1
|
Locke ER, Thomas RM, Simpson TL, Fortney JC, Battaglia C, Trivedi RB, Gylys-Colwell J, Swenson ER, Edelman JD, Fan VS. Cognitive and Emotional Responses to Chronic Obstructive Pulmonary Disease Exacerbations and Patterns of Care Seeking. Ann Am Thorac Soc 2024; 21:559-567. [PMID: 37966313 DOI: 10.1513/annalsats.202303-287oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/15/2023] [Indexed: 11/16/2023] Open
Abstract
Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood.Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles.Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought.Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%).Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).
Collapse
Affiliation(s)
- Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Rachel M Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Tracy L Simpson
- Center of Excellence in Substance Addiction Treatment and Education, and
- Department of Psychiatry and Behavioral Sciences and
| | - John C Fortney
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Department of Psychiatry and Behavioral Sciences and
| | - Catherine Battaglia
- Veterans Affairs Eastern Colorado Health Care System, U.S. Department of Veterans Affairs, Aurora, Colorado
- Department of Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ranak B Trivedi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | | | - Erik R Swenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jeffrey D Edelman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Vincent S Fan
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
2
|
Pattock AM, Locke ER, Hebert PL, Simpson T, Battaglia C, Trivedi RB, Swenson ER, Edelman J, Fan VS. Predictors of Patient-reported and Pharmacy Refill Measures of Maintenance Inhaler Adherence in Veterans with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2024; 21:384-392. [PMID: 37774091 DOI: 10.1513/annalsats.202211-975oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 09/29/2023] [Indexed: 10/01/2023] Open
Abstract
Rationale: Suboptimal adherence to inhaled medications in patients with chronic obstructive pulmonary disease (COPD) remains a challenge. Objectives: To examine the sociodemographic and clinical characteristics and medication beliefs associated with adherence measured by self-report and pharmacy data. Methods: A cross-sectional analysis of data from a prospective observational cohort study of patients with COPD was completed. Participants underwent spirometry and completed questionnaires regarding sociodemographic data, inhaler use, dyspnea, social support, psychological and medical comorbidities, and medication beliefs (Beliefs about Medicines Questionnaire [BMQ]). Self-reported adherence to inhaled medications was measured with the Adherence to Refills and Medications Scale (ARMS), and pharmacy-based adherence was calculated from administrative data using the ReComp score. Multivariable linear regression was used to examine the sociodemographic, clinical, and medication-belief factors associated with both adherence measures. Results: Among 269 participants with ARMS and ReComp data, adherence was the same for each measure (38.3%), but only 18% of participants were adherent by both measures. In multivariable adjusted analysis, a 10-year increase in age (β = 0.54; 95% confidence interval, 0.14-0.94) and the number of maintenance inhalers used (β = 0.53; 0.04-1.02) were associated with increased adherence by self-report. Improved ReComp adherence was associated with chronic prednisone use (β = 0.18; 0.04-0.31) and the number of maintenance inhalers used (β = 0.11; 0.05-0.17). In adjusted analyses examining patient beliefs about medications, increases in the COPD-specific BMQ concerns score (β = -0.10; -0.17 to -0.02) were associated with reduced self-reported adherence. No significant associations between ReComp adherence and BMQ score were found in adjusted analyses. Conclusions: Adherence to inhaled COPD medications was poor as measured by self-report or pharmacy refill data. There were notable differences in factors associated with adherence based on the method of adherence measurement. Older age, chronic prednisone use, the number of prescribed maintenance inhalers used, and patient beliefs about medication safety were associated with adherence. Overall, fewer variables were associated with adherence as measured based on pharmacy refills. Pharmacy refill-based and self-reported adherence may measure distinct aspects of adherence and may be affected by different factors. These results also underscore the importance of addressing patient beliefs when developing interventions to improve medication adherence.
Collapse
Affiliation(s)
| | - Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Paul L Hebert
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Tracy Simpson
- Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington
| | - Catherine Battaglia
- Center of Innovation for Veteran-Centered and Value-Driven Care, Eastern Colorado VA Health Care System, Aurora, Colorado
- Department of Health System Management and Policy, Colorado School of Public Health, Aurora, Colorado
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Erik R Swenson
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Jeff Edelman
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Vincent S Fan
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| |
Collapse
|
3
|
Ritchey KC, Yohannes AM, Locke ER, Chen S, Simpson T, Battaglia C, Trivedi RB, Swenson ER, Edelman J, Fan VS. Association between self-reported falling risk and risk of hospitalization for patients with chronic obstructive pulmonary disease. Respir Med 2023; 220:107466. [PMID: 37981244 DOI: 10.1016/j.rmed.2023.107466] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
RATIONALE The association between self-report falling risk in persons with COPD and hospitalization has not been previously explored. OBJECTIVE To examine whether self-reported risk is associated with hospitalizations in patients with COPD. METHODS A secondary analysis from a prospective observational cohort study of veterans with COPD. Participants completed questions from the Stopping Elderly Accidents, Deaths and Injuries (STEADI) tool kit at either baseline or at the end of the 12-month study. A prospective or cross-sectional analysis examined the association between responses to the STEADI questions and risk of all-cause or COPD hospitalizations. RESULTS Participants (N = 388) had a mean age of 69.6 ± 7.5 years, predominately male (96 %), and 144 (37.1 %) reported having fallen in the last year. More than half reported feeling unsteady with walking (52.6 %) or needing to use their arms to stand up from a chair (61.1 %). A third were concerned about falling (33.3 %). Three questions were associated with all-cause (not COPD) hospitalization in both unadjusted and adjusted cross-sectional analysis (N = 213): "fallen in the past year" (IRR 1.77, 95 % CI 1.10 to 2.86); "unsteady when walking" (IRR 1.88, 95 % CI 1.14 to 3.10); "advised to use a cane or walker" (IRR 1.89, 95 % CI 1.16 to 3.08). CONCLUSIONS The prevalence of self-reported falling risk was high in this sample of veterans with COPD. The association between falling risk and all-cause hospitalization suggests that non-COPD hospitalizations can negatively impact intrinsic risk factors for falling. Further research is needed to clarify the effects of all-cause hospitalization on falling risk in persons with COPD.
Collapse
Affiliation(s)
- Katherine C Ritchey
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA; Division of Geriatrics and Gerontology, Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Box 359755, Seattle, WA, 98104-2499, USA.
| | - Abebaw M Yohannes
- Department of Physical Therapy, School of Health Professions Building, University of Alabama at Birmingham, 1716 9th Avenue South, Birmingham, AL, 35233, USA.
| | - Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA.
| | - Sunny Chen
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
| | - Tracy Simpson
- Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA; Department of Psychiatry, University of Washington School of Medicine, 959 NE Pacific Street Box 356560, Seattle, WA, 98195-6560, USA.
| | - Catherine Battaglia
- Eastern Colorado VA Health Care System, 1700 N. Wheeling, Aurora, CO, 80045, USA; University of Colorado Anschutz Medical Campus, 13001 E. 17th Pl, Aurora, CO, 80045, USA.
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795. Willow Road, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA, 94305, USA
| | - Erik R Swenson
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| | - Jeff Edelman
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| | - Vincent S Fan
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| |
Collapse
|
4
|
Iyer SS, Ngo V, Humber MB, Chen P, Pallaki M, Dolinar T, Brodrick MFB, Gould CE, Trivedi RB. Caregiver Experience of Tele-dementia Care for Older Veterans. J Gen Intern Med 2023; 38:2960-2969. [PMID: 37131102 PMCID: PMC10153773 DOI: 10.1007/s11606-023-08188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/22/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND For the 5 million persons living with dementia (PLWD) in the USA, telemedicine may improve access to specialty care from their homes. OBJECTIVE To elicit informal caregiver perceptions of tele-dementia care provided during COVID-19. DESIGN Qualitative, observational study using grounded theory. PARTICIPANTS Informal caregivers aged 18 + who cared for an older adult who received tele-dementia services at two major VA healthcare systems participated in 30-60-min semi-structured telephone interviews. INTERVENTIONS Interviews were designed using Fortney's Access to Care model. MAIN MEASURES Thirty caregivers (mean age = 67, SD = 12, 87% women) were interviewed. KEY RESULTS Five major themes were (1) Tele-dementia care avoids routine disruption and pre-visit stress; (2) Transportation barriers to in-person visits include not only travel logistics but navigating the sequelae of dementia and comorbid medical conditions. These include cognitive, behavioral, physical, and emotional challenges such as balance issues, incontinence, and agitation in traffic; (3) Tele-dementia care saves time and money and improves access to specialists; (4) Tele-dementia facilitated communication between caregiver and provider without hindering communication between PLWD and provider; and (5) Caregivers described ideal future dementia care as a combination of virtual and in-person modalities with in-home help, financial and medical support, and dementia-sensitive caregiver access. Caregivers interviewed saved 2.6 h ± 1.5 h (range: 0.5 to 6 h) of travel time. Multiple caregivers described disruption of routines as difficult in PLWD and appreciated the limited preparation and immediate return to routine post telemedicine visit as positives. CONCLUSIONS Caregivers found tele-dementia care convenient, comfortable, stress reducing, timesaving, and highly satisfactory. Caregivers would prefer a combination of in-person and telemedicine visits, with an opportunity to communicate with providers privately. This intervention prioritizes care for older Veterans with dementia who have high care needs and are at higher risk for hospitalization than their same age counterparts without dementia.
Collapse
Affiliation(s)
- Sowmya S Iyer
- Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
- Division of Primary Care and Population Health, Geriatrics Section, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Victoria Ngo
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, Health Services Research & Development, U.S. Department of Veteran Affairs, Palo Alto, CA, USA
- Department of Health Policy, Freeman Spogli Institute & Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marika Blair Humber
- Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Peijun Chen
- Geriatric Research, Education, and Clinical Center, VA Northeast Ohio Health Care System, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Muralidhar Pallaki
- Geriatric Research, Education, and Clinical Center, VA Northeast Ohio Health Care System, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Dolinar
- Geriatric Research, Education, and Clinical Center, VA Northeast Ohio Health Care System, Cleveland, OH, USA
| | | | - Christine E Gould
- Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, San Francisco, CA, USA
| |
Collapse
|
5
|
Humber MB, Yefimova M, Lessios AS, Trivedi RB, Sheffrin M, Martin M. "It Isn't the Same": Experiences of Informal Caregivers of Older Adults Enrolled in a Home-Based Senior Care Program During COVID-19. J Gerontol Nurs 2023; 49:19-26. [PMID: 36852991 DOI: 10.3928/00989134-20230209-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic placed new strains on informal caregivers, who are already vulnerable to negative psychosocial effects due to demands of the caregiving role. The current study aimed to explore the early impact of COVID-19 on caregivers living with and apart from care recipients. Semi-structured qualitative interviews with seven cohabitating and 10 distanced caregivers of patients in a home-based primary care program were conducted from April to November 2020. A framework matrix was used to identify patterns in caregiver experiences. Cohabitating and distanced caregivers reported shared concerns about COVID-19 and unique concerns dependent on cohabitation status. Cohabitating caregivers reported financial worries, care recipients with dementia being unable to understand restrictions, and concerns about community business changes. Distanced caregivers reported communication challenges with cognitively impaired care recipients and challenges with visitation policies. During pandemics, caregivers' clinical and policy support needs may differ depending on their place of residence relative to care recipients. [Journal of Gerontological Nursing, 49(3), 19-26.].
Collapse
|
6
|
Wooldridge JS, Tynan M, Rossi FS, Gasperi M, McLean CL, Bosch J, Trivedi RB, Herbert MS, Afari N. Patterns of adverse childhood experiences and cardiovascular risk factors in U.S. adults. Stress Health 2023; 39:48-58. [PMID: 35618265 PMCID: PMC9699903 DOI: 10.1002/smi.3167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 02/06/2023]
Abstract
Adverse Childhood Experiences (ACEs) are associated with poor health yet, we know little about how distinct patterns of ACE types are associated with cardiovascular (cardiovascular (CVD)) risk factors. The current study 1) examined associations of latent ACE classes with modifiable CVD risk factors including high cholesterol, smoking, diabetes, hypertension, high triglycerides, physical inactivity, overweight/obesity, and lifetime depression; and 2) examined the impact of socioeconomic status-related (SES) factors on these relationships. Using a cross-sectional analysis of the National Epidemiologic Survey of Alcohol and Related Conditions-III (n = 36,309) data, four latent classes of ACEs were previously identified: 1) low adversity, 2) primarily household dysfunction, 3) primarily maltreatment, and 4) multiple adversity types. We examined the association of these classes with CVD risk factors in adulthood and subsequently, the same model accounting for SES-related factors. Tobacco smoking, overweight/obesity, and lifetime depression were each associated with higher odds of being in classes 2, 3, and 4 than class 1, respectively. These relationships held after adjusting for SES-related factors. Class 4 was associated with the most CVD risk factors, including high triglycerides and high cholesterol after controlling for SES-related factors. The consistent associations between tobacco smoking, overweight/obesity, and lifetime depression with each adverse ACE profile, even after controlling for SES, suggest behavioural CVD prevention programs should target these CVD risk factors simultaneously.
Collapse
Affiliation(s)
- Jennalee S. Wooldridge
- VA San Diego Healthcare System
- University of California San Diego, Department of Psychiatry
- VA Center of Excellence for Stress and Mental Health
| | - Mara Tynan
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology
| | - Fernanda S. Rossi
- VA Palo Alto Health Care System, Center for Innovation to Implementation
- Stanford University Department of Psychiatry and Behavioral Sciences
| | - Marianna Gasperi
- VA San Diego Healthcare System
- University of California San Diego, Department of Psychiatry
- VA Center of Excellence for Stress and Mental Health
| | - Caitlin L. McLean
- VA San Diego Healthcare System
- University of California San Diego, Department of Psychiatry
| | - Jeane Bosch
- National Center for PTSD, Dissemination & Training Division
| | - Ranak B. Trivedi
- VA Palo Alto Health Care System, Center for Innovation to Implementation
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Division of Public Mental Health and Population Sciences
| | - Matthew S. Herbert
- VA San Diego Healthcare System
- University of California San Diego, Department of Psychiatry
- VA Center of Excellence for Stress and Mental Health
| | - Niloofar Afari
- VA San Diego Healthcare System
- University of California San Diego, Department of Psychiatry
- VA Center of Excellence for Stress and Mental Health
| |
Collapse
|
7
|
Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
Collapse
Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
8
|
Wooldridge JS, Rossi FS, Anderson C, Yarish NM, Pukhraj A, Trivedi RB. Systematic Review of Dyadic Interventions for Ambulatory Care Sensitive Conditions: Current Evidence and Key Gaps. Clin Gerontol 2022:1-29. [PMID: 35713392 DOI: 10.1080/07317115.2022.2086089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Identify non-pharmacological interventions to support patient/caregiver dyads with ACSCs; review the effects of dyadic interventions on health services outcomes; and review the effectiveness of dyadic interventions on patient and caregiver biopsychosocial outcomes. METHODS A systematic review of randomized controlled trials (RCTs). RESULTS Twenty-six manuscripts representing 20 unique RCTs (Mean N = 154 patients, 140 caregivers) were eligible. Eleven RCTs examined caregiving in patients with HF, seven with T2DM, one with COPD, and one with mixed ACSCs. Dyadic interventions for ACSCs were diverse in terms of length and content, with most including an educational component. Only 4/26 included studies had a low risk of bias. Interventions were most successful at improving quality of life, clinical health outcomes, health behaviors, and health services outcomes, with fewer improvements in patient mental health outcomes, psychosocial outcomes, relationship outcomes, and caregiver outcomes in general. The largest effect sizes were reported from trials focused on T2DM. CONCLUSIONS High-quality research with consistent measuring instruments is needed to understand which interventions are associated with improved patient and caregiver outcomes. CLINICAL IMPLICATIONS There may be clinically relevant benefits to including caregivers in interventions for patients with ACSCs, and clinicians should consider this when devising treatment plans.
Collapse
Affiliation(s)
- Jennalee S Wooldridge
- VA San Diego Health Care System
- Department of Psychiatry, University of California, San Diego, United States
| | - Fernanda S Rossi
- VA Palo Alto Healthcare System
- Department of Psychiatry Stanford University Stanford, California, United States
| | | | - Natalie M Yarish
- VA San Diego Health Care System
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, United States
| | - Ambri Pukhraj
- VA Palo Alto Healthcare System
- Department of Psychiatry Stanford University Stanford, California, United States
| | - Ranak B Trivedi
- VA Palo Alto Healthcare System
- Department of Psychiatry Stanford University Stanford, California, United States
| |
Collapse
|
9
|
Slightam C, Risbud R, Guetterman TC, Nevedal AL, Nelson KM, Piette JD, Trivedi RB. Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration. Chronic Illn 2022; 18:330-342. [PMID: 33115281 DOI: 10.1177/1742395320966366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians. METHODS Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies. RESULTS Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF. DISCUSSION Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.
Collapse
Affiliation(s)
- Cindie Slightam
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Rashmi Risbud
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | | | - Andrea L Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karin M Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - John D Piette
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
10
|
Leykum LK, Penney LS, Dang S, Trivedi RB, Noël PH, Pugh JA, Shepherd-Banigan ME, Pugh MJ, Rupper R, Finley E, Parish-Johnson J, Delgado R, Peacock K, Kalvesmaki A, Van Houtven CH. Recommendations to Improve Health Outcomes Through Recognizing and Supporting Caregivers. J Gen Intern Med 2022; 37:1265-1269. [PMID: 34981348 PMCID: PMC8722428 DOI: 10.1007/s11606-021-07247-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Luci K Leykum
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA.
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.
- University of Texas at Austin Dell Medical School, Austin, USA.
- VA Palo Alto Health Care System, Palo Alto, USA.
| | - Lauren S Penney
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Stuti Dang
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- Miami VA Healthcare System, Miami, USA
- University of Miami School of Medicine, Miami, USA
| | - Ranak B Trivedi
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- VA Greater Los Angeles Health Care System, Los Angeles, USA
- VA Palo Alto Health Care System, Palo Alto, USA
- Stanford University School of Medicine, Stanford, USA
| | - Polly H Noël
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Jacqueline A Pugh
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Megan E Shepherd-Banigan
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- Duke University School of Medicine, Durham, USA
- Center of Innovation To Accelerate Discovery and Practice Transformation, Durham VAMC, Durham, USA
| | - Mary Jo Pugh
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- VA Salt Lake City Health Care System/GRECC, Salt Lake City, USA
- University of Utah Health Care School of Medicine, Salt Lake City, USA
| | - Rand Rupper
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- VA Salt Lake City Health Care System/GRECC, Salt Lake City, USA
- University of Utah Health Care School of Medicine, Salt Lake City, USA
| | - Erin Finley
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Julie Parish-Johnson
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Roxana Delgado
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Kimberly Peacock
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Andrea Kalvesmaki
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- VA Salt Lake City Health Care System/GRECC, Salt Lake City, USA
- University of Utah Health Care School of Medicine, Salt Lake City, USA
| | - Courtney H Van Houtven
- Department of Veterans Affairs Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, San Antonio, USA
- Duke University School of Medicine, Durham, USA
- Center of Innovation To Accelerate Discovery and Practice Transformation, Durham VAMC, Durham, USA
| |
Collapse
|
11
|
Zulman DM, Greene L, Slightam C, Singer SJ, Maciejewski ML, Goldstein MK, Vanneman ME, Yoon J, Trivedi RB, Wagner T, Asch SM, Boothroyd D. Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health Serv Res 2022; 57:764-774. [PMID: 35178702 PMCID: PMC9264453 DOI: 10.1111/1475-6773.13956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization. DATA SOURCES Veterans Affairs (VA) and Medicare data. STUDY DESIGN We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization. DATA EXTRACTION METHODS We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year. PRINCIPAL FINDINGS Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively). CONCLUSIONS Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.
Collapse
Affiliation(s)
- Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Cindie Slightam
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, United States.,Department of Population Health Sciences, Duke University, Durham, North Carolina, United States
| | - Mary K Goldstein
- Office of Geriatrics and Extended Care, Veterans Health Administration.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, United States
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, United States.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of General Internal Medicine, UCSF School of Medicine, San Francisco, California, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, United States
| | - Todd Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Derek Boothroyd
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California, United States
| |
Collapse
|
12
|
Lee AA, Sripada RK, Hale AC, Ganoczy D, Trivedi RB, Arnow B, Pfeiffer PN. Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models. J Consult Clin Psychol 2021; 89:379-392. [PMID: 34124925 DOI: 10.1037/ccp0000645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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
Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Collapse
Affiliation(s)
- Aaron A Lee
- Department of Psychology, University of Mississippi
| | - Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | - Ranak B Trivedi
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Bruce Arnow
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Paul N Pfeiffer
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| |
Collapse
|
13
|
Yank V, Gale RC, Nevedal A, Okwara L, Koenig CJ, Trivedi RB, Dupke NJ, Kabat M, Asch SM. Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. J Med Internet Res 2021; 23:e16495. [PMID: 33410759 PMCID: PMC7819783 DOI: 10.2196/16495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/13/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated. OBJECTIVE This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed. METHODS We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time. RESULTS A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers. CONCLUSIONS This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.
Collapse
Affiliation(s)
- Veronica Yank
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Leonore Okwara
- Department of Behavioral and Community Health, University of Maryland, Baltimore, MD, United States
| | - Christopher J Koenig
- Department of Communication Studies, San Francisco State University, San Francisco, CA, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
| | - Nancy J Dupke
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Margaret Kabat
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, United States
| |
Collapse
|
14
|
Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Netw Open 2020; 3:e2020955. [PMID: 33079197 PMCID: PMC7576407 DOI: 10.1001/jamanetworkopen.2020.20955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
Collapse
Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Ranak B. Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Menlo Park, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Jean Yoon
- VA Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California, San Francisco
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| |
Collapse
|
15
|
Wyman MF, Voils CI, Trivedi RB, Gleason CE. DEVELOPING DEMENTIA-SPECIFIC PROVIDER TRAINING IN MENTAL HEALTH: WHAT IS THE TARGET? Innov Aging 2019. [PMCID: PMC6840969 DOI: 10.1093/geroni/igz038.1390] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Most persons with dementia (PwD) live in the community and receive mental health care in the outpatient setting, making these providers an important target for education to improve dementia care. To inform the development of training curricula, we surveyed 65 mental health providers in a Veterans Affairs outpatient clinic on perceived barriers and training needs related to service delivery to PwD and caregivers. We used an adapted version of the Sense of Competence in Dementia Care Staff scale to assess domain-specific competencies. Respondents rated this work as highly important and wanted dementia-related training. They reported low competency in person-centered care approaches and challenging clinical situations, e.g., managing risk of harm. System-level barriers affecting services for PwD were noted. Findings suggest that outpatient mental health professionals are an underutilized resource in dementia care. This work can inform the development of provider training and identification of system-level barriers in this setting.
Collapse
Affiliation(s)
- Mary F Wyman
- WS MIDDLETON MEMORIAL VETERANS HOSPITAL, Madison, Wisconsin, United States
| | - Corrine I Voils
- WS Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
| | - Ranak B Trivedi
- Stanford University/Palo Alto VA, Menlo Park, California, United States
| | - Carey E Gleason
- W.S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States
| |
Collapse
|
16
|
Browne KC, Hoerster KD, Piegari R, Fortney JC, Nelson KN, Post EP, Fihn SD, Mori AM, Trivedi RB. Clinical Care Quality Among Veterans Health Administration Patients With Mental Illness Following Medical Home Implementation. Psychiatr Serv 2019; 70:816-823. [PMID: 31310189 DOI: 10.1176/appi.ps.201800474] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness. METHODS VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators. RESULTS The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50-64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease. CONCLUSIONS Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.
Collapse
Affiliation(s)
- Kendall C Browne
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Katherine D Hoerster
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Rebecca Piegari
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - John C Fortney
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Karin N Nelson
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Edward P Post
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Stephan D Fihn
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Alaina M Mori
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| | - Ranak B Trivedi
- Centers of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Browne); Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care System (Hoerster, Fortney, Nelson); Department of Psychiatry and Behavioral Sciences (Browne, Hoerster, Fortney) and School of Medicine (Nelson, Fihn), University of Washington, Seattle; Office of Clinical Systems Development and Evaluation, Veterans Health Administration (VHA), Washington, D.C. (Piegari); VA Ann Arbor Health Care System, Ann Arbor, Michigan (Post); VHA Office of Primary Care, Primary Care Analytics Team (PCAT), Seattle (Mori); Center for Innovation to Implementation, Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Trivedi)
| |
Collapse
|
17
|
Bouldin ED, Aikens JE, Piette JD, Trivedi RB. Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms. Aging Ment Health 2019; 23:1122-1129. [PMID: 30569750 PMCID: PMC6586543 DOI: 10.1080/13607863.2018.1481923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 12/30/2022]
Abstract
Objectives: Informal caregivers who recognize patients' depressive symptoms can better support self-care and encourage patients to seek treatment. We examined patient-caregiver agreement among patients with heart failure (HF). Our objectives were to (1) identify distinct groups of HF patients and their out-of-home informal caregivers (CarePartners) based on their relationship and communication characteristics, and (2) compare how these groups agree on the patients' depressive symptoms. Method: We used baseline data from a comparative effectiveness trial of a self-care support program for veterans with HF treated in outpatient clinics from 2009-2012. We used a cross-sectional design and latent class analysis (LCA) approach to identify distinct groups of patient-CarePartner dyads (n = 201) based on relationship and communication characteristics then evaluated agreement on patients' depressive symptoms within these groups. Results: The LCA analysis identified four groups: Collaborative (n = 102 dyads, 51%), Avoidant (n = 33 dyads, 16%), Distant (n = 35 dyads, 17%), and Antagonistic (n = 31 dyads, 15%). Dyadic agreement on the patients' depressive symptoms was highest in the Distant (Kappa (κ) = 0.44, r = 0.39) and Collaborative groups (κ = 0.19, r = 0.32), and relatively poor in the Avoidant (κ = -0.20, r = 0.17) and Antagonistic (κ =-0.01, r = 0.004) groups. Patients in Avoidant (61%) and Antagonistic groups (74%) more frequently had depression based on self-report than patients in Collaborative (46%) and Distant (34%) groups. Conclusion: Caregiver relationships in HF tend to be either Collaborative, Avoidant, Distant, or Antagonistic. Patients' depressive symptoms may negatively affect how they communicate with their caregivers. At the same time, improved patient-caregiver communication could enhance dyadic consensus about the patient's depressive symptoms.
Collapse
Affiliation(s)
- Erin D. Bouldin
- Department of Health and Exercise Science, Appalachian State University, Boone, NC,Corresponding author: Erin Bouldin, MPH, PhD, Department of Health and Exercise Science, Beaver College of Health Sciences, Appalachian State University, 111 Rivers Street, ASU Box 32071, Boone, NC 28608-2071, Phone: 828-262-6892, Fax: 828-262-3138,
| | - James E. Aikens
- Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - John D. Piette
- Center for Clinical Management Research, Ann Arbor Department of Veterans Affairs, Ann Arbor, MI,Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Ranak B. Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| |
Collapse
|
18
|
Leung LB, Rubenstein LV, Yoon J, Post EP, Jaske E, Wells KB, Trivedi RB. Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access. Health Aff (Millwood) 2019; 38:1281-1288. [DOI: 10.1377/hlthaff.2019.00270] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lucinda B. Leung
- Lucinda B. Leung is a core investigator in the Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the University of California Los Angeles (UCLA) David Geffen School of Medicine
| | - Lisa V. Rubenstein
- Lisa V. Rubenstein is a professor emerita of medicine in the Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, and the Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Jean Yoon
- Jean Yoon is a health economist at the Health Economics Resource Center, VA Palo Alto Healthcare System, in Menlo Park, California, and the University of California San Francisco
| | - Edward P. Post
- Edward P. Post is the national Primary Care–Mental Health Integration medical director in the Veterans Health Administration based out of the VA Ann Arbor Healthcare System and a professor of medicine in the Division of General Medicine, University of Michigan, in Ann Arbor
| | - Erin Jaske
- Erin Jaske is a data analyst in the Primary Care Analytics Team, VA Puget Sound Healthcare System, in Seattle, Washington
| | - Kenneth B. Wells
- Kenneth B. Wells is the director of the UCLA Center for Health Services and Society; a professor of psychiatry in the Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior; and an associate investigator at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System
| | - Ranak B. Trivedi
- Ranak B. Trivedi is a core investigator at the Center for Innovation to Implementation, VA Palo Alto Healthcare System, and an assistant professor of psychiatry in the Department of Public Mental Health and Population Sciences, Stanford University, in Menlo Park, California
| |
Collapse
|
19
|
Wooldridge JS, Gray C, Pukhraj A, Geller J, Trivedi RB. Understanding communal coping among patients and informal caregivers with heart failure: A mixed methods secondary analysis of patient-caregiver dyads. Heart Lung 2019; 48:486-495. [PMID: 31171368 DOI: 10.1016/j.hrtlng.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dyads that view illnesses as shared stressors ("shared appraisal"), and collaboratively respond to it, have better outcomes. This process, known as communal coping, has received little attention in heart failure (HF). OBJECTIVES To examine communal coping among patient-caregiver dyads managing HF. METHODS We conducted semi-structured interviews with 34 dyads. Shared appraisal was measured using we-ratio, as calculated with Linguistic Inquiry Word Count. We-ratio was divided into "high" and "low" for patients and caregivers, and concordance was examined. Thematic analyses were used to explore collaboration. RESULTS Caregivers had higher we-ratios than patients (p=.005); 29.6% and 33.3% dyads were concordant on high and low "we-ratio," respectively. In thematic analyses, we found that 1) dyads collaborated around diet, appointments, and medications, but less around physical activity; 2) dyads collaborated across all illnesses, not just HF; and 3) dyads concordant on high we-ratio reported stronger collaborations. CONCLUSIONS Communal coping varied by shared appraisal and collaboration. Understanding this variability may help develop tailored self-management interventions.
Collapse
Affiliation(s)
- Jennalee S Wooldridge
- Veteran Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Rd, Menlo Park, CA 94025, United States.
| | - Caroline Gray
- Veteran Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Rd, Menlo Park, CA 94025, United States
| | - Ambri Pukhraj
- Veteran Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Rd, Menlo Park, CA 94025, United States
| | - Jessica Geller
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, Aurora, CO, United States
| | - Ranak B Trivedi
- Veteran Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Rd, Menlo Park, CA 94025, United States; Stanford University, Department of Psychiatry and Behavioral Sciences, Stanford, CA, United States
| |
Collapse
|
20
|
Bouldin ED, Trivedi RB, Reiber GE, Rosland AM, Silverman JB, Krieger J, Nelson KM. Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes. Chronic Illn 2017; 13:239-250. [PMID: 29119864 PMCID: PMC6993051 DOI: 10.1177/1742395317690032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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] [Indexed: 12/23/2022]
Abstract
Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.
Collapse
Affiliation(s)
- Erin D Bouldin
- 1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.,2 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Ranak B Trivedi
- 3 Center for Innovation to Implementation, Health Services Research & Development, VA Palo Alto Health Care System, Palo Alto, CA, USA.,4 Department of Psychiatry and Behavioral Sciences, Stanford University, Menlo Park, CA, USA
| | - Gayle E Reiber
- 1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.,2 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Ann-Marie Rosland
- 5 Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,6 Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Julie B Silverman
- 1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.,2 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA.,7 Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - James Krieger
- 2 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA.,8 Action for Healthy Food, Seattle, WA, USA
| | - Karin M Nelson
- 1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.,2 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA.,7 Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
21
|
Abstract
BACKGROUND Heart failure is a progressive condition characterized by frequent hospitalizations for exacerbated symptoms. Informal family caregivers may help patients improve self-care, which may in turn reduce hospitalizations. However, little is known about how mutuality, defined as the quality of the patient-caregiver relationship, and caregiver burden affect self-care. OBJECTIVE This study examines the associations among mutuality, patient self-care confidence (beliefs in abilities to engage in self-care behaviors) and maintenance (behaviors such as medication adherence, activity, and low salt intake), caregiver confidence in and maintenance of patient care, and caregiver perceived burden. METHODS This study used cross-sectional baseline data from a multi-site randomized clinical trial of a symptom and psychosocial care intervention. Patient-caregiver dyads ( N=99) completed self-report surveys of mutuality and self-care confidence and maintenance, and caregivers completed a measure of caregiver burden. Path analysis, with actor (effects within a person) partner (effects across the dyad) interdependence model paths and regression models were used to examine the associations among mutuality, caregiver burden, and self-care. RESULTS The majority of patients ( M age=66, 21% female) and caregivers ( M age=57, 81% female) were spouses (60%). The path model demonstrated significant actor effects; patients and caregivers with better mutuality were more confident in patient self-care ( p<.05). Partner effects were not significant. Regression models indicated that caregivers with greater mutuality reported less perceived burden ( p<.01). CONCLUSIONS Mutuality in patient-caregiver dyads is associated with patient self-care and caregiver burden and may be an important intervention target to improve self-care and reduce hospitalizations.
Collapse
Affiliation(s)
- Stephanie A Hooker
- 1 Department of Psychology, University of Colorado Denver, USA.,2 Department of Family Medicine and Community Health, University of Minnesota, USA
| | - Sarah J Schmiege
- 3 Department of Biostatistics and Informatics, Colorado School of Public Health at the Anschutz Medical Campus, University of Colorado Denver, USA
| | - Ranak B Trivedi
- 4 Center for Innovation to Implementation, VA Palo Alto Health Care System, Department of Psychiatry and Behavioral Sciences, Stanford University, USA
| | - Nicole R Amoyal
- 5 Division of General Internal Medicine, University of Colorado School of Medicine, USA
| | - David B Bekelman
- 5 Division of General Internal Medicine, University of Colorado School of Medicine, USA.,6 Department of Veterans Affairs, Eastern Colorado Health Care System, USA
| |
Collapse
|
22
|
Trivedi RB, Post EP, Sun H, Pomerantz A, Saxon AJ, Piette JD, Maynard C, Arnow B, Curtis I, Fihn SD, Nelson K. Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans. Am J Public Health 2015; 105:2564-9. [PMID: 26474009 DOI: 10.2105/ajph.2015.302836] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI). METHODS A total of 4 461 208 veterans were seen in the Veterans Health Administration's patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement. RESULTS A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes. CONCLUSIONS Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.
Collapse
Affiliation(s)
- Ranak B Trivedi
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Edward P Post
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Haili Sun
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Andrew Pomerantz
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Andrew J Saxon
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - John D Piette
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Charles Maynard
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Bruce Arnow
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Idamay Curtis
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Stephan D Fihn
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| | - Karin Nelson
- Ranak B. Trivedi is with the Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA. Haili Sun, Andrew J. Saxon, Charles Maynard, Idamay Curtis, and Karin Nelson are with the VA Puget Sound Health Care System, Seattle, WA. Edward P. Post and John D. Piette are with the Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI. Andrew Pomerantz is with the VA Mental Health Services, Washington, DC. Bruce Arnow is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA. Stephan D. Fihn is with the Office of Analytics and Business Informatics, Seattle
| |
Collapse
|
23
|
Trivedi RB, Humphreys K. Participant exclusion criteria in treatment research on neurological disorders: Are unrepresentative study samples problematic? Contemp Clin Trials 2015; 44:20-25. [DOI: 10.1016/j.cct.2015.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 07/06/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
|
24
|
Piette JD, Striplin D, Marinec N, Chen J, Trivedi RB, Aron DC, Fisher L, Aikens JE. A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial. J Med Internet Res 2015; 17:e142. [PMID: 26063161 PMCID: PMC4526929 DOI: 10.2196/jmir.4550] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [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: 04/17/2015] [Revised: 05/22/2015] [Accepted: 05/24/2015] [Indexed: 12/19/2022] Open
Abstract
Background Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers’ needs for information about the patient’s status or how the caregiver can help. Objective We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach. Methods We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a “CarePartner” outside their household. Patients randomized to “standard mHealth” (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients’ responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to “mHealth+CP” (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments. Results Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls. Conclusions Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’ medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys. Trial Registration ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).
Collapse
Affiliation(s)
- John D Piette
- Center for Clinical Management Research and Center for Managing Chronic Disease, VA Ann Arbor Healthcare System and University of Michigan School of Public Health, Ann Arbor, MI, United States.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Eugenio EC, Beaver KA, Fan VS. Response to Thomas E. Finucane, MD. J Am Geriatr Soc 2015; 63:203-4. [PMID: 25597586 DOI: 10.1111/jgs.13209] [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: 11/27/2022]
Affiliation(s)
- Denise C Cooper
- Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | | | | | | | | | | | | |
Collapse
|
26
|
Trivedi RB, Piette JD. Shedding Light on the Association Between Social Support and Adherence in Hypertension: a Comment on Magrin et al. Ann Behav Med 2015; 49:297-8. [DOI: 10.1007/s12160-014-9682-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
27
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Beaver KA, Eugenio EC, Fan VS. Post-traumatic Stress Disorder, Race/Ethnicity, and Coronary Artery Disease Among Older Patients with Depression. J Racial Ethn Health Disparities 2014. [DOI: 10.1007/s40615-014-0020-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
28
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Eugenio EC, Beaver KA, Fan VS. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014; 62:1238-45. [PMID: 24890000 DOI: 10.1111/jgs.12849] [Citation(s) in RCA: 13] [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: 01/22/2023]
Abstract
OBJECTIVES To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression. DESIGN Retrospective cohort study. SETTING Department of Veterans Affairs outpatient clinics nationwide. PARTICIPANTS Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups. MEASUREMENTS After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models. RESULTS Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults. CONCLUSION Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.
Collapse
Affiliation(s)
- Denise C Cooper
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | | | | | | | | | | | | |
Collapse
|
29
|
Quiñones AR, Thielke SM, Beaver KA, Trivedi RB, Williams EC, Fan VS. Racial and ethnic differences in receipt of antidepressants and psychotherapy by veterans with chronic depression. Psychiatr Serv 2014; 65:193-200. [PMID: 24178411 PMCID: PMC7108428 DOI: 10.1176/appi.ps.201300057] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans. METHODS Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments). RESULTS Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant. CONCLUSIONS A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.
Collapse
|
30
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Zonderman AB, Evans MK, Waldstein SR. Sex Differences in Associations of Depressive Symptoms with Cardiovascular Risk Factors and Metabolic Syndrome among African Americans. Cardiovasc Psychiatry Neurol 2013; 2013:979185. [PMID: 24151548 PMCID: PMC3787626 DOI: 10.1155/2013/979185] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 01/24/2023] Open
Abstract
Young to middle-aged women usually have notably lower rates of cardiovascular disease (CVD) than their male counterparts, but African American women lack this advantage. Their elevated CVD may be influenced by sex differences in associations between depressed mood and CVD risk factors. This cross-sectional study examined whether relations between scores on the Center for Epidemiologic Studies-Depression (CES-D) scale and a spectrum of CVD risk factors varied by sex among African Americans (n = 1076; ages 30-64) from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Sex-stratified multiple regressions and logistic regressions were conducted. Among women, CES-D scores correlated positively with systolic blood pressure and waist-to-hip ratio (P's < .05), but inversely with high-density lipoprotein cholesterol (HDL-C) (P < .01). Women had twice the odds for metabolic syndrome if CES-D scores ≥16 and had a ≥14% increase in odds of hypertension, abdominal obesity, and low HDL-C with each 5-unit increase in CES-D scores. Among men, CES-D scores correlated positively with high-sensitivity C-reactive protein (P < .05), and odds of hypertension increased by 21% with each 5-unit increase in CES-D scores. Depressive symptoms may promote premature CVD risk in African Americans, at least in part, via CVD risk factors and prevalent metabolic syndrome, particularly in African American women.
Collapse
Affiliation(s)
- Denise C. Cooper
- Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA
- Department of Health Services, University of Washington, Seattle, WA 98195, USA
| | - Ranak B. Trivedi
- Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA
- Department of Health Services, University of Washington, Seattle, WA 98195, USA
| | - Karin M. Nelson
- Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Gayle E. Reiber
- Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA
- Health Services and Epidemiology, University of Washington, Seattle, WA 98195, USA
| | - Alan B. Zonderman
- National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Michele K. Evans
- National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Shari R. Waldstein
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD 21250, USA
- Geriatric Research Education and Clinical Center, Baltimore VA Medical Center, Baltimore, MD 21201, USA
| |
Collapse
|
31
|
Trivedi RB, Szarka JG, Beaver K, Brousseau K, Nevins E, Yancy WS, Slade A, Voils CI. Recruitment and retention rates in behavioral trials involving patients and a support person: a systematic review. Contemp Clin Trials 2013; 36:307-18. [PMID: 23916918 DOI: 10.1016/j.cct.2013.07.009] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recruitment and retention challenges impede the study of behavioral interventions among patient-support person dyads. PURPOSE The aim of the study was to characterize recruitment and retention rates of behavioral interventions involving dyads. METHODS Using PRISMA guidelines and with the guidance of a medical librarian, we searched Medline, EMBASE, Cochrane Controlled Trials, PsycInfo, and CINAHL from inception until July 2011. Eligible articles involved RCTs of behavioral interventions targeting adult patients with a non-psychiatric illness and a support person. Sample and study characteristics, recruitment and retention strategies, and recruitment and retention rates were abstracted in duplicate. Quality of reporting was determined on a 5-point scale. Due to the heterogeneity in data reporting and missing data, a narrative synthesis was undertaken. RESULTS 53 unique studies involving 8081 dyads were included. 9 studies were ascertained to have a "high quality" of reporting. A majority of the studies did not report target sample size, time to complete recruitment, and sample sizes at each follow-up time point. Strategies employed to recruit support persons were rarely reported. 16 studies did not report the number of dyads screened. The mean recruitment rate was 51.2% (range: 4.3%-95.4%), and mean retention rate was 77.5% (range: 36%-100%). CONCLUSIONS Details regarding recruitment and retention methodology were sparse in these interventions. Where available, data suggests that resources need to be devoted towards recruitment of sample but that retention rates are generally adequate.
Collapse
Affiliation(s)
- Ranak B Trivedi
- Department of Health Services, University of Washington, Seattle, WA 98195, USA.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Zeliadt SB, Hannon PA, Trivedi RB, Bonner LM, Vu TT, Simons C, Kimmie CA, Hu EY, Zipperer C, Lin DW. A preliminary exploration of the feasibility of offering men information about potential prostate cancer treatment options before they know their biopsy results. BMC Med Inform Decis Mak 2013; 13:19. [PMID: 23388205 PMCID: PMC3599913 DOI: 10.1186/1472-6947-13-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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: 09/26/2012] [Accepted: 01/25/2013] [Indexed: 11/12/2022] Open
Abstract
Background A small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making. Methods Men with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic’s usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18). Results A total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results. Conclusions In this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.
Collapse
Affiliation(s)
- Steven B Zeliadt
- Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, Metropolitan Park West, 1100 Olive Way #1400, Seattle, WA 98101, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
|
34
|
Abstract
OBJECTIVE Because evidence-based psychotherapies of 12 to 20 sessions can be perceived as too lengthy and time intensive for the treatment of depression in primary care, a number of studies have examined abbreviated psychotherapy protocols. The purpose of this study was to conduct a systematic review and meta-analysis to determine the efficacy of brief psychotherapy (i.e., < or =8 sessions) for depression. METHODS We used combined literature searches in PubMed, EMBASE, PsycINFO, and an Internet-accessible database of clinical trials of psychotherapy to conduct two systematic searches: one for existing systematic reviews and another for randomized controlled trials (RCTs). Included studies examined evidence-based psychotherapy(s) of eight or fewer sessions, focused on adults with depression, contained an acceptable control condition, were published in English, and used validated measures of depressive symptoms. RESULTS We retained 2 systematic reviews and 15 RCTs evaluating cognitive behavioral therapy, problem-solving therapy, and mindfulness-based cognitive therapy. The systematic reviews found brief psychotherapies to be more efficacious than control, with effect sizes ranging from -0.33 to -0.25. Our meta-analysis found six to eight sessions of cognitive behavioral therapy to be more efficacious than control (ES -0.42, 95% CI -0.74 to -0.10, 12 = 56%). A sensitivity analysis controlled for statistical heterogeneity but showed smaller treatment effects (ES -0.24, 95% CI -0.42 to -0.06, 12 = 0%). CONCLUSIONS Depression can be efficaciously treated with six to eight sessions of psychotherapy, particularly cognitive behavioral therapy and problem-solving therapy. Access to non-pharmacologic treatments for depression could be improved by training healthcare providers to deliver brief psychotherapies.
Collapse
|
35
|
Trivedi RB, Nieuwsma JA, Williams JW. Examination of the utility of psychotherapy for patients with treatment resistant depression: a systematic review. J Gen Intern Med 2011; 26:643-50. [PMID: 21184287 PMCID: PMC3101965 DOI: 10.1007/s11606-010-1608-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [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: 03/09/2010] [Revised: 08/05/2010] [Accepted: 12/03/2010] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the utility of psychotherapy in managing treatment resistant depression. DATA SOURCES PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies. REVIEW METHODS Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted. RESULTS Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy. CONCLUSIONS Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.
Collapse
Affiliation(s)
- Ranak B Trivedi
- VA Puget Sound Health Care System, University of Washington School of Public Health, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
| | | | | |
Collapse
|
36
|
Trivedi RB, Ayotte BJ, Thorpe CT, Edelman D, Bosworth HB. Is there a nonadherent subtype of hypertensive patient? A latent class analysis approach. Patient Prefer Adherence 2010; 4:255-62. [PMID: 20694185 PMCID: PMC2915558 DOI: 10.2147/ppa.s11335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Indexed: 11/23/2022] Open
Abstract
To determine subtypes of adherence, 636 hypertensive patients (48% White, 34% male) reported adherence to medications, diet, exercise, smoking, and home blood pressure monitoring. A latent class analysis approach was used to identify subgroups that adhere to these five self-management behaviors. Fit statistics suggested two latent classes. The first class (labeled "more adherent") included patients with greater probability of adhering to recommendations compared with the second class (labeled "less adherent") with regard to nonsmoking (97.7% versus 76.3%), medications (75.5% versus 49.5%), diet (70.7% versus 46.9%), exercise (63.4% versus 27.2%), and blood pressure monitoring (32% versus 3.4%). Logistic regression analyses used to characterize the two classes showed that "more adherent" participants were more likely to report full-time employment, adequate income, and better emotional and physical well-being. Results suggest the presence of a less adherent subtype of hypertensive patients. Behavioral interventions designed to improve adherence might best target these at-risk patients for greater treatment efficiency.
Collapse
Affiliation(s)
- Ranak B Trivedi
- Northwest Health Services Research and Development Service Center of Excellence, VA Puget Sound Health Care System, Seattle, Washington
- Correspondence: Ranak B Trivedi, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA, Tel +1 206 764 2208, Fax +1 206 764 2935, Email
| | | | - Carolyn T Thorpe
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin
| | - David Edelman
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Hayden B Bosworth
- Research Professor, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
37
|
Trivedi RB, Ayotte B, Edelman D, Bosworth HB. The association of emotional well-being and marital status with treatment adherence among patients with hypertension. J Behav Med 2008; 31:489-97. [PMID: 18780175 DOI: 10.1007/s10865-008-9173-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Accepted: 08/25/2008] [Indexed: 01/14/2023]
Abstract
We were interested in examining the relationship between psychosocial factors and hypertension-related behaviors. We hypothesized that lower emotional well-being and unmarried status would be related to higher BP, poorer medication adherence, greater difficulty adhering to diet and exercise, and current smoking. In a cross-sectional design, 636 hypertensive patients completed the Mental Component Summary (MCS) Scale of the SF-12 and rated their difficulty with adherence to diet, exercise, and medication-taking. In logistic regression analyses, lower MCS scores were associated with difficulty adhering to diet (OR = 0.97, p < .05) and exercise (OR = 0.97, p < .01), and current smoking status (OR = 0.98, p < .05). Being married was associated with higher probability of medication adherence (OR = 1.66, p < .01) and a lower probability of being a current smoker (OR = 0.34, p < .0001). Neither MCS scores nor being married were related to BP levels in adjusted analyses. Results emphasize the importance of assessing psychosocial factors to optimize hypertension treatment.
Collapse
Affiliation(s)
- Ranak B Trivedi
- Department of Medicine, Duke University Medical Center, 2424 Erwin Rd, Hock Plaza Ste 1105, P.O. Box 2720, Durham, NC 27705, USA.
| | | | | | | |
Collapse
|
38
|
Abhyankar SC, Vast RR, Trivedi RB, Deodhar KP. Acoustic and spinal neurilemmomas: a study of vascular pattern. J Postgrad Med 1984; 30:101-4. [PMID: 6527291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
|