A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions

PURPOSE

Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities.

METHODS

We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration.

RESULTS

Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7).

CONCLUSION

Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Econometric evaluation of implementing a behavioral health integration intervention in primary care settings

Integrated behavioral health (IBH) is an approach to patient care that brings medical and behavioral health providers (BHPs) together to address both behavioral and medical needs within primary care settings. A large, pragmatic, national study aimed to test the effectiveness and measure the implementation costs of an intervention to improve IBH integration within primary care practices (IBH-PC). Assess the time and cost to practices of implementing a comprehensive practice-level intervention designed from the perspective of clinic owners to move behavioral service integration from co-location toward full integration as part of the IBH-PC study. IBH-PC program implementation costs were estimated in a representative sample of 8 practices using standard micro-econometric evaluation of activities outlined in the implementation workbook, including program implementation tasks, remote quality improvement coaching services, educational curricula, and learning community activities, over a 24-month period. The total median cost of implementing the IBH-PC program across all stages was $20,726 (range: $12,381 - $60,427). The median cost of the Planning Stage was $10,258 (range: $4,625 - $14,840), while the median cost of the Implementation Stage was $9,208 (range: $6,017 - 49,993). There were no statistically significant differences in practice or patient characteristics between the 8 selected practices and the larger IBH-PC practice sample (N=34). This study aimed to quantify the relative costs associated with integrating behavioral health into primary care. Although the cost assessment approach did not include all costs (fixed, variable, operational, and opportunity costs), the study aimed to develop a replicable and pragmatic measurement process with flexibility to adapt to emerging developments in each practice environment, providing a reasonable ballpark estimate of costs associated with implementation to help guide future executive decisions.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial

BACKGROUND

Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.

METHODS

Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.

DISCUSSION

As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Ultrasound Elastographic Measurement of Sciatic Nerve Displacement and Shear Strain During Active and Passive Knee Extension

There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.

A neural network approach to motor-sensory relations during postural disturbance

This study explored whether artificial neural networks (ANN) can be used to quantify the motor-sensory relationship during postural disturbance. An ANN model was constructed with seven mechanical stimuli to the visual, vestibular and somatosensory systems (i.e., head angular and linear accelerations, eye-target distance, ankle joint rotation and velocity, as well as normal and shear ground contact forces under the feet) as inputs, and electromyographic activities of tibialis anterior and gastrocnemius muscles as outputs. These inputs and outputs were directly measured during a sudden toes-up-down rotation of the supporting base in two groups of elderly subjects: people with peripheral neuropathy (NP) who have severe loss of mechanoreception in the sole of their feet and people without NP. The products of ANN weights were used in a summary statistic called the Q-value to estimate the contribution of each mechanical stimulus to sensory systems in determining each leg muscle activity. It was found that: (1) the stimuli to the vestibular system and/or ankle proprioceptors have greater contributions to leg muscle activities, especially the TA muscle, in people with NP than people without NP; (2) the stimuli to somatosensory receptors have the greatest contribution, and the stimuli to the vestibular system have the least contribution to both muscle activities in both groups. These findings are supported by previous studies and have demonstrated the potential of the Q-value concept in the ANN model in studying the motor-sensory relationship in human postural control.

Anomalous functional organization of barrel cortex in GAP-43 deficient mice

Growth associated protein 43 (GAP-43), found only in the nervous system, regulates the response of neurons to axon guidance signals. It is also critical for establishing normal somatotopy. Mice lacking GAP-43 (KO) show aberrant pathfinding by thalamocortical afferents, and do not form cortical whisker/barrels. GAP-43 heterozygous (HZ) mice show more subtle deficits--delayed barrel segregation and enlarged barrels at postnatal day 7. Here, we used cortical intrinsic signal imaging to characterize adult somatotopy in wildtype (WT), GAP-43 KO, and HZ mice. We found clear foci of activation in GAP-43 KO cortex in response to single-whisker stimulation. However, the KO spatial activation patterns showed severe anomalies, indicating a loss of functional somatotopy. In some cases, multiple foci were activated by single whiskers, while in other cases, the same cortical zone was activated by several whiskers. The results are consistent with our previous findings of aberrant pathfinding and clustering by thalamocortical afferent axons, and absence of barrel patterning. Our findings indicate that cortex acts to cluster afferents from a given whisker, even in the absence of normal topography. By contrast, single-whisker stimulation revealed normal adult topographic organization in WT and HZ mice. However, we found that functional representations of adult HZ barrels are larger than those found in WT mice. Since histological HZ barrels recover normal dimensions by postnatal day 26, the altered circuit function in GAP-43 HZ cortex could be a secondary consequence of the rescue of barrel dimensions.

Use-dependent plasticity in barrel cortex: intrinsic signal imaging reveals functional expansion of spared whisker representation into adjacent deprived columns

We used optical imaging of intrinsic cortical signals, elicited by whisker stimulation, to define areas of activation in primary sensory cortex of normal hamsters and hamsters subjected to neonatal follicle ablation at postnatal day seven (P7). Follicle ablations were unilateral, and spared either C-row whiskers or the second whisker arc. This study was done to determine if the intrinsic cortical connectivity pattern of the barrel cortex, established during the critical period, affects the process of representational plasticity that follows whisker follicle ablation. Additionally, we tested the ability to monitor such changes in individual cortical whisker representations using intrinsic signal imaging. Stimulation of a single whisker yielded peak activation of a barrel-sized patch in the somatotopically appropriate location in normal cortex. In both row and arc-spared animals, functional representations corresponding to spared follicles were significantly stronger and more oblong than normal. The pattern of activation differed in the row-sparing and arc-sparing groups, in that the expansion was preferentially into deprived, not spared areas. Single whisker stimulation in row-spared cases preferentially activated the corresponding barrel arc, while stimulation of one whisker in arc-spared cases produced elongated activation down the barrel row. Since whisker deflection normally has a net inhibitory effect on neighboring barrels, our data suggest that intracortical inhibition fails to develop normally in deprived cortical columns. Because thalamocortical projections are not affected by follicle ablation after P7, we suggest that the effects we observed are largely cortical, not thalamocortical.

Ground contact characteristics of Tai Chi gait

BACKGROUND

To date, no direct measurement has been done that quantitatively characterizes the foot-ground contact during Tai Chi Chuan movements. The goal of this study was to quantify the biomechanical characteristics of foot-ground contact during a Tai Chi gait (TCG), one of the basic but common Tai Chi Chuan movements.

METHODS

The ground reaction force profiles, center of pressure (COP) and plantar pressure patterns under the stance foot of TCG were directly measured in a sample of 10 healthy young individuals.

RESULTS

The medial force reached a peak value of 12 +/- 2% body weight (BW) during early stance. The vertical force reached and maintained a peak value of 109 +/- 2% BW during single stance, and shifted within a range of 10% and 70% BW during double stance phases. There was a uniformly small rate of loading in all three directions throughout stance. The peak plantar pressure was fairly constant throughout stance in the rear-foot region (maximum value of 0.27 +/- 0.07 kPa/kg), but changed from 0 to 0.16 +/- 0.04 kPa/kg in the fore-foot region. The peak pressure difference between the fore-foot and rear-foot regions was less than 0.06 +/- 0.01 kPa/kg during single stance and the second double stance. The maximum plantar contact area during TCG was 60 +/- 9% of the foot area. The foot COP displaced largely during the early and late part of the stance and maintained fairly stationary during single stance. The maximum COP displacement in the medial-lateral direction was 64 +/- 8% of foot width.

CONCLUSIONS

TCG had a low impact force, a fairly evenly distributed body weight between the fore-foot and rear-foot regions, and a large medial-lateral displacement of the foot COP.

Spatial, temporal and muscle action patterns of Tai Chi gait

This study was to quantitatively characterize the spatial, temporal, and neuromuscular activation patterns of Tai Chi gait (TCG). Ten healthy young subjects were tested. The kinematics of TCG and normal gait (NG) were measured using a marker-based motion analysis system and two biomechanical force plates. Surface electromyography (EMG) was recorded from six left-side muscles: tibialis anterior, soleus, peronaeus longus, rectus femoris, semitendinosus, and tensor fasciae latae. The results showed that TCG had (1) a longer cycle duration (11.9+/-2.4 vs. 1.3+/-0.2 s) and a longer duration of single-leg stance time (1.8+/-0.6 vs. 0.4+/-0.05 s); (2) a larger joint motion in ankle dorsi/plantar flexion (40+/-9 degrees vs. 20+/-8 degrees), knee flexion (82+/-8 degrees vs. 53+/-10 degrees), hip flexion (81+/-7 degrees vs. 24+/-4 degrees), and hip abduction (20+/-8 degrees vs. 0+/-3 degrees); (3) a larger lateral body shift (>25% vs. 5% body height); and (4) significant involvement of ankle dorsiflexors, knee extensors/hip flexors and hip abductors, as indicated by significantly higher peak (88+/-14%, 80+/-18% and 83+/-17% vs. 35+/-10%, 14+/-8% and 28+/-19% peak amplitude, respectively) and root-mean-square values of their EMG (37+/-6%, 32+/-7% and 33+/-7% vs. 23+/-7%, 11+/-8% and 22+/-11% peak amplitude, respectively), longer proportions of action (76+/-19%, 68+/-8% and 65+/-19% vs. 59+/-23%, 16+/-23% and 40+/-32% gait cycle duration, respectively), longer proportions of isometric and eccentric actions, and longer proportions of co-activations. These results demonstrate that the biomechanical characteristics of TCG can be quantified. The quantification of TCC movements is important for understanding its effect on balance, flexibility, strength, and health.

Impact of quality of life on patient expectations regarding phase I clinical trials

PURPOSE

Quality of life (QOL) is increasingly recognized as a critical cancer-treatment outcome measure, but little is known about the impact of QOL on the patient decision-making process. A pilot study was conducted in an effort to (1) measure the expectations of patients, physicians, and research nurses regarding the potential benefits and toxicities from experimental and standard therapies, and (2) determine the relationship of QOL to patient perceptions regarding treatment options.

METHODS

Thirty cancer patients enrolling in phase I clinical trials, their physicians, and their research nurses were administered questionnaires that assessed demographics, QOL, and treatment expectations.

RESULTS

Compared with their physicians, patients overestimated potential benefits and toxicities from experimental therapy (mean expected benefit, 59.8% v 23.8%, P <.01; mean expected toxicity, 29.8% v 16.0%, P <.01). Patients estimated a greater potential for benefit (59.8% v 36.8%, P <.01) and less potential for toxicity (29.8% v 45.6%, P =.01) for experimental therapy, compared with standard therapy. Short Form-36 general health perception correlated with patient perception of potential benefit from experimental therapy (r =.48, P =.01).

CONCLUSION

Participants in phase I clinical trial have high expectations regarding the success of experimental therapy and discount potential toxicity. Patient QOL may affect the expectation of benefit from experimental therapy and, ultimately, treatment choice. Understanding the interactions between QOL and patient expectations may guide the development of improved strategies to present appropriate information to patients considering early-phase clinical trials.

Retaining sealant on salivary contaminated enamel

A two-year clinical study comparing sealants done with intentional salivary contamination shows that sealant retention is possible on wet enamel if a bonding agent is used between enamel and sealant. Dental material research implications and clinical possibilities are discussed.

Suppression of human peripheral blood mononuclear cell function by methadone and morphine

Recent studies have shown that in vitro exposure of peripheral blood mononuclear cells (PBMC) to morphine results in suppressed respiratory-burst activity of monocytes and impaired interferon-gamma (IFN-gamma) production by lymphocytes. To investigate the potential in vivo effect of an opiate on these cell functions, PBMC were obtained from patients maintained on methadone. These freshly isolated mononuclear cells had a significantly impaired capacity to generate superoxide anion (O2-) in response to phorbol myristate acetate (PMA), while production of IFN-gamma by concanavalin A-stimulated cells was intact. After cell culture for 48 h, the defective O2- generating capacity was sustained. Also, culturing PBMC from healthy controls in the presence of methadone or morphine at concentrations as low as 10(-12) M caused significant suppression of PMA-stimulated O2- release. Because reactive oxygen intermediates produced by PBMC may participate in host defense against opportunistic pathogens in AIDS, these results underscore the need for investigations of the biological consequences of opiate-mediated immunosuppression.