer support with as-needed peer coaching is an acceptable and feasible way to expand the potential reach and effectiveness of peer support for behavior change among veterans.
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Affiliation(s)
- Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC 27701, USA
| | - Corrine I Voils
- William S Middleton Memorial Veterans Hospital, Madison, WI 53705, USA
- Department of Surgery, University of Wisconsin, Madison, WI 53792, USA
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Medicine, Yale University, New Haven, CT 06520, USA
| | - Michele Heisler
- Ann Arbor VA Medical Center, Ann Arbor, MI 48015, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48019, USA
| | - Maren K Olsen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC 27710, USA
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
| | - Jennifer Zervakis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC 27701, USA
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Zullig LL, Peterson ED, Shah BR, Grambow SC, Oddone EZ, McCant F, Lindquist JH, Bosworth HB. Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management. Patient Educ Couns 2022; 105:2962-2968. [PMID: 35618550 DOI: 10.1016/j.pec.2022.05.011] [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: 01/30/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI. METHODS Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013. RESULTS Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%). CONCLUSIONS The main effects were not statistically significant. PRACTICAL IMPLICATIONS Completing the full dose of the intervention may be essential to experience the intervention effect. CLINICAL TRIAL REGISTRATION The unique identifier is NCT00901277 (http://www. CLINICALTRIALS gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).
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Affiliation(s)
- Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | | | | | - Steven C Grambow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Jennifer Hoff Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.
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Goldstein KM, Zullig LL, Andrews SM, Sperber N, Lewinski AA, Voils CI, Oddone EZ, Bosworth HB. Patient experiences with a phone-based cardiovascular risk reduction intervention: Are there differences between women and men? Patient Educ Couns 2021; 104:2834-2838. [PMID: 33838939 DOI: 10.1016/j.pec.2021.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/16/2021] [Accepted: 03/24/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To explore gender-based differences in experiences with a telehealth-delivered intervention for reduction of cardiovascular risk. METHODS We conducted 23 semi-structured qualitative interviews by telephone with 11 women and 12 men who received a 12-month, pharmacist-delivered, telephone-based medication and behavioral management intervention. We used content analysis to identify themes. RESULTS We identified three common themes for both men and women: ease and convenience of phone support, preference for proactive outreach, and need for trust building in the context of telehealth. While both genders appreciated the social support from the intervention pharmacist, women voiced appreciation for accountability whereas men generally spoke about encouragement. CONCLUSIONS Rapport building may differ between telehealth and in-person healthcare visits; our work highlights how men and women's experiences can differ with telehealth care and which can inform the development of future, purposeful rapport building activities to strengthen the clinician-patient interaction. PRACTICE IMPLICATIONS Clinicians should seek opportunities to provide frequent and routine support for patients with chronic disease. Telehealth interventions may benefit from gender-specific tailoring of social support.
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Affiliation(s)
- K M Goldstein
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - L L Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - S M Andrews
- Genomics, Bioinformatics, and Translational Research Center, RTI International, Durham, NC, USA
| | - N Sperber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - A A Lewinski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; School of Nursing, Duke University, Durham, NC, USA
| | - C I Voils
- William S Middleton Memorial Veterans Hospital, Madison, NC, USA; Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, NC, USA
| | - E Z Oddone
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - H B Bosworth
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; School of Nursing, Duke University, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
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Ramos K, Shepherd-Banigan ME, Stechuchak KM, Coffman C, Oddone EZ, Van Houtven C, Hendrix CC, Mahanna EP, Hastings SN. Psychological distress among medically complex veterans with a recent emergency department visit. Psychol Serv 2021; 19:353-359. [PMID: 33793285 PMCID: PMC8484334 DOI: 10.1037/ser0000437] [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: 11/08/2022]
Abstract
Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥14 unhealthy days due to poor mental health in the past month) at 30 and 180 days following enrollment in a randomized control trial of 513 medically complex Veterans after a nonpsychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors [baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living (ADL), and deficits in instrumental activities of daily living] with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR = 0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 days assessments, included having the inadequate income (OR = 1.61; 95% CI: 1.02-2.55), having low health literacy (OR = 1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR = 1.94; 95% CI: 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Megan E Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Cynthia Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Courtney Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Cristina C Hendrix
- Geriatric Research, Education, and Clinical Center (GRECC), Durham VA Health Care System
| | - Elizabeth P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System
| | - Susan Nicole Hastings
- Geriatric Research, Education, and Clinical Center (GRECC), Durham VA Health Care System
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6
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Griesemer I, Hausmann LR, Arbeeva L, Campbell LC, Cené CW, Coffman CJ, Keefe FJ, Oddone EZ, Somers TJ, Allen KD. Discrimination Experiences and Depressive Symptoms among African Americans with Osteoarthritis Enrolled in a Pain Coping Skills Training Randomized Controlled Trial. J Health Care Poor Underserved 2021; 32:145-155. [PMID: 33678687 PMCID: PMC10513122 DOI: 10.1353/hpu.2021.0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
African Americans are more likely than members of other racial groups to report perceived discrimination in health care settings, and discrimination is linked to depression. Using data from a randomized controlled trial of pain coping skills training (PCST) for African Americans with osteoarthritis (N=164), we evaluated the interaction between discrimination experiences and experimental condition (PCST or control group) in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms (interaction term coefficient: b=-3.2, 95% CI [- 6.4, - .02], p=.05). Discrimination was associated with depressive symptoms among those in the control group but not among those who received PCST. Participation in a PCST intervention may have reduced the association between discrimination experiences and depressive symptoms among participants in this sample. Future research should explore whether interventions aimed at teaching coping skills may be effective in ameliorating the harmful mental health effects of perceived discrimination.
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7
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Dharmasri CJ, Griesemer I, Arbeeva L, Campbell LC, Cené CW, Keefe FJ, Oddone EZ, Somers TJ, Allen KD. Acceptability of telephone-based pain coping skills training among African Americans with osteoarthritis enrolled in a randomized controlled trial: a mixed methods analysis. BMC Musculoskelet Disord 2020; 21:545. [PMID: 32795282 PMCID: PMC7427940 DOI: 10.1186/s12891-020-03578-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 08/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Osteoarthritis (OA) disproportionately impacts African Americans compared to Caucasians, including greater pain severity. The Pain Coping Skills Training for African Americans with Osteoarthritis (STAART) study examined a culturally enhanced Pain Coping Skills Training (CST) program among African Americans with OA. This mixed methods study evaluated the acceptability of the Pain CST program among STAART participants. METHODS STAART was a randomized controlled trial evaluating the effectiveness of an 11-session, telephone-based pain CST program, compared to a usual care control group. Participants were from the University of North Carolina and Durham Veterans Affairs Healthcare Systems. The present analyses included 93 participants in the CST group who completed a questionnaire about experiences with the program. Descriptive statistics of the questionnaire responses were calculated using SAS software. Thematic analysis was applied to open-response data using Dedoose software. RESULTS Participants' mean rating of overall helpfulness of the pain CST program for managing arthritis symptoms was 8.0 (SD = 2.2) on a scale of 0-10. A majority of participants reported the program made a positive difference in their experience with arthritis (83.1%). Mean ratings of helpfulness of the specific skills ranged from 7.7 to 8.8 (all scales 0-10). Qualitative analysis of the open-response data identified four prominent themes: Improved Pain Coping, Mood and Emotional Benefits, Improved Physical Functioning, and experiences related to Intervention Delivery. CONCLUSIONS The high ratings of helpfulness demonstrate acceptability of this culturally enhanced pain CST program by African Americans with OA. Increasing access to cognitive-behavioral therapy-based programs may be a promising strategy to address racial disparities in OA-related pain and associated outcomes. TRIAL REGISTRATION NCT02560922 , registered September 25, 2015.
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Affiliation(s)
- Chamara J. Dharmasri
- grid.410711.20000 0001 1034 1720Department of Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Ida Griesemer
- grid.410711.20000 0001 1034 1720Department of Health Behavior, University of North Carolina, Chapel Hill, NC USA
| | - Liubov Arbeeva
- grid.410711.20000 0001 1034 1720Department of Medicine, University of North Carolina, Chapel Hill, NC USA ,grid.410711.20000 0001 1034 1720Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Bldg, CB# 7280, Chapel Hill, NC 27599 USA
| | - Lisa C. Campbell
- grid.255364.30000 0001 2191 0423Department of Psychology, East Carolina University, Greenville, NC USA
| | - Crystal W. Cené
- grid.410711.20000 0001 1034 1720Department of Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Francis J. Keefe
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Science, Duke University, Durham, NC USA
| | - Eugene Z. Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC USA ,grid.189509.c0000000100241216Department of Medicine, Duke University Medical Center, Durham, NC USA
| | - Tamara J. Somers
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Science, Duke University, Durham, NC USA
| | - Kelli D. Allen
- grid.410711.20000 0001 1034 1720Department of Medicine, University of North Carolina, Chapel Hill, NC USA ,grid.410711.20000 0001 1034 1720Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Bldg, CB# 7280, Chapel Hill, NC 27599 USA ,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC USA
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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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Damschroder LJ, Buis LR, McCant FA, Kim HM, Evans R, Oddone EZ, Bastian LA, Hooks G, Kadri R, White-Clark C, Richardson CR, Gierisch JM. Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial. J Med Internet Res 2020; 22:e19216. [PMID: 32687474 PMCID: PMC7435619 DOI: 10.2196/19216] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023] Open
Abstract
Background Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone. Objective The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching. Methods Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation. Results The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm. Conclusions Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial’s 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up. Trial Registration ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 International Registered Report Identifier (IRRID) RR2-10.2196/12526
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Affiliation(s)
- Laura J Damschroder
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Lorraine R Buis
- University of Michigan, Department of Family Medicine, Ann Arbor, MI, United States
| | - Felicia A McCant
- Veterans Affairs Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Hyungjin Myra Kim
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Richard Evans
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Eugene Z Oddone
- Veterans Affairs Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Lori A Bastian
- Veterans Affairs Pain Research, Informatics, Multimorbidities, and Education Center, Veterans Affairs Connecticut, West Haven, CT, United States.,Division of General Internal Medicine, Department of Medicine, Yale University, West Haven, CT, United States
| | - Gwendolyn Hooks
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Reema Kadri
- University of Michigan, Department of Family Medicine, Ann Arbor, MI, United States
| | - Courtney White-Clark
- Veterans Affairs Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | | | - Jennifer M Gierisch
- Veterans Affairs Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, United States
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10
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Sloan C, Stechuchak KM, Olsen MK, Oddone EZ, Damschroder LJ, Maciejewski ML. Short-Term VA Health Care Expenditures Following a Health Risk Assessment and Coaching Trial. J Gen Intern Med 2020; 35:1452-1457. [PMID: 31898118 PMCID: PMC7210324 DOI: 10.1007/s11606-019-05455-z] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Short-term health care costs following completion of health risk assessments and coaching programs in the VA have not been assessed. OBJECTIVE To compare VA health care expenditures among veterans who participated in a behavioral intervention trial that randomized patients to complete a HRA followed by health coaching (HRA + coaching) or to complete the HRA without coaching (HRA-alone). DESIGN Four-hundred seventeen veterans at three Veterans Affairs (VA) Medical Centers or Clinics were randomized to HRA + coaching or HRA-alone. Veterans randomized to HRA-alone (n = 209) were encouraged to discuss HRA results with their primary care team, while veterans randomized to HRA + coaching (n = 208) received two brief telephone-delivered health coaching calls. PARTICIPANTS We included 411 veterans with available cost data. MAIN MEASURES Total VA health expenditures 6 months following trial enrollment were estimated using a generalized linear model with a gamma distribution and log link function. In exploratory analysis, model-based recursive partitioning was used to determine whether the intervention effect on short-term costs differed among any patient subgroups. KEY RESULTS Most participants were male (85%); mean age was 56, and mean body mass index was 34. From the generalized linear model, 6-month estimated mean total VA expenditures were similar ($8665 for HRA + coaching vs $9900 for HRA-alone, p = 0.25). In exploratory subgroup analysis, among unemployed veterans with good sleep and fair or poor perceived health, mean observed expenditures in the HRA + coaching group were higher than in the HRA-alone group ($12,814 vs $7971). Among unemployed veterans with good sleep and good general health, mean observed expenditures in the HRA + coaching group were lower than in the HRA-alone group ($5082 vs $11,612). CONCLUSIONS Compared to completing and receiving HRA results, working with health coaches to set actionable health behavior change goals following HRA completion did not reduce short-term health expenditures. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01828567.
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Affiliation(s)
- Caroline Sloan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), , Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), , Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), , Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Eugene Z Oddone
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), , 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, P.O. Box 130170, Ann Arbor, MI, USA.,VA Diabetes QUERI, Ann Arbor, MI, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), , 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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11
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Allen KD, Sheets B, Bongiorni D, Choate A, Coffman CJ, Hoenig H, Huffman K, Mahanna EP, Oddone EZ, Van Houtven C, Wang V, Woolson S, Hastings SN. Implementation of a group physical therapy program for Veterans with knee osteoarthritis. BMC Musculoskelet Disord 2020; 21:67. [PMID: 32013914 PMCID: PMC6998361 DOI: 10.1186/s12891-020-3079-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/20/2020] [Indexed: 11/28/2022] Open
Abstract
Background A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program. Methods This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0–96)) and a 30-s chair rise test. Results During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0). Conclusions Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.
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Affiliation(s)
- Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA. .,Department of Medicine and Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Brandon Sheets
- Physical Medicine and Rehabilitation Service, Durham VA Medical Center, Durham, USA
| | - Dennis Bongiorni
- Physical Medicine and Rehabilitation Service, Durham VA Medical Center, Durham, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, USA
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Service, Durham VA Medical Center, Durham, USA.,Center for Aging and Human Development, Duke University, Durham, USA.,Department of Medicine, Duke University Medical Center, Durham, USA
| | - Kim Huffman
- Physical Medicine and Rehabilitation Service, Durham VA Medical Center, Durham, USA.,Center for Aging and Human Development, Duke University, Durham, USA.,Department of Medicine, Duke University Medical Center, Durham, USA
| | - Elizabeth P Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Department of Medicine, Duke University Medical Center, Durham, USA
| | - Courtney Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Department of Medicine, Duke University Medical Center, Durham, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, USA
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Department of Medicine, Duke University Medical Center, Durham, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, USA.,Geriatrics Research Education and Clinical Center, Durham VA Health Care System, Durham, USA.,Center for the Study of Aging, Duke University School of Medicine, Durham, USA
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12
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Van Houtven CH, Smith VA, Lindquist JH, Chapman JG, Hendrix C, Hastings SN, Oddone EZ, King HA, Shepherd-Banigan M, Weinberger M. Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial. J Gen Intern Med 2019; 34:2114-2122. [PMID: 31388914 PMCID: PMC6816649 DOI: 10.1007/s11606-019-05209-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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] [Received: 08/27/2018] [Revised: 04/03/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES), a skills training program for caregivers of persons with functional or cognitive impairments. DESIGN A two-arm RCT. SETTING Single Veterans Affairs Medical Center. PARTICIPANTS Patients and their primary caregivers referred in the past 6 months to home and community-based services or geriatrics clinic. INTERVENTION All caregivers received usual care. Caregivers in HI-FIVES also received five training calls and four group training sessions. MAIN MEASURES Cumulative patient days at home 12 months post-randomization, defined as days not in an emergency department, inpatient hospital, or post-acute facility. Secondary outcomes included patients' total VA health care costs, caregiver and patient rating of the patient's experience of VA health care, and caregiver depressive symptoms. RESULTS Of 241 dyads, caregivers' (patients') mean age was 61 (73) years, 54% (53%) Black and 89% (4%) female. HI-FIVES was associated with a not statistically significant 9% increase in the rate of days at home (95% CI 0.72, 1.65; mean difference 1 day over 12 months). No significant differences were observed in health care costs or caregiver depressive symptoms. Model-estimated mean baseline patient experience of VA care (scale of 0-10) was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p = .27), 0.31 (p = 0.26) at 6 months, and 0.48 (p = 0.03) at 12 months. For caregivers, it was 8.34 (95% CI 8.10, 8.57); the modeled mean difference at 3 months was 0.28 (p = .18), 0.53 (p < .01) at 6 months, and 0.46 (p = 0.054) at 12 months. CONCLUSIONS HI-FIVES did not increase patients' days at home; it showed sustained improvements in caregivers' and patients' experience of VA care at clinically significant levels, nearly 0.5 points. The training holds promise in increasing an important metric of care quality-reported experience with care.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA.
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
| | - Cristina Hendrix
- School of Nursing, Duke University Medical Center, 307 Trent Drive, Box 102400, Durham, NC, 27710, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Susan Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Eugene Z Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, HSRD 152, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101A McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599, USA
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13
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Nouri SS, Damschroder LJ, Olsen MK, Gierisch JM, Fagerlin A, Sanders LL, McCant F, Oddone EZ. Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE. J Gen Intern Med 2019; 34:552-558. [PMID: 30756302 PMCID: PMC6445901 DOI: 10.1007/s11606-019-04861-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 04/29/2018] [Revised: 10/25/2018] [Accepted: 12/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated. OBJECTIVE To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy). DESIGN Secondary analysis of a randomized controlled trial. PARTICIPANTS Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly. METHODS A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy. RESULTS The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI - 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI - 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (- 4.6; 95% CI - 9.1, - 0.15; p = 0.04). CONCLUSIONS We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention. CLINICALTRIALS. GOV IDENTIFIER NCT01828567.
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Affiliation(s)
- Sarah S Nouri
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA.
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Maren K Olsen
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jennifer M Gierisch
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Angela Fagerlin
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center for Innovation, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Linda L Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Felicia McCant
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Eugene Z Oddone
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
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14
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Allen KD, Lo G, Abbate LM, Floegel TA, Lindquist JH, Coffman C, Oddone EZ, Taylor SS, Hall K. Composite measures of physical activity and pain associate better with functional assessments than pain alone in knee osteoarthritis. Clin Rheumatol 2019; 38:2241-2247. [PMID: 30929153 DOI: 10.1007/s10067-019-04530-4] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/05/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Recent research showed that physical activity (PA)-adjusted pain measures were more strongly associated with radiographic osteoarthritis (OA) severity than an unadjusted pain measure. This exploratory study examined whether PA-adjusted pain measures were more closely associated with other key OA-related measures, compared to unadjusted pain scores. METHOD Participants were 122 Veterans (mean age = 61.2 years, 88.5% male) with knee OA. Baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were adjusted for accelerometer-derived daily: (1) step counts, (2) minutes of any activity, (3) minutes of moderate or greater intensity activity, (4) minutes of light intensity activity, and (5) energy expenditure. Partial correlations, adjusted for age, sex, and body mass index, estimated associations of unadjusted and PA-adjusted WOMAC pain scores with functional assessments (6-minute walk test, 8-foot walk test, chair stand test, satisfaction with physical function), fatigue (Brief Fatigue Inventory), and anxiety/depressive symptoms (single item). RESULTS Significant (p < 0.05) associations were found in 29 of 36 of models. For the four function-related assessments, step count and energy expenditure-adjusted WOMAC pain scores had stronger associations (partial rs = 0.24-0.48) than WOMAC pain score (partial rs = 0.19-0.25). For fatigue and anxiety/depressive symptoms, WOMAC pain score had stronger, positive associations than most PA-adjusted pain scores. Of the PA-adjusted measures, the strongest associations overall were observed for step count and energy expenditure. CONCLUSION PA-adjusted pain scores may have particular value for OA studies involving functional assessments, whereas unadjusted WOMAC pain scores are more closely associated with psychological symptoms. This has implications for measurement in clinical OA studies. TRIAL REGISTRATION NCT01058304 KEY POINTS: • Among patents with osteoarthritis, physical activity-adjusted pain measures (particularly those adjusted for step count and energy expenditure) were more strongly associated with measures of physical function, compared to unadjusted pain scores, whereas unadjusted pain score was more strongly associated with a measure of psychological symptoms. • In clinical osteoarthritis research, the most appropriate or sensitive symptom measure (pain vs. physical activity-adjusted pain) may depend on the type of intervention or outcome being studied.
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Affiliation(s)
- Kelli D Allen
- Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Bld., CB# 7280, Chapel Hill, NC, 27599-7280, USA. .,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA. .,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.
| | - Grace Lo
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Medical Care Line and Research Care Line, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Medical Center, Houston, TX, USA
| | - Lauren M Abbate
- Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jennifer H Lindquist
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Cynthia Coffman
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Eugene Z Oddone
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Shannon Stark Taylor
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA.,Greenville Health System, Greenville, SC, USA
| | - Katherine Hall
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Center for Aging and Human Development, Duke University, Durham, NC, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA
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15
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Miller KEM, Lindquist JH, Olsen MK, Smith V, Voils CI, Oddone EZ, Sperber NR, Shepherd‐Banigan M, Wieland GD, Henius J, Kabat M, Van Houtven CH. Invisible partners in care: Snapshot of well-being among caregivers receiving comprehensive support from Veterans Affairs. Health Sci Rep 2019; 2:e112. [PMID: 30937391 PMCID: PMC6427058 DOI: 10.1002/hsr2.112] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/22/2018] [Accepted: 12/07/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND AND AIMS Since May 2011, over 23 000 caregivers of Veterans seriously injured on or after September 11, 2001 have enrolled in the Program of Comprehensive Assistance for Family Caregivers (PCAFC). PCAFC provides caregivers training, a stipend, and access to health care. The aim of this study is to describe the characteristics of caregivers in PCAFC and examine associations between caregiver characteristics and caregiver well-being outcomes. METHODS We sent a web survey invitation to 10 000 PCAFC caregivers enrolled as of September 2015. Using linear and logistic regressions, we examine associations between PCAFC caregiver characteristics and caregiver outcomes: perceived financial strain, depressive symptoms (Center for Epidemiologic Studies Depression Scale [CESD-10]), perceived quality of Veteran's Veterans Health Administration (VHA) care, and self-reported caregiver health. RESULTS We had complete survey data for 899 respondents. Since becoming a caregiver, approximately 50% of respondents reported reducing or stopping work. Mean time spent providing care was 3.8 years (median 3, IQR 1-5) with an average of 4.9 weekdays (median 5, IQR 5-5) and 1.9 weekend days (median 2, IQR 2-2). The mean CESD-10 score was 8.2 (median 7, 4-12), at the cutoff for screening positive for depressive symptoms. A longer duration of caregiving was associated with having 0.08 increase in rating of financial strain (95% CI, 0.02-0.14). Caregiver rating of the Veteran's health status as "fair" or better was a strong predictor of better caregiver outcomes, ie, self-reported caregiver health. However, higher levels of education were associated with worse caregiver outcomes, ie, lower global satisfaction with VHA care, higher CESD-10 score, and higher rating of financial strain. CONCLUSIONS Higher depressive symptoms among longer duration caregivers, coupled with high rates of reductions in hours worked, suggest interventions are needed to address the long-term emotional and financial needs of these caregivers of post-9/11 Veterans and identify subpopulations at risk for worse outcomes.
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Affiliation(s)
- Katherine E. M. Miller
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Health Policy and ManagementUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Jennifer H. Lindquist
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
| | - Maren K. Olsen
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Biostatistics and BioinformaticsDuke UniversityDurhamNorth CarolinaUSA
| | - Valerie Smith
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Corrine I. Voils
- Research ServiceWilliam S. Middleton Veterans Memorial HospitalMadisonWisconsinUSA
- Department of SurgeryUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Eugene Z. Oddone
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Nina R. Sperber
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - Megan Shepherd‐Banigan
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - G. Darryl Wieland
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
| | - Jennifer Henius
- Caregiver Support ProgramDepartment of Veterans AffairsWashington DCUSA
| | - Margaret Kabat
- Caregiver Support ProgramDepartment of Veterans AffairsWashington DCUSA
| | - Courtney Harold Van Houtven
- Health Services Research and Development ServiceDurham VA Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
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Van Houtven CH, Smith VA, Stechuchak KM, Shepherd-Banigan M, Hastings SN, Maciejewski ML, Wieland GD, Olsen MK, Miller KEM, Kabat M, Henius J, Campbell-Kotler M, Oddone EZ. Comprehensive Support for Family Caregivers: Impact on Veteran Health Care Utilization and Costs. Med Care Res Rev 2019; 76:89-114. [PMID: 29148338 PMCID: PMC5726944 DOI: 10.1177/1077558717697015] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 12/15/2022]
Abstract
This study aimed to examine the early impact of the Program of Comprehensive Assistance for Family Caregivers (PCAFC) on Veteran health care utilization and costs. A pre-post cohort design including a nonequivalent control group was used to understand how Veterans' use of Veteran Affairs health care and total health care costs changed in 6-month intervals up to 3 years after PCAFC enrollment. The control group was an inverse probability of treatment weighted sample of Veterans whose caregivers applied for, but were not accepted into, PCAFC. Veterans in PCAFC had similar acute care utilization postenrollment when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30, and up to 36, months postenrollment. Estimated total health care costs for PCAFC Veterans were $1,500 to $3,400 higher per 6-month interval than for control group Veterans. PCAFC may have increased Veterans' access to care.
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Affiliation(s)
| | - Valerie A. Smith
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | | | | | - Susan Nicole Hastings
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
- Duke University, Durham, NC, USA
| | - Matthew L. Maciejewski
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | | | - Maren K. Olsen
- Durham VA Medical Center, Durham, NC, USA
- Duke University, Durham, NC, USA
| | | | | | | | | | - Eugene Z. Oddone
- Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
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17
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Buis LR, McCant FA, Gierisch JM, Bastian LA, Oddone EZ, Richardson CR, Kim HM, Evans R, Hooks G, Kadri R, White-Clark C, Damschroder LJ. Understanding the Effect of Adding Automated and Human Coaching to a Mobile Health Physical Activity App for Afghanistan and Iraq Veterans: Protocol for a Randomized Controlled Trial of the Stay Strong Intervention. JMIR Res Protoc 2019; 8:e12526. [PMID: 30694208 PMCID: PMC6371069 DOI: 10.2196/12526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 12/25/2018] [Indexed: 12/18/2022] Open
Abstract
Background Although maintaining a healthy weight and physical conditioning are requirements of active military duty, many US veterans rapidly gain weight and lose conditioning when they separate from active-duty service. Mobile health (mHealth) interventions that incorporate wearables for activity monitoring have become common, but it is unclear how to optimize engagement over time. Personalized health coaching, either through tailored automated messaging or by individual health coaches, has the potential to increase the efficacy of mHealth programs. In an attempt to preserve conditioning and ward off weight gain, we developed Stay Strong, a mobile app that is tailored to veterans of recent conflicts and tracks physical activity monitored by Fitbit Charge 2 devices and weight measured on a Bluetooth-enabled scale. Objective The goal of this study is to determine the effect of activity monitoring plus health coaching compared with activity monitoring alone. Methods In this randomized controlled trial, with Stay Strong, a mobile app designed specifically for veterans, we plan to enroll 350 veterans to engage in an mHealth lifestyle intervention that combines the use of a wearable physical activity tracker and a Bluetooth-enabled weight scale. The Stay Strong app displays physical activity and weight data trends over time. Enrolled participants are randomized to receive the Stay Strong app (active comparator arm) or Stay Strong + Coaching, an enhanced version of the program that adds coaching features (automated tailored messaging with weekly physical activity goals and up to 3 telephone calls with a health coach—intervention arm) for 1 year. Our primary outcome is change in physical activity at 12 months, with weight, pain, patient activation, and depression serving as secondary outcome measures. All processes related to recruitment, eligibility screening, informed consent, Health Insurance Portability and Accountability Act authorization, baseline assessment, randomization, the bulk of intervention delivery, and outcome assessment will be accomplished via the internet or smartphone app. Results The study recruitment began in September 2017, and data collection is expected to conclude in 2019. A total of 465 participants consented to participate and 357 (357/465, 77%) provided baseline levels of physical activity and were randomized to 1 of the 2 interventions. Conclusions This novel randomized controlled trial will provide much-needed findings about whether the addition of telephone-based human coaching and other automated supportive-coaching features will improve physical activity compared with using a smartphone app linked to a wearable device alone. Trial Registration ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 (Archived by WebCite at http://www.webcitation.org/75KQeIFwh) International Registered Report Identifier (IRRID) DERR1-10.2196/12526
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Affiliation(s)
- Lorraine R Buis
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Felicia A McCant
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States
| | - Jennifer M Gierisch
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Lori A Bastian
- Division of General Internal Medicine, Department of Medicine, Yale University, New Haven, CT, United States.,Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut, West Haven, CT, United States
| | - Eugene Z Oddone
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | | | - Hyungjin Myra Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Richard Evans
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Gwendolyn Hooks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Reema Kadri
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Courtney White-Clark
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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18
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Taylor SS, Oddone EZ, Coffman CJ, Jeffreys AS, Bosworth HB, Allen KD. Cognitive Mediators of Change in Physical Functioning in Response to a Multifaceted Intervention for Managing Osteoarthritis. Int J Behav Med 2019; 25:162-170. [PMID: 29453622 DOI: 10.1007/s12529-017-9689-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE Although non-pharmacological interventions have been shown to improve physical functioning in individuals with osteoarthritis (OA), the mechanisms by which this occurs are often unclear. This study assessed whether changes in arthritis self-efficacy, perceived pain control, and pain catastrophizing mediated changes in physical functioning following an osteoarthritis intervention involving weight management, physical activity, and cognitive-behavioral pain management. METHOD Three hundred Veteran patients of 30 primary care providers with knee and/or hip OA were cluster randomized to an OA intervention group or usual care. The OA intervention included a 12-month phone-based patient behavioral protocol (weight management, physical activity, and cognitive-behavioral pain management) plus patient-specific OA treatment recommendations delivered to primary care providers. RESULTS Using linear mixed models adjusted for provider clustering, we observed that baseline to 6-month changes in arthritis self-efficacy and pain control partially mediated baseline to 12-month physical functioning improvements for the intervention group; catastrophizing did not. CONCLUSION Findings of a mediating role of arthritis self-efficacy and pain control in intervention-related functional changes are consistent with hypotheses and align with theoretical assertions of the role of cognitions in cognitive and behavioral interventions for chronic pain. However, contrary to hypotheses, catastrophizing was not found to be a mediator of these changes.
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Affiliation(s)
- Shannon Stark Taylor
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA.
| | - Eugene Z Oddone
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA.,Duke University Medical Center, Durham, NC, USA
| | - Cynthia J Coffman
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA.,Duke University Medical Center, Durham, NC, USA
| | - Amy S Jeffreys
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA
| | - Hayden B Bosworth
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA.,Duke University Medical Center, Durham, NC, USA
| | - Kelli D Allen
- Durham VA HealthCare System (152), HSR&D, 508 Fulton St., Durham, NC, 27705, USA.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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19
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Oddone EZ, Gierisch JM, Sanders LL, Fagerlin A, Sparks J, McCant F, May C, Olsen MK, Damschroder LJ. A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial. J Gen Intern Med 2018; 33:1487-1494. [PMID: 29736750 PMCID: PMC6108991 DOI: 10.1007/s11606-018-4398-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/17/2017] [Accepted: 03/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. OBJECTIVE To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone. DESIGN Two-arm randomized trial at three sites. SETTING Primary care clinics at Veterans Affairs facilities. PARTICIPANTS Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker). INTERVENTION Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors. MEASUREMENTS Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS). RESULTS Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33). CONCLUSIONS Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS. GOV IDENTIFIER NCT01828567.
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Affiliation(s)
- Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Linda L Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Angela Fagerlin
- VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Jordan Sparks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Felicia McCant
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Carrie May
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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20
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Corsino L, Coffman CJ, Stanwyck C, Oddone EZ, Bosworth HB, Chatterjee R, Jeffreys AS, Dolor RJ, Allen KD. A feasibility study to develop and test a Spanish patient and provider intervention for managing osteoarthritis in Hispanic/Latino adults (PRIMO-Latino). Pilot Feasibility Stud 2018; 4:89. [PMID: 29997898 PMCID: PMC6030802 DOI: 10.1186/s40814-018-0280-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/26/2018] [Indexed: 02/04/2023] Open
Abstract
Background Arthritis affects approximately 50 million adults in the USA. Hispanics/Latinos have a higher prevalence of arthritis-attributed activity limitations primarily related to osteoarthritis (OA). Hispanic/Latinos are less likely to receive hip replacement independent of health care access, and they are less likely to receive knee replacement. There have been few interventions to improve OA treatment among the Hispanic/Latino population in the USA. In our study, we aimed to develop and test a telephone delivered culturally appropriate Spanish behavioral intervention for the management of OA in Hispanic/Latino adults. Methods We conducted a feasibility study in an academic health center and local community in Durham, North Carolina. We enrolled self-identified Spanish speaking overweight/obese adults (≥ 18) with OA of the knee and/or hip under the care of a primary health care provider. The 12-month patient intervention focused on physical activity, weight management, and cognitive behavioral pain management skills. The patient intervention was delivered via telephone with calls scheduled twice per month for the first 6 months, then monthly for the last 6 months (18 sessions). The one-time provider intervention included delivery of patient-specific OA treatment recommendations, based on patients' baseline data and published guidelines. The primary measures were metrics of feasibility, including recruitment and intervention delivery. We also assessed pain, stiffness, and function using the Spanish-Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results A total of 1879 participants were identified for potential enrollment. Of those, 1864 did not meet inclusion criteria, were not able to be reached or refused. Fifteen participants enrolled in the intervention. The mean number of phone calls completed was 14.7. Eighty percent completed more than 16 calls. The mean WOMAC baseline score (SD) was 39 (20); mean improvement in WOMAC scores between baseline and 12 months, among 11 participants who completed the study, was - 13.27 [95% CI, - 25.09 to - 1.46] points. Conclusion Recruitment of Hispanics/Latinos, continues to be a major challenge. A Spanish-based telephone delivering lifestyle intervention for OA management in Hispanic/Latino adults is feasible to deliver and may lead to improved OA symptoms. Future research is needed to further test the feasibility and effectiveness of this type of intervention in this segment of the population. Trial registration NCT01782417.
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Affiliation(s)
- Leonor Corsino
- 1Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University Medical Center, Box 3451, Durham, NC 27710 USA
| | - Cynthia J Coffman
- 2Center for Health Services Research in Primary Care, Department of Biostatistics and Bioinformatics, Durham VA Medical Center, Duke University Medical Center, Duke Box 3827, Med Ctr, Durham, NC 27710 USA.,3Durham VAMC, 508 Fulton St (152), Durham, NC 27705 USA
| | - Catherine Stanwyck
- 4Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC USA
| | - Eugene Z Oddone
- 5Center for Health Services Research in Primary Care, Durham VA, Health Services Research, Durham VA Medical Center, Durham, NC 27705 USA
| | - Hayden B Bosworth
- 6Population Health Science Department, Professor in Psychiatry and Behavioral Science, Center for Health Services Research in Primary Care, Durham VA Medical Center, 411 West Chapel Hill Street, Suite 600, Durham, NC 27701 USA.,HSR&D (152) VA, 508 Fulton St, Durham, NC 27705 USA
| | - Ranee Chatterjee
- 8Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701 USA
| | - Amy S Jeffreys
- 9Center for Health Services Research in Primary Care, Durham VA Medical Center, 411 West Chapel Hill Street, Suite 600, Durham, NC 27701 USA
| | - Rowena J Dolor
- 8Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701 USA
| | - Kelli D Allen
- 10Department of Medicine and Thurston Arthritis Research Center, University of North Carolina and Center for Health Services Research in Primary Care and Durham VA Medical Center, 3300 Thurston Building Campus Box 7280, Chapell Hill, NC 27599-7280 USA.,11Center for Health Services Research in Primary Care, Durham VA Medical Center, 411 West Chapel Hill Street, Suite 600, Durham, NC 27701 USA
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Bosworth HB, Olsen MK, McCant F, Stechuchak KM, Danus S, Crowley MJ, Goldstein KM, Zullig LL, Oddone EZ. Telemedicine cardiovascular risk reduction in veterans: The CITIES trial. Am Heart J 2018; 199:122-129. [PMID: 29754649 DOI: 10.1016/j.ahj.2018.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/05/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Comprehensive programs addressing tailored patient self-management and pharmacotherapy may reduce barriers to cardiovascular disease (CVD) risk reduction. METHODS This is a 2-arm (clinical pharmacist specialist-delivered, telehealth intervention and education control) randomized controlled trial including Veterans with poorly controlled hypertension and/or hypercholesterolemia. Primary outcome was Framingham CVD risk score at 6 and 12 months, with systolic blood pressure; diastolic blood pressure; total cholesterol; low-density lipoprotein; high-density lipoprotein; body mass index; and, for those with diabetes, HbA1c as secondary outcomes. RESULTS Among 428 Veterans, 50% were African American, 85% were men, and 33% had limited health literacy. Relative to the education control group, the clinical pharmacist specialist-delivered intervention did not show a reduction in CVD risk score at 6 months (-1.8, 95% CI -3.9 to 0.3; P = .10) or 12 months (-0.3, 95% CI -2.4 to 1.7; P = .74). No differences were seen in systolic blood pressure, diastolic blood pressure, or low-density lipoprotein at 6 or 12 months. We did observe a significant decline in total cholesterol at 6 months (-7.0, 95% CI -13.4 to -0.6; P = .03) in the intervention relative to education control group. Among patients in the intervention group, 34% received at least 5 of the 12 planned intervention calls and were considered "compliers." A sensitivity analysis of the "complier average causal effect" of intervention compared to control showed a mean difference in CVD risk score reduction of 5.7 (95% CI -12.0 to 0.7) at 6 months and -1.7 (95% CI -7.6 to 4.8) at 12 months. CONCLUSIONS Despite increased access to pharmacist resources, we did not observe significant improvements in CVD risk for patients randomized to the intervention compared to education control over 12 months. However, the intervention may have positive impact among those who actively participate, particularly in the short term.
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Goldstein KM, Zullig LL, Oddone EZ, Andrews SM, Grewe ME, Danus S, Heisler M, Bastian LA, Voils CI. Understanding women veterans' preferences for peer support interventions to promote heart healthy behaviors: A qualitative study. Prev Med Rep 2018; 10:353-358. [PMID: 29868391 PMCID: PMC5984244 DOI: 10.1016/j.pmedr.2018.04.016] [Citation(s) in RCA: 8] [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: 01/31/2018] [Revised: 03/23/2018] [Accepted: 04/21/2018] [Indexed: 11/25/2022] Open
Abstract
Peer support may be an effective strategy to improve heart healthy behaviors among populations who have a strong communal identity, such as women veterans. Women veterans are a particularly important group to target as they are the fastest growing sub-population within the Veterans Affairs healthcare system. Our goal was to identify aspects of peer support and modalities for providing peer support that are preferred by women veterans at risk for cardiovascular disease (CVD). In 2016, we conducted 25 semi-structured individual interviews with women veterans from the Durham VA Healthcare System aged 35–64 who were at risk of CVD, defined as presence of at least one of the following: hypertension, hyperlipidemia, obesity (BMI ≥ 30), non-insulin dependent diabetes or prediabetes, or current smoking. Interview guide design and data analysis involved conventional content analysis. Important themes for effective peer partnerships included sharing a common behavior change goal, the need for trust between peers, compatibility around level of engagement, maintaining a positive attitude, and the need for accountability. Peer support interventions may prove beneficial to address the burden of common and preventable conditions such as CVD. Among women veterans, peer support interventions should account for individual preferences in peer matching and provide opportunities for peers to engage in relationship building in-person initially through trust-building activities. Women veterans endorsed peer support to promote heart healthy behaviors. Women Veterans prefer peers with similar health goals and level of engagement. Developing trust is key to facilitate emotional support with peers.
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Affiliation(s)
- Karen M Goldstein
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, USA
| | - Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA.,Department of Population Health Sciences, Duke University, 2200 West Main Street, Suite 720A, Durham, NC 27707, USA
| | - Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701, USA
| | - Sara M Andrews
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA
| | - Mary E Grewe
- Cooperative Studies Program Epidemiology Center - Durham, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA
| | - Susanne Danus
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Healthcare System, 508 Fulton Street, Durham, NC 27705, USA
| | - Michele Heisler
- Ann Arbor VA Medical Center, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI 48015, USA.,University of Michigan, Institute for Healthcare Policy & Innovation, 2800 Plymouth Road, Ann Arbor, MI 48019, USA
| | - Lori A Bastian
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA.,Department of Medicine, Yale University, 330 Cedar Street, New Haven, CT 06520, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace (151), Madison, WI 53705, USA.,Department of Surgery, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, K6/100 CSC, Madison, WI 53792-1690, USA
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Taylor SS, Hughes JM, Coffman CJ, Jeffreys AS, Ulmer CS, Oddone EZ, Bosworth HB, Yancy WS, Allen KD. Prevalence of and characteristics associated with insomnia and obstructive sleep apnea among veterans with knee and hip osteoarthritis. BMC Musculoskelet Disord 2018; 19:79. [PMID: 29523117 PMCID: PMC5845198 DOI: 10.1186/s12891-018-1993-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/26/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Few studies have examined patterns of specific sleep problems among individuals with osteoarthritis (OA). The primary objective of this study was to examine prevalence of symptoms of insomnia and obstructive sleep apnea (OSA) among Veterans with OA. Secondary objectives were to assess proportions of individuals with insomnia and OSA symptoms who may have been undiagnosed and to examine Veterans' characteristics associated with insomnia and OSA symptoms. METHODS Veterans (n = 300) enrolled in a clinical trial completed the Insomnia Severity Index (ISI) and the Berlin Questionnaire (BQ) at baseline; proportions of participants with symptoms consistent with insomnia and OSA were calculated, using standard cut-offs for ISI and BQ. For Veterans with insomnia and OSA symptoms, electronic medical records were searched to identify whether there was a diagnosis code for these conditions. Multivariable linear (ISI) and logistic (BQ) regression models examined associations of the following characteristics with symptoms of insomnia and OSA: age, gender, race, self-reported general health, body mass index (BMI), diagnosis of post-traumatic stress disorder (PTSD), pain severity, depressive symptoms, number of joints with arthritis symptoms and opioid use. RESULTS Symptoms consistent with insomnia and OSA were found in 53 and 66% of this sample, respectively. Among participants screening positive for insomnia and OSA, diagnosis codes for these disorders were present in the electronic medical record for 22 and 51%, respectively. Characteristics associated with insomnia were lower age (β (SE) = - 0.09 (0.04), 95% confidence interval [CI] = - 0.16, - 0.02), having a PTSD diagnosis (β (SE) = 1.68 (0.73), CI = 0.25, 3.11), greater pain severity (β (SE) = 0.36 (0.09), CI = 0.17, 0.55), and greater depressive symptoms (β (SE) = 0.84 (0.07), CI = 0.70, 0.98). Characteristics associated with OSA were higher BMI (odds ratio [OR] = 1.13, CI = 1.06, 1.21), greater depressive symptoms (OR = 1.12, CI = 1.05, 1.20), and opioid use (OR = 0.51, CI = 0.26, 0.99). CONCLUSIONS Insomnia and OSA symptoms were very common in Veterans with OA, and a substantial proportion of individuals with symptoms may have been undiagnosed. Characteristics associated with insomnia and OSA symptoms were consistent with prior studies. TRIAL REGISTRATION NCT01130740 .
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Affiliation(s)
- Shannon Stark Taylor
- University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605 USA
| | - Jaime M. Hughes
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
| | - Cynthia J. Coffman
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- Duke University School of Medicine, Durham, NC USA
| | - Amy S. Jeffreys
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
| | - Christi S. Ulmer
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- Duke University School of Medicine, Durham, NC USA
| | - Eugene Z. Oddone
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- Duke University School of Medicine, Durham, NC USA
| | - Hayden B. Bosworth
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- Duke University School of Medicine, Durham, NC USA
| | - William S. Yancy
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- Duke University School of Medicine, Durham, NC USA
| | - Kelli D. Allen
- Durham VA Health Care System, VA Medical Center (152), 508 Fulton Street, Durham, NC 27705 USA
- University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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Damschroder LJ, Reardon CM, Sperber N, Robinson CH, Fickel JJ, Oddone EZ. Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation. Transl Behav Med 2018; 7:233-241. [PMID: 27688249 DOI: 10.1007/s13142-016-0424-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 02/01/2023] Open
Abstract
The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.
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Affiliation(s)
- Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (152), 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48105, USA.
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (152), 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48105, USA
| | - Nina Sperber
- VA Center for Health Services Research in Primary Care, VA Durham Healthcare System and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Claire H Robinson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (152), 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48105, USA
| | - Jacqueline J Fickel
- VA Center for Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Eugene Z Oddone
- VA Center for Health Services Research in Primary Care, VA Durham Healthcare System and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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25
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Whigham B, Oddone EZ, Woolson S, Coffman C, Allingham RR, Shieh C, Muir KW. The influence of oral statin medications on progression of glaucomatous visual field loss: A propensity score analysis. Ophthalmic Epidemiol 2017; 25:207-214. [PMID: 29172840 DOI: 10.1080/09286586.2017.1399427] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to examine the association between oral statin use and the progression of open angle glaucoma. METHODS Medical records of 847 Veterans were reviewed to collect statin use history, record demographic and comorbid medical conditions, and review visual fields. Visual field progression was judged by an ophthalmologist masked to statin use history. Progression rates in a propensity score matched cohort were compared between statin users and nonusers using McNemar's test with the propensity model derived using associated medical and demographic factors. RESULTS The mean length of observation was 1324 days with a standard deviation of 464 days. Thirty-one per cent of Veterans demonstrated glaucomatous progression in at least one eye, 49% did not demonstrate progression, and 20% were indeterminate. Approximately 74% of subjects had previously used a statin, with this group having heavier burdens of several comorbid medical conditions and less severe baseline glaucoma than nonusers. The matched cohort was 196 statin users and 196 nonusers, each with similar baseline characteristics (standardised differences <0.10). Progression rates were 35% for statin users compared to 56% for nonusers in the matched cohort (McNemar's p<0.001). CONCLUSIONS In this population of Veterans, glaucoma patients with any history of statin use have lower visual field progression rates than statin nonusers.
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Affiliation(s)
- Ben Whigham
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA.,b Department of Ophthalmology , Duke University School of Medicine , Durham , NC, USA
| | - Eugene Z Oddone
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA.,c Department of Internal Medicine , Duke University School of Medicine , Durham , NC , USA
| | - Sandra Woolson
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA
| | - Cynthia Coffman
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA.,d Department of Biostatistics and Bioinformatics , Duke University Medical Center , Durham , NC
| | - R Rand Allingham
- b Department of Ophthalmology , Duke University School of Medicine , Durham , NC, USA
| | - Christine Shieh
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA.,c Department of Internal Medicine , Duke University School of Medicine , Durham , NC , USA
| | - Kelly W Muir
- a Health Services Research and Development , Durham VA Medical Center , Durham , NC, USA.,c Department of Internal Medicine , Duke University School of Medicine , Durham , NC , USA
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26
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Goldstein KM, Oddone EZ, Bastian LA, Olsen MK, Batch BC, Washington DL. Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans. Womens Health Issues 2017; 27:700-706. [PMID: 28890128 DOI: 10.1016/j.whi.2017.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population. METHODS We describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among participants of the National Survey of Women Veterans (conducted 2008-2009). FINDINGS Fifty-four percent of respondents were at risk for CVD (defined as a diagnosis of hypertension, diabetes, current tobacco use, or obesity without CVD). In unadjusted analysis, ORs for being at risk for CVD were greater among those interested in gender-specific clinical settings (OR, 2.0; 95% CI, 1.2-3.4) and gender-specific weight loss programs (OR, 1.8; 95% CI, 1.1-2.9). ORs were also greater for women who were physically inactive (OR, 1.9; 95% CI, 1.1-3.3), with current symptoms of depression (OR, 2.5; 95% CI, 1.1-6.1), anxiety (OR, 2.1; 95% CI, 1.2-3.6), and posttraumatic stress disorder (OR, 2.4; 95% CI, 1.2-4.8). Adjusting for age, race/ethnicity, marital status, education level, employment, and source of health care use, the ORs for CVD risk were higher for women with current posttraumatic stress disorder symptoms (2.5; 95% CI, 1.1-5.3) and gender-specific health care preferences (2.0; 95% CI, 1.1-3.4), and gender-specific weight loss programs (1.9; 95% CI, 1.1-3.2). CONCLUSIONS Risk for CVD was common and preferences for gender-specific care and posttraumatic stress disorder were associated with being at risk for CVD. Women's health clinics may be a good location for targeted CVD prevention interventions for women veterans both in and outside the Veterans Health Administration.
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Affiliation(s)
- Karen M Goldstein
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Medicine, Yale University, New Haven, Connecticut
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, North Carolina
| | - Donna L Washington
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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27
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Miller KEM, Duan-Porter W, Stechuchak KM, Mahanna E, Coffman CJ, Weinberger M, Van Houtven CH, Oddone EZ, Morris K, Schmader KE, Hendrix CC, Kessler C, Hastings SN. Risk stratification for return emergency department visits among high-risk patients. Am J Manag Care 2017; 23:e275-e279. [PMID: 29087151 PMCID: PMC6415920] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare 2 methods of identifying patients at high-risk of repeat emergency department (ED) use: high Care Assessment Need (CAN) score (≥90), derived from a model using Veterans Health Administration (VHA) data, and "Super User" status, defined as more than 3 ED visits within 6 months of the index ED visit. STUDY DESIGN Retrospective cohort study. METHODS Using McNemar's test, we compared rates of high-risk classification between CAN score and Super User status. We examined differences in patient characteristics and healthcare utilization across 4 levels of risk classification: high CAN and Super User status (n = 198), CAN <90 and non-Super User (n = 622), high CAN and non-Super User (n = 616), or Super User and CAN score <90 (n = 106). We used logistic regression to identify associations between risk classification and any ED visit within 90 days. RESULTS Of 1542 veterans, 52.8% (n = 814) had a CAN score ≥90 and 19.7% (n = 304) were Super Users (P <.0001), indicating discrepant rates of high-risk classification. However, we found no differences in patient characteristics. Rates of subsequent ED use were high: 63.1% of patients had 1 or more ED visits. No levels of risk classification were associated with subsequent ED use within 90 days (P = .25). CONCLUSIONS Among the VHA users with multimorbidity and 3 or more prior ED visits or hospitalizations, subsequent ED use was high. Although CAN scores have demonstrated utility for predicting hospitalizations and deaths, prior utilization and multimorbidity without further risk classification identified a high-risk group for repeat ED use.
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28
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Jackson GL, Roumie CL, Rakley SM, Kravetz JD, Kirshner MA, Del Monte PS, Bowen ME, Oddone EZ, Weiner BJ, Shaw RJ, Bosworth HB. Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research. Learn Health Syst 2017; 1:e10013. [PMID: 31245556 PMCID: PMC6516710 DOI: 10.1002/lrh2.10013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/28/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022] Open
Abstract
Organizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.
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Affiliation(s)
- George L. Jackson
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Christianne L. Roumie
- VA Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Health Services Research & DevelopmentVA Tennessee Valley Healthcare SystemNashvilleTN
- Department of MedicineVanderbilt UniversityNashvilleTN
| | - Susan M. Rakley
- Division of General Internal MedicineDuke UniversityDurhamNC
- Durham VA Medical CenterDurhamNC
| | - Jeffrey D. Kravetz
- VA Connecticut Healthcare SystemWest HavenCT
- School of MedicineYale UniversityNew HavenCT
| | - Miriam A. Kirshner
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
| | | | - Michael E. Bowen
- Departments of Internal Medicine, Clinical Sciences, and PediatricsUniversity of Texas Southwestern Medical CenterDallasTX
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
| | - Bryan J. Weiner
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
| | - Ryan J. Shaw
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- School of NursingDuke UniversityDurhamNC
| | - Hayden B. Bosworth
- Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamNC
- Division of General Internal MedicineDuke UniversityDurhamNC
- School of NursingDuke UniversityDurhamNC
- Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamNC
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29
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Allen KD, Oddone EZ, Coffman CJ, Jeffreys AS, Bosworth HB, Chatterjee R, McDuffie J, Strauss JL, Yancy WS, Datta SK, Corsino L, Dolor RJ. Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial. Ann Intern Med 2017; 166:401-411. [PMID: 28114648 PMCID: PMC6862719 DOI: 10.7326/m16-1245] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 01/05/2023] Open
Abstract
BACKGROUND A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions. OBJECTIVE To examine whether patient-based, provider-based, and patient-provider interventions improve osteoarthritis outcomes. DESIGN Cluster randomized trial with assignment to patient, provider, and patient-provider interventions or usual care. (ClinicalTrials.gov: NCT01435109). SETTING 10 Duke University Health System community-based primary care clinics. PARTICIPANTS 537 outpatients with symptomatic hip or knee osteoarthritis. INTERVENTION The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved electronic delivery of patient-specific osteoarthritis treatment recommendations to providers. MEASUREMENTS The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups. RESULTS No difference was observed in WOMAC score changes from baseline to 12 months in the patient (-1.5 [95% CI, -5.1 to 2.0]; P = 0.40), provider (2.5 [CI, -0.9 to 5.9]; P = 0.152), or patient-provider (-0.7 [CI, -4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, -3.7 to -7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care. LIMITATIONS The study involved 1 health care network. Data on provider referrals were not collected. CONCLUSION Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically significant improvements in the osteoarthritis intervention groups compared with usual care. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Kelli D Allen
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Eugene Z Oddone
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Cynthia J Coffman
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Amy S Jeffreys
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Hayden B Bosworth
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Ranee Chatterjee
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer McDuffie
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer L Strauss
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - William S Yancy
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Santanu K Datta
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Leonor Corsino
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
| | - Rowena J Dolor
- From Durham Veterans Affairs Medical Center, Duke University, and Duke University Medical Center, Durham, and University of North Carolina, Chapel Hill, North Carolina
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30
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Goldstein KM, Stechuchak KM, Zullig LL, Oddone EZ, Olsen MK, McCant FA, Bastian LA, Batch BC, Bosworth HB. Impact of Gender on Satisfaction and Confidence in Cholesterol Control Among Veterans at Risk for Cardiovascular Disease. J Womens Health (Larchmt) 2017; 26:806-814. [PMID: 28192012 DOI: 10.1089/jwh.2016.5739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 12/21/2022] Open
Abstract
BACKGROUND Compared with men, women have poorer lipid control. Although potential causes of this disparity have been explored, it is unknown whether patient-centered factors such as satisfaction and confidence contribute. We evaluated (1) whether satisfaction with lipid control and confidence in ability to improve it vary by gender and (2) whether sociodemographic characteristics modify the association. MATERIALS AND METHODS We evaluated baseline survey responses from the Cardiovascular Intervention Improvement Telemedicine Study, including self-rated satisfaction with cholesterol levels and confidence in controlling cholesterol. Participants had poorly controlled hypertension and/or hypercholesterolemia. RESULTS A total of 428 veterans (15% women) participated. Compared with men, women had higher low-density lipoprotein values at 141.2 versus 121.7 mg/dL, respectively (p < 0.05), higher health literacy, and were less likely to have someone to help track their medications (all p < 0.05). In an adjusted model, women were less satisfied with their cholesterol levels than men with estimated mean scores of 4.3 versus 5.6 on a 1-10 Likert scale (p < 0.05). There was no significant difference in confidence by gender. Participants with support for tracking medications reported higher confidence levels than those without, estimated mean 7.8 versus 7.2 (p < 0.05). CONCLUSIONS Women veterans at high risk for cardiovascular disease were less satisfied with their lipid control than men; however, confidence in ability to improve lipid levels was similar. Veterans without someone to help to track medications were less confident, and women were less likely to have this type of social support. Lack of social support for medication tracking may be a factor in lingering gender-based disparities in hyperlipidemia.
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Affiliation(s)
- Karen M Goldstein
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Karen M Stechuchak
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina
| | - Leah L Zullig
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Eugene Z Oddone
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Maren K Olsen
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,3 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina
| | - Felicia A McCant
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina
| | - Lori A Bastian
- 4 VA Connecticut Healthcare System , West Haven, Connecticut.,5 Department of Medicine, Yale University , New Haven, Connecticut
| | - Bryan C Batch
- 6 Division of Endocrinology, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Hayden B Bosworth
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina.,7 School of Nursing, Duke University School of Medicine , Durham, North Carolina.,8 Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine , Durham, North Carolina
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31
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Oddone EZ, Damschroder LJ, Gierisch J, Olsen M, Fagerlin A, Sanders L, Sparks J, Turner M, May C, McCant F, Curry D, White-Clark C, Juntilla K. A Coaching by Telephone Intervention for Veterans and Care Team Engagement (ACTIVATE): A study protocol for a Hybrid Type I effectiveness-implementation randomized controlled trial. Contemp Clin Trials 2017; 55:1-9. [PMID: 28126455 DOI: 10.1016/j.cct.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/17/2017] [Accepted: 01/21/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION A large proportion of deaths and many illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. Health risk assessments (HRAs) are widely available online but have not been consistently used in healthcare systems to activate patients to participate in prevention programs aimed at improving lifestyle behaviors. OBJECTIVES The goal of this study is to test whether adding telephone-based coaching to use of a comprehensive HRA increases at-risk patients' activation and enrollment into a prevention program compared to HRA use alone. METHODS Participants were randomized to either complete an HRA alone or in conjunction with a telephone coaching intervention. To be eligible Veterans had to have at least one modifiable risk factor (current smoker, overweight/obese, or physically inactive). The primary outcome is enrollment and participation in a prevention program by 6months. Secondary outcomes include change in a Patient Activation Measure and Framingham Risk Score. DISCUSSION This study is the first to test a web-based health risk assessment coupled with a health coaching intervention within a large healthcare system. Results from this study will help the Veterans Health Administration (VHA) implement its national plan to include comprehensive health risk assessments as a tool to engage Veterans in prevention. The results will also inform health systems outside VHA who seek to implement Medicare's advisement that health risk assessment become a mandatory component of care under the Affordable Care Act.
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Affiliation(s)
- Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jennifer Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Maren Olsen
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Angela Fagerlin
- VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT, USA; Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Linda Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jordan Sparks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Marsha Turner
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Carrie May
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Felicia McCant
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - David Curry
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Courtney White-Clark
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Karen Juntilla
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
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Schrubbe LA, Ravyts SG, Benas BC, Campbell LC, Cené CW, Coffman CJ, Gunn AH, Keefe FJ, Nagle CT, Oddone EZ, Somers TJ, Stanwyck CL, Taylor SS, Allen KD. Pain coping skills training for African Americans with osteoarthritis (STAART): study protocol of a randomized controlled trial. BMC Musculoskelet Disord 2016; 17:359. [PMID: 27553385 PMCID: PMC4994196 DOI: 10.1186/s12891-016-1217-2] [Citation(s) in RCA: 8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND African Americans bear a disproportionate burden of osteoarthritis (OA), with higher prevalence rates, more severe pain, and more functional limitations. One key barrier to addressing these disparities has been limited engagement of African Americans in the development and evaluation of behavioral interventions for management of OA. Pain Coping Skills Training (CST) is a cognitive-behavioral intervention with shown efficacy to improve OA-related pain and other outcomes. Emerging data indicate pain CST may be a promising intervention for reducing racial disparities in OA symptom severity. However, there are important gaps in this research, including incorporation of stakeholder perspectives (e.g. cultural appropriateness, strategies for implementation into clinical practice) and testing pain CST specifically among African Americans with OA. This study will evaluate the effectiveness of a culturally enhanced pain CST program among African Americans with OA. METHODS/DESIGN This is a randomized controlled trial among 248 participants with symptomatic hip or knee OA, with equal allocation to a pain CST group and a wait list (WL) control group. The pain CST program incorporated feedback from patients and other stakeholders and involves 11 weekly telephone-based sessions. Outcomes are assessed at baseline, 12 weeks (primary time point), and 36 weeks (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include self-efficacy, pain coping, pain interference, quality of life, depressive symptoms, and global assessment of change. Linear mixed models will be used to compare the pain CST group to the WL control group and explore whether participant characteristics are associated with differential improvement in the pain CST program. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, Durham Veterans Affairs Medical Center, East Carolina University, and Duke University Health System. DISCUSSION This culturally enhanced pain CST program could have a substantial impact on outcomes for African Americans with OA and may be a key strategy in the reduction of racial health disparities. TRIAL REGISTRATION ClinicalTrials.gov, NCT02560922 , registered 9/22/2015.
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Affiliation(s)
- Leah A Schrubbe
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA. .,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA.
| | - Scott G Ravyts
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA
| | - Bernadette C Benas
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA
| | - Lisa C Campbell
- Department of Psychology, East Carolina University, Greenville, NC, USA
| | - Crystal W Cené
- Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA
| | - Cynthia J Coffman
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Alexander H Gunn
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Science, Duke University, Durham, NC, USA
| | - Caroline T Nagle
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA
| | - Eugene Z Oddone
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Tamara J Somers
- Department of Psychiatry and Behavioral Science, Duke University, Durham, NC, USA
| | - Catherine L Stanwyck
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Shannon S Taylor
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Kelli D Allen
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.,Department of Medicine, University of North Carolina at Chapel Hill, 125 MacNider Hall CB# 7005, Chapel Hill, NC, 27599, USA.,Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
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Abstract
Primary care is the cornerstone of effective and efficient healthcare systems. Patients prefer a trusted primary care provider to serve as the first contact for all of their healthcare questions, to help them make important health decisions, to help guide them through an expanding amount of medical information and to help coordinate their care with all other providers. Patients also prefer to establish an ongoing, continuous relationship with their primary care provider. However, fewer and fewer physicians are choosing primary care as a career, threatening the foundation of the health system. We explore the central challenges of primary care defined by work-force controversies about who can best deliver primary care. We also explore the current challenging reimbursement model for primary care that often results in fragmenting care for patients and providers. Finally, we explore new models of primary care health delivery that may serve as partial solutions to the current challenges.
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Affiliation(s)
- Eugene Z Oddone
- Division of General Internal Medicine, Duke University School of Medicine, North Carolina; Department of Medicine, Center for Health Services Research in Primary Care, Durham, VA Medical Center, North Carolina..
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, North Carolina
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Crowley MJ, Olsen MK, Woolson SL, King HA, Oddone EZ, Bosworth HB. Baseline Antihypertensive Drug Count and Patient Response to Hypertension Medication Management. J Clin Hypertens (Greenwich) 2016; 18:322-8. [PMID: 26370918 PMCID: PMC4792789 DOI: 10.1111/jch.12669] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/24/2015] [Accepted: 07/26/2015] [Indexed: 12/20/2022]
Abstract
Telemedicine-based medication management improves hypertension control, but has been evaluated primarily in patients with low antihypertensive drug counts. Its impact on patients taking three or more antihypertensive agents is not well-established. To address this evidence gap, the authors conducted an exploratory analysis of an 18-month, 591-patient trial of telemedicine-based hypertension medication management. Using general linear models, the effect of medication management on blood pressure for patients taking two or fewer antihypertensive agents at study baseline vs those taking three or more was compared. While patients taking two or fewer antihypertensive agents had a significant reduction in systolic blood pressure with medication management, those taking three or more had no such response. The between-subgroup effect difference was statistically significant at 6 months (-6.4 mm Hg [95% confidence interval, -12.2 to -0.6]) and near significant at 18 months (-6.0 mm Hg [95% confidence interval, -12.2 to 0.2]). These findings suggest that baseline antihypertensive drug count may impact how patients respond to hypertension medication management and emphasize the need to study management strategies specifically in patients taking three or more antihypertensive medications.
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Affiliation(s)
- Matthew J. Crowley
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of Endocrinology, Diabetes, and MetabolismDepartment of MedicineDuke UniversityDurhamNC
| | - Maren K. Olsen
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNC
| | - Sandra L. Woolson
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
| | - Heather A. King
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
| | - Hayden B. Bosworth
- Center for Health Services Research in Primary CareDurham VA Medical CenterDurhamNC
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNC
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Feussner JR, Oddone EZ, Rich EC. "To Improve Is to Change": Improving U.S. Healthcare. Am J Med Sci 2016; 351:1-2. [PMID: 26802751 DOI: 10.1016/j.amjms.2015.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- John R Feussner
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Eugene Z Oddone
- Division of General Internal Medicine, Durham VA Medical Center, Duke University, Durham, North Carolina
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Allen KD, Yancy WS, Bosworth HB, Coffman CJ, Jeffreys AS, Datta SK, McDuffie J, Strauss JL, Oddone EZ. A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial. Ann Intern Med 2016; 164:73-83. [PMID: 26720751 PMCID: PMC4732728 DOI: 10.7326/m15-0378] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused. OBJECTIVE To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes. DESIGN Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740). SETTING Department of Veterans Affairs Medical Center in Durham, North Carolina. PARTICIPANTS 30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis. INTERVENTION The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record. MEASUREMENTS The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes. RESULTS At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ. LIMITATION The study was conducted in a single Veterans Affairs medical center. CONCLUSION The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis. PRIMARY FUNDING SOURCE Department of Veterans Affairs, Health Services Research and Development Service.
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Goldstein KM, Zullig LL, Bosworth HB, Oddone EZ. Consideration of Out-of-Office Blood Pressure Monitoring in Hypertension Management. J Clin Hypertens (Greenwich) 2015; 18:381-2. [PMID: 26541118 DOI: 10.1111/jch.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Karen M Goldstein
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, NC.,Division of General Internal Medicine, Duke University, Durham, NC
| | - Leah L Zullig
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Division of General Internal Medicine, Duke University, Durham, NC
| | - Hayden B Bosworth
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Division of General Internal Medicine, Duke University, Durham, NC.,Departments of Psychiatry and School of Nursing, Duke University, Durham, NC
| | - Eugene Z Oddone
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC.,Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, NC.,Division of General Internal Medicine, Duke University, Durham, NC
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Yancy WS, Mayer SB, Coffman CJ, Smith VA, Kolotkin RL, Geiselman PJ, McVay MA, Oddone EZ, Voils CI. Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial. Ann Intern Med 2015; 162:805-14. [PMID: 26075751 PMCID: PMC4470323 DOI: 10.7326/m14-2358] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Choosing a diet rather than being prescribed one could improve weight loss. OBJECTIVE To examine whether offering choice of diet improves weight loss. DESIGN Double-randomized preference trial of choice between 2 diets (choice) versus random assignment to a diet (comparator) over 48 weeks. (ClinicalTrials.gov: NCT01152359). SETTING Outpatient clinic at a Veterans Affairs medical center. PATIENTS Outpatients with a body mass index of at least 30 kg/m2. INTERVENTION Choice participants received information about their food preferences and 2 diet options (low-carbohydrate diet [LCD] or low-fat diet [LFD]) before choosing and were allowed to switch diets at 12 weeks. Comparator participants were randomly assigned to 1 diet for 48 weeks. Both groups received group and telephone counseling for 48 weeks. MEASUREMENTS The primary outcome was weight at 48 weeks. RESULTS Of 105 choice participants, 61 (58%) chose the LCD and 44 (42%) chose the LFD; 5 (3 on the LCD and 2 on the LFD) switched diets at 12 weeks, and 87 (83%) completed measurements at 48 weeks. Of 102 comparator participants, 53 (52%) were randomly assigned to the LCD and 49 (48%) were assigned to the LFD; 88 (86%) completed measurements. At 48 weeks, estimated mean weight loss was 5.7 kg (95% CI, 4.3 to 7.0 kg) in the choice group and 6.7 kg (CI, 5.4 to 8.0 kg) in the comparator group (mean difference, -1.1 kg [CI, -2.9 to 0.8 kg]; P = 0.26). Secondary outcomes of dietary adherence, physical activity, and weight-related quality of life were similar between groups at 48 weeks. LIMITATIONS Only 2 diet options were provided. Results from this sample of older veterans might not be generalizable to other populations. CONCLUSION Contrary to expectations, the opportunity to choose a diet did not improve weight loss.
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Affiliation(s)
- William S. Yancy
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Stephanie B. Mayer
- Division of Endocrinology and Metabolism, Virginia Commonwealth University, Richmond, VA
| | - Cynthia J. Coffman
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Valerie A. Smith
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
| | - Ronette L. Kolotkin
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC
- Department of Health Studies, Sogn og Fjordane University College, Førde, Norway Department of Surgery, Førde Central Hospital, Førde, Norway Morbid Obesity Centre, Vestfold Hospital Trust, Tønsberg, Norway
| | - Paula J. Geiselman
- Pennington Biomedical Research Center and Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| | - Megan A. McVay
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Eugene Z. Oddone
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Corrine I. Voils
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Zullig LL, Stechuchak KM, Goldstein KM, Olsen MK, McCant FM, Danus S, Crowley MJ, Oddone EZ, Bosworth HB. Patient-reported medication adherence barriers among patients with cardiovascular risk factors. J Manag Care Spec Pharm 2015; 21:479-85. [PMID: 26011549 PMCID: PMC10401992 DOI: 10.18553/jmcp.2015.21.6.479] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many patients experience barriers that make it difficult to take cardiovascular disease (CVD)-related medications as prescribed. The Cardiovascular Intervention Improvement Telemedicine Study (CITIES) was a tailored behavioral pharmacist-administered and telephone-based intervention for reducing CVD risk. OBJECTIVES To (a) describe patient-reported barriers to taking their medication as prescribed and (b) evaluate patient-level characteristics associated with reporting medication barriers. METHODS We recruited patients receiving care at primary care clinics affiliated with Durham Veterans Affairs Medical Center. Eligible patients were diagnosed with hypertension and/or hyperlipidemia that were poorly controlled (blood pressure of > 150/100 mmHg and/or low-density lipoprotein value > 130 mg/dL). At the time of enrollment, patients completed an interview with 7 questions derived from a validated medication barriers measure. Patient characteristics and individual medication treatment barriers are described. Multivariable linear regression was used to examine the association between a medication barrier score and patient characteristics. RESULTS Most patients (n = 428) were married or living with their partners (57%) and were men (85%) who were diagnosed with hypertension and hyperlipidemia (64%). The most commonly reported barriers were having too much medication to take (31%) and forgetting whether medication was taken at a particular time (24%). In adjusted analysis, those who were not employed (1.32, 95% CI = 0.50-2.14) or did not have someone to help with tasks, if needed (1.66, 95% CI = 0.42-2.89), reported higher medication barrier scores. Compared with those diagnosed with hypertension and hyperlipidemia, those with only hypertension (0.91, 95% CI = 0.04-1.79) reported higher medication barrier scores. CONCLUSIONS Barriers to medication adherence are common. Evaluating and addressing barriers may increase medication adherence.
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Affiliation(s)
- Leah L Zullig
- Duke University Medical Center, 411 W. Chapel Hill St., Ste. 600, Durham, NC 27701.
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Allen KD, Bosworth HB, Chatterjee R, Coffman CJ, Corsino L, Jeffreys AS, Oddone EZ, Stanwyck C, Yancy WS, Dolor RJ. Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management. BMC Musculoskelet Disord 2014; 15:413. [PMID: 25481809 PMCID: PMC4295303 DOI: 10.1186/1471-2474-15-413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/25/2014] [Indexed: 01/02/2023] Open
Abstract
Background The Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics. Methods Baseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants’ Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants’ Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation. Results Study clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from “rural” to “small city”), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%). Conclusions Although PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation. Trial registration Clinical Trial Registration Number: NCT 01435109 Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-413) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kelli D Allen
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.
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Hastings SN, Betts E, Schmader KE, Weinberger M, Van Houtven CH, Hendrix CC, Coffman CJ, Stechuchak KM, Weiner M, Morris K, Kessler C, Oddone EZ. Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods. Contemp Clin Trials 2014; 39:342-50. [PMID: 25445314 DOI: 10.1016/j.cct.2014.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 08/08/2014] [Revised: 10/24/2014] [Accepted: 10/26/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND An explicit goal of Patient Aligned Care Teams (PACTs) within the Veterans Health Administration is to promote continuity of care in primary care clinics and thereby reduce Emergency Department (ED) utilization; however, there has been little research to guide PACTs on how to accomplish this. OBJECTIVES The overall goal of this study is to examine the impact of a primary care-based nurse telephone support program [DISPO ED] on Veterans treated and released from the ED who are at high risk for repeat visits. METHODS This study is a two group randomized, controlled trial to evaluate DISPO ED for Veterans treated and released from the ED who are at high risk for repeat visits. We define high risk as those who have had an ED visit or hospitalization during the 6 month period before the index ED visit and have ≥2 chronic conditions. Veterans are randomized to nurse telephone support or usual care. The primary outcome is repeat ED use within 30 days; secondary outcomes are patient satisfaction with care and total costs. DISCUSSION The results of this randomized, controlled trial with an Effectiveness-Implementation Type I Hybrid design will be directly relevant to the care of more than 500,000 high risk patients seen in Veterans' Affairs Medical Center (VAMC) EDs annually. Results will also be informative to health systems outside VA aiming to reduce ED use through accountable care organizations.
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Affiliation(s)
- Susan Nicole Hastings
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA.
| | - Elizabeth Betts
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Kenneth E Schmader
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA
| | - Morris Weinberger
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney Harold Van Houtven
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Cristina C Hendrix
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University, Durham, NC, USA; Duke University School of Nursing, Durham, NC, USA
| | - Cynthia J Coffman
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Madeline Weiner
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Katina Morris
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA
| | - Chad Kessler
- Ambulatory Care Service, Durham VA Medical Center, Durham, NC, USA
| | - Eugene Z Oddone
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Van Houtven CH, Oddone EZ, Hastings SN, Hendrix C, Olsen M, Neelon B, Lindquist J, Weidenbacher H, Boles J, Chapman J, Weinberger M. Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES): study design and methodology. Contemp Clin Trials 2014; 38:260-9. [PMID: 24837544 DOI: 10.1016/j.cct.2014.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 05/02/2014] [Accepted: 05/05/2014] [Indexed: 10/25/2022]
Abstract
Within the Veterans Health Administration (VHA), the largest integrated health care system in the US, approximately 8.5 million Veteran patients receive informal care. Despite a need for training, half of VHA caregivers report that they have not received training that they deemed necessary. Rigorous study is needed to identify effective ways of providing caregivers with the skills they need. This paper describes the Helping Invested Families Improve Veterans' Experience Study (HI-FIVES), an ongoing randomized controlled trial that is evaluating a skills training program designed to support caregivers of cognitively and/or functionally impaired, community-dwelling Veterans who have been referred to receive additional formal home care services. This two-arm randomized controlled trial will enroll a total of 240 caregiver-patient dyads. For caregivers in the HI-FIVES group, weekly individual phone training occurs for 3 weeks, followed by 4 weekly group training sessions, and two additional individual phone training calls. Caregivers in usual care receive information about the VA Caregiver Support Services Program services, including a hotline number. The primary outcome is the number of days a Veteran patient spends at home in the 12 months following randomization (e.g. not in the emergency department, inpatient or nursing home setting). Secondary outcomes include patient VHA health care costs, patient and caregiver satisfaction with VHA health care, and caregiver depressive symptoms. Outcomes from HI-FIVES have the potential to improve our knowledge of how to maximize the ability to maintain patients safely at home for caregivers while preventing poor mental health outcomes among caregivers.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 W. Chapel Hill Street, NC Mutual Building, Ste 500, Durham, NC 27710, USA.
| | - Eugene Z Oddone
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 W. Chapel Hill Street, NC Mutual Building, Ste 500, Durham, NC 27710, USA.
| | - Susan N Hastings
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Division of Geriatrics, Department of Medicine, Duke University Medical Center, DUMC Box 3003, Durham, NC 27710, USA; Geriatric Research, Education, and Clinical Center, Durham VAMC 508 Fulton Street Durham NC 27705, USA; Center for the Study of Aging and Human Development Box 3003 DUMC, Room 3502 Busse Building, Blue Zone, Duke South, Durham, NC 27710, USA.
| | - Cristina Hendrix
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; School of Nursing, Duke University Medical Center, 307 Trent Drive, Box 102400, Durham, NC 27710, USA; Center for the Study of Aging and Human Development Box 3003 DUMC, Room 3502 Busse Building, Blue Zone, Duke South, Durham, NC 27710, USA.
| | - Maren Olsen
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Department of Biostatistics, Duke University Medical Center, 2424 Erwin Road, Suite 1102 Hock Plaza, Box 2721, Durham, NC 27710, USA.
| | - Brian Neelon
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Department of Biostatistics, Duke University Medical Center, 2424 Erwin Road, Suite 1102 Hock Plaza, Box 2721, Durham, NC 27710, USA.
| | - Jennifer Lindquist
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
| | - Hollis Weidenbacher
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
| | - Jillian Boles
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, 411 W. Chapel Hill Street, NC Mutual Building, Ste 500, Durham, NC 27710, USA.
| | - Jennifer Chapman
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
| | - Morris Weinberger
- Center for Health Services Research in Primary Care, U.S. Department of Veterans Affairs, Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA; Department of Health Policy and Management, 1105B McGavran-Greenberg Hall, Campus Box 7411, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Maciejewski ML, Bosworth HB, Olsen MK, Smith VA, Edelman D, Powers BJ, Kaufman MA, Oddone EZ, Jackson GL. Do the benefits of participation in a hypertension self-management trial persist after patients resume usual care? Circ Cardiovasc Qual Outcomes 2014; 7:269-75. [PMID: 24619321 DOI: 10.1161/circoutcomes.113.000309] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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: 12/18/2022]
Abstract
BACKGROUND Hypertension self-management has been shown to improve systolic blood pressure (BP) control, but longer-term economic and clinical impacts are unknown. The purpose of this article is to examine clinical and economic outcomes 18 months after completion of a hypertension self-management trial. METHODS AND RESULTS This study is a follow-up analysis of an 18-month, 4-arm, hypertension self-management trial of 591 veterans with hypertension who were randomized to usual care or 1 of 3 interventions. Clinic-derived systolic blood pressure obtained before, during, and after the trial were estimated using linear mixed models. Inpatient admissions, outpatient expenditures, and total expenditures were estimated using generalized estimating equations. The 3 telephone-based interventions were nurse-administered health behavior promotion, provider-administered medication adjustments based on hypertension treatment guidelines, or a combination of both. Intervention calls were triggered by home BP values transmitted via telemonitoring devices. Clinical and economic outcomes were examined 12 months before, 18 months during, and 18 months after trial completion. Compared with usual care, patients randomized to the combined arm had greater improvement in proportion of BP control during and after the 18-month trial and estimated proportion of BP control improved 18 months after trial completion for patients in the behavioral and medication management arms. Among the patients with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined arm as compared with usual care during and after the 18-month trial. Utilization and expenditure trends were similar for patients in all 4 arms. CONCLUSIONS Behavioral and medication management can generate systolic BP improvements that are sustained 18 months after trial completion. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00237692.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
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Shaw RJ, Kaufman MA, Bosworth HB, Weiner BJ, Zullig LL, Lee SYD, Kravetz JD, Rakley SM, Roumie CL, Bowen ME, Del Monte PS, Oddone EZ, Jackson GL. Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study. Implement Sci 2013; 8:106. [PMID: 24010683 PMCID: PMC3847033 DOI: 10.1186/1748-5908-8-106] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [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: 03/29/2013] [Accepted: 09/04/2013] [Indexed: 11/10/2022] Open
Abstract
Background Hypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success. Objectives Through implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change? Study design Each intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation. Results Key ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space. The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses. Conclusions The model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.
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Affiliation(s)
- Ryan J Shaw
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 411 West Chapel Street, suite 600, Durham, NC, USA.
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Hastings SN, Smith VA, Weinberger M, Oddone EZ, Olsen MK, Schmader KE. Health services use of older veterans treated and released from veterans affairs medical center emergency departments. J Am Geriatr Soc 2013; 61:1515-21. [PMID: 24004193 DOI: 10.1111/jgs.12417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine predictors of repeat health service use in older veterans treated and released from the emergency department (ED). DESIGN Retrospective cohort study. SETTING Veterans Affairs Medical Center (VAMC) EDs. PARTICIPANTS Nationally representative sample of veterans aged 65 and older treated and released from one of 102 VAMC EDs between October 1, 2007, and June 30, 2008. MEASUREMENTS Logistic regression models were used to examine the association between independent variables and primary outcomes (30-day repeat ED visits and hospital admissions). RESULTS In 31,206 older veterans, ED diagnoses were commonly related to chronic conditions (22.5%), injuries and acute musculoskeletal conditions (19%), and infections (13.5%). Within 30 days, 22% of older veterans had returned to the ED (n = 4,779) or been hospitalized (n = 2,005). In adjusted models, factors associated with greater odds of repeat ED visits than injury were homelessness (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.1), previous ED visits (OR = 1.7, 95% CI = 1.6-1.8), previous hospitalization (OR = 1.3, 95% CI = 1.2-1.4), and index ED visit related to infection (1.2, 95% CI = 1.1-1.3). Odds of subsequent hospital admission were higher in veterans with previous hospitalization (OR = 2.5, 95% CI = 2.2-2.8), who were homeless (OR = 1.5, 95% CI = 1.1-2.0), who had aid and attendance benefits (OR = 1.5, 95% CI = 1.2-1.8), who were unmarried (OR = 1.2, 95% CI = 1.1-1.3), and who had an ED visit related to a chronic condition (OR = 1.4, 95% CI = 1.2-1.6) than in those with injury. CONCLUSION A substantial proportion of older veterans treated and released from a VAMC ED returned to the ED or were hospitalized within 30 days. Intervening with high-risk older veterans after an ED visit may reduce unscheduled healthcare use.
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Affiliation(s)
- Susan Nicole Hastings
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina; Geriatrics Research, Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina; Division of Geriatrics, Department of Medicine, Duke University, Durham, North Carolina; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
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Strauss JL, Zervakis JB, Stechuchak KM, Olsen MK, Swanson J, Swartz MS, Weinberger M, Marx CE, Calhoun PS, Bradford DW, Butterfield MI, Oddone EZ. Adverse impact of coercive treatments on psychiatric inpatients' satisfaction with care. Community Ment Health J 2013; 49:457-65. [PMID: 23054144 DOI: 10.1007/s10597-012-9539-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [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] [Received: 07/04/2011] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
Consumers' satisfaction with inpatient mental health care is recognized as a key quality indicator that prospectively predicts functional and clinical outcomes. Coercive treatment experience is a frequently cited source of dissatisfaction with inpatient care, yet more research is needed to understand the factors that influence consumers' perceptions of coercion and its effects on satisfaction, including potential "downstream" effects of past coercive events on current treatment satisfaction. The current study examined associations between objective and subjective indices of coercive treatments and patients' satisfaction with care in a psychiatric inpatient sample (N = 240). Lower satisfaction ratings were independently associated with three coercive treatment variables: current involuntary admission, perceived coercion during current admission, and self-reported history of being refused a requested medication. Albeit preliminary, these results document associations between patients' satisfaction ratings and their subjective experiences of coercion during both current and prior hospitalizations.
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Affiliation(s)
- Jennifer L Strauss
- Center for Health Services Research in Primary Care, VISN 6 MIRECC, Bldg 6, 508 Fulton Street, Durham, NC 27705, USA.
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Sperber NR, Bosworth HB, Coffman CJ, Lindquist JH, Oddone EZ, Weinberger M, Allen KD. Differences in osteoarthritis self-management support intervention outcomes according to race and health literacy. Health Educ Res 2013; 28:502-511. [PMID: 23525779 DOI: 10.1093/her/cyt043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
We explored whether the effects of a telephone-based osteoarthritis (OA) self-management support intervention differed by race and health literacy. Participants included 515 veterans with hip and/or knee OA. Linear mixed models assessed differential effects of the intervention compared with health education (HE) and usual care (UC) on pain (Arthritis Impact Measurement Scales-2 [AIMS2] and Visual Analogue Scale), function (AIMS2 mobility and walking/bending), affect (AIMS2) and arthritis self-efficacy by: (i) race (white/non-white), (ii) health literacy (high/low) and (iii) race by health literacy. AIMS2 mobility improved more among non-whites than whites in the intervention compared with HE and UC (P = 0.02 and 0.008). AIMS2 pain improved more among participants with low than high literacy in the intervention compared with HE (P = 0.05). However, we found a differential effect of the intervention on AIMS2 pain compared with UC according to the combination of race and health literacy (P = 0.05); non-whites with low literacy in the intervention had the greatest improvement in pain. This telephone-based OA intervention may be particularly beneficial for patients with OA who are racial/ethnic minorities and have low health literacy. These results warrant further research designed specifically to assess whether this type of intervention can reduce OA disparities.
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Affiliation(s)
- Nina R Sperber
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.
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Yancy WS, Coffman CJ, Geiselman PJ, Kolotkin RL, Almirall D, Oddone EZ, Mayer SB, Gaillard LA, Turner M, Smith VA, Voils CI. Considering patient diet preference to optimize weight loss: design considerations of a randomized trial investigating the impact of choice. Contemp Clin Trials 2013; 35:106-16. [PMID: 23506974 PMCID: PMC4351659 DOI: 10.1016/j.cct.2013.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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] [Received: 12/25/2012] [Revised: 02/11/2013] [Accepted: 03/10/2013] [Indexed: 02/06/2023]
Abstract
A variety of diet approaches achieve moderate weight loss in many individuals. Yet, most diet interventions fail to achieve meaningful weight loss in more than a few individuals, likely due to inadequate adherence to the diet. It is widely conjectured that targeting the diet to an individual's food preferences will enhance adherence, thereby improving weight loss. This article describes the design considerations of a study protocol aimed at testing this hypothesis. The study is a 2-arm randomized trial recruiting 216 medical outpatients with BMI ≥30 kg/m(2) followed for 48 weeks. Participants in the experimental arm (Choice) select from two of the most widely studied diets for weight loss, a low-carbohydrate, calorie-unrestricted diet (LCD) or a low-fat, reduced-calorie diet (LFD). The participant's choice is informed by results from a validated food preference questionnaire and a discussion of diet options with trained personnel. Choice participants are given the option to switch to the other diet after three months, if desired. Participants in the Control arm are randomly assigned to follow one of the two diets for the duration of follow-up. The primary outcome is weight assessed every 2-4 weeks for 48 weeks. Secondary outcomes include adherence to diet by food frequency questionnaire and obesity-specific health-related quality of life. If assisting patients to choose their diet enhances adherence and increases weight loss, the results will support the provision of diet options to patients who desire weight loss, and bring us one step closer to remediating the obesity epidemic faced by our healthcare systems.
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Affiliation(s)
- William S Yancy
- Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA.
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Allen KD, Bongiorni D, Walker TA, Bartle J, Bosworth HB, Coffman CJ, Datta SK, Edelman D, Hall KS, Hansen G, Jennings C, Lindquist JH, Oddone EZ, Senick MJ, Sizemore JC, St John J, Hoenig H. Group physical therapy for veterans with knee osteoarthritis: study design and methodology. Contemp Clin Trials 2012; 34:296-304. [PMID: 23279750 DOI: 10.1016/j.cct.2012.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/20/2012] [Accepted: 12/21/2012] [Indexed: 10/27/2022]
Abstract
Physical therapy (PT) is a key component of treatment for knee osteoarthritis (OA) and can decrease pain and improve function. Given the expected rise in prevalence of knee OA and the associated demand for treatment, there is a need for models of care that cost-effectively extend PT services for patients with this condition. This manuscript describes a randomized clinical trial of a group-based physical therapy program that can potentially extend services to more patients with knee OA, providing a greater number of sessions per patient, at lower staffing costs compared to traditional individual PT. Participants with symptomatic knee OA (n = 376) are randomized to either a 12-week group-based PT program (six 1 h sessions, eight patients per group, led by a physical therapist and physical therapist assistant) or usual PT care (two individual visits with a physical therapist). Participants in both PT arms receive instruction in an exercise program, information on joint care and protection, and individual consultations with a physical therapist to address specific functional and therapeutic needs. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and the secondary outcome is the Short Physical Performance Test Protocol (objective physical function). Outcomes are assessed at baseline and 12-week follow-up, and the primary outcome is also assessed via telephone at 24-week follow-up to examine sustainability of effects. Linear mixed models will be used to compare outcomes for the two study arms. An economic cost analysis of the PT interventions will also be conducted.
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Affiliation(s)
- Kelli D Allen
- Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.
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