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Cerimele JM, Russo J, Bauer AM, Hawrilenko M, Pyne JM, Dalack GW, Kroenke K, Unützer J, Fortney JC. The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms. J Gen Intern Med 2022; 37:1680-1687. [PMID: 34145517 PMCID: PMC9130397 DOI: 10.1007/s11606-021-06947-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Measurement-based care is an effective clinical strategy underutilized for bipolar disorder partly due to lacking a widely adopted patient-reported manic symptom measure. OBJECTIVE To report development and psychometric properties of a brief patient-reported manic symptom measure. DESIGN Secondary analysis of data collected in a randomized effectiveness trial comparing two treatments for 1004 primary care patients screening positive for bipolar disorder and/or PTSD. PARTICIPANTS Two analytic samples included 114 participants with varied diagnoses and test-retest data, and 179 participants with psychiatrist-diagnosed bipolar disorder who had two or more assessments with the nine-item Patient Mania Questionnaire-9 [PMQ-9]). MAIN MEASURES Internal and test-retest reliability, concurrent validity, and sensitivity to change were assessed. Minimally important difference (MID) was estimated by standard error of measurement (SEM) and by standard deviation (SD) effect sizes. KEY RESULTS The PMQ-9 had high internal reliability (Cronbach's alpha = 0.88) and test-retest reliability (0.85). Concurrent validity correlation with manic symptom measures was high for the Internal State Scale-Activation Subscale (0.70; p<0.0001), and lower for the Altman Mania Rating Scale (0.26; p=0.007). Longitudinally, PMQ-9 was completed at 1511 clinical encounters in 179 patients with bipolar disorder. Mean PMQ-9 score at first and last encounters was 14.5 (SD 6.5) and 10.1 (SD 7.0), a 27% decrease in mean score during treatment, suggesting sensitivity to change. A point estimate of the MID was approximately 3 points (range of 2-4). CONCLUSIONS The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Matt Hawrilenko
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jeffrey M Pyne
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gregory W Dalack
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Kurt Kroenke
- Center for Health Services and Outcomes Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
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Pal Choudhury P, Brook MN, Hurson AN, Lee A, Mulder CV, Coulson P, Schoemaker MJ, Jones ME, Swerdlow AJ, Chatterjee N, Antoniou AC, Garcia-Closas M. Comparative validation of the BOADICEA and Tyrer-Cuzick breast cancer risk models incorporating classical risk factors and polygenic risk in a population-based prospective cohort of women of European ancestry. Breast Cancer Res 2021; 23:22. [PMID: 33588869 PMCID: PMC7885342 DOI: 10.1186/s13058-021-01399-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/25/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) and the Tyrer-Cuzick breast cancer risk prediction models are commonly used in clinical practice and have recently been extended to include polygenic risk scores (PRS). In addition, BOADICEA has also been extended to include reproductive and lifestyle factors, which were already part of Tyrer-Cuzick model. We conducted a comparative prospective validation of these models after incorporating the recently developed 313-variant PRS. METHODS Calibration and discrimination of 5-year absolute risk was assessed in a nested case-control sample of 1337 women of European ancestry (619 incident breast cancer cases) aged 23-75 years from the Generations Study. RESULTS The extended BOADICEA model with reproductive/lifestyle factors and PRS was well calibrated across risk deciles; expected-to-observed ratio (E/O) at the highest risk decile :0.97 (95 % CI 0.51 - 1.86) for women younger than 50 years and 1.09 (0.66 - 1.80) for women 50 years or older. Adding reproductive/lifestyle factors and PRS to the BOADICEA model improved discrimination modestly in younger women (area under the curve (AUC) 69.7 % vs. 69.1%) and substantially in older women (AUC 64.6 % vs. 56.8%). The Tyrer-Cuzick model with PRS showed evidence of overestimation at the highest risk decile: E/O = 1.54(0.81 - 2.92) for younger and 1.73 (1.03 - 2.90) for older women. CONCLUSION The extended BOADICEA model identified women in a European-ancestry population at elevated breast cancer risk more accurately than the Tyrer-Cuzick model with PRS. With the increasing availability of PRS, these analyses can inform choice of risk models incorporating PRS for risk stratified breast cancer prevention among women of European ancestry.
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Affiliation(s)
- Parichoy Pal Choudhury
- Division of Cancer Epidemiology and Genetics, National Cancer Institute of Health, 9609 Medical Center Drive 7E-342, Rockville, MD, 20850, USA
| | - Mark N Brook
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Amber N Hurson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute of Health, 9609 Medical Center Drive 7E-342, Rockville, MD, 20850, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Lee
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Charlotta V Mulder
- Division of Cancer Epidemiology and Genetics, National Cancer Institute of Health, 9609 Medical Center Drive 7E-342, Rockville, MD, 20850, USA
| | - Penny Coulson
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Minouk J Schoemaker
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Michael E Jones
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Anthony J Swerdlow
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
- Division of Breast Cancer Research, The Institute of Cancer Research, London, UK
| | - Nilanjan Chatterjee
- Department of Biostatistics, The Johns Hopkins University, MD, Baltimore, USA
| | - Antonis C Antoniou
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Montserrat Garcia-Closas
- Division of Cancer Epidemiology and Genetics, National Cancer Institute of Health, 9609 Medical Center Drive 7E-342, Rockville, MD, 20850, USA.
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Pekmezaris R, Williams MS, Pascarelli B, Finuf KD, Harris YT, Myers AK, Taylor T, Kline M, Patel VH, Murray LM, McFarlane SI, Pappas K, Lesser ML, Makaryus AN, Martinez S, Kozikowski A, Polo J, Guzman J, Zeltser R, Marino J, Pena M, DiClemente RJ, Granville D. Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study. BMC Med Inform Decis Mak 2020; 20:324. [PMID: 33287815 PMCID: PMC7720574 DOI: 10.1186/s12911-020-01346-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/22/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.
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Affiliation(s)
- Renee Pekmezaris
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA.
| | - Myia S Williams
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Briana Pascarelli
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Kayla D Finuf
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA.
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA.
| | - Yael T Harris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY, USA
| | - Alyson K Myers
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY, USA
| | - Tonya Taylor
- College of Medicine, Division of Infectious Disease, SUNY-Downstate Health Sciences University, Brooklyn, NY, USA
| | - Myriam Kline
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Vidhi H Patel
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Lawrence M Murray
- Annie E. Casey Foundation Children and Family Fellowship, Baltimore, MD, USA
| | - Samy I McFarlane
- Department of Medicine, SUNY-Downstate Health Sciences University, Brooklyn, NY, USA
| | - Karalyn Pappas
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Martin L Lesser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Amgad N Makaryus
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY, USA
| | - Sabrina Martinez
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Andrjez Kozikowski
- Department of Medicine, Division of Health Services Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | | | | | - Roman Zeltser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Nassau University Medical Center, East Meadow, NY, USA
| | - Jose Marino
- Center for Health Innovations and Outcomes Research, Northwell Health, Manhasset, NY, USA
| | - Maria Pena
- Nassau University Medical Center, East Meadow, NY, USA
- Mount Sinai Hospital, Mount Sinai Health System, New York, NY, USA
| | - Ralph J DiClemente
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, USA
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Chakravarthy R, Stallings SC, Williams M, Hollister M, Davidson M, Canedo J, Wilkins CH. Factors influencing precision medicine knowledge and attitudes. PLoS One 2020; 15:e0234833. [PMID: 33175834 PMCID: PMC7657499 DOI: 10.1371/journal.pone.0234833] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/25/2020] [Indexed: 11/25/2022] Open
Abstract
Precision medicine holds great promise for improving health and reducing health disparities that can be most fully realized by advancing diversity and inclusion in research participants. Without engaging underrepresented groups, precision medicine could not only fail to achieve its promise but also further exacerbate the health disparities already burdening the most vulnerable. Yet underrepresentation by people of non-European ancestry continues in precision medicine research and there are disparities across racial groups in the uptake of precision medicine applications and services. Studies have explored possible explanations for population differences in precision medicine participation, but full appreciation of the factors involved is still developing. To better inform the potential for addressing health disparities through PM, we assessed the relationship of precision medicine knowledge and trust in biomedical research with sociodemographic variables. Using a series of linear regression models applied to survey data collected in a diverse sample, we analyzed variation in both precision medicine knowledge and trust in biomedical research with socioeconomic factors as a way to understand the range of precision medicine knowledge (PMK) in a broadly representative group and its relationship to trust in research and demographic characteristics. Our results demonstrate that identifying as Black, while significantly PMK, explains only 1.5% of the PMK variance in unadjusted models and 7% of overall variance in models adjusted for meaningful covariates such as age, marital status, employment, and education. We also found a positive association between PMK and trust in biomedical research. These results indicate that race is a factor affecting PMK, even after accounting for differences in sociodemographic variables. Additional work is needed, however, to identify other factors contributing to variation in PMK as we work to increase diversity and inclusion in precision medicine applications.
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Affiliation(s)
- Rohini Chakravarthy
- Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | | | - Michael Williams
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Megan Hollister
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Mario Davidson
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Juan Canedo
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Consuelo H. Wilkins
- Meharry-Vanderbilt Alliance, Nashville, TN, United States of America
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Li H, Marks KM, Talal AH, van Seggelen WO, Akil B, Radix A, Huprikar S, Branch AD, Wang S, Shaw GM, Fierer DS. Assessing routes of hepatitis C transmission in HIV-infected men who have sex with men using single genome sequencing. PLoS One 2020; 15:e0235237. [PMID: 32667919 PMCID: PMC7363067 DOI: 10.1371/journal.pone.0235237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
The epidemic of hepatitis C virus (HCV) infection among HIV-infected men who have sex with men (MSM) is in its second decade, but the routes of transmission remain poorly understood. We hypothesized that by pairing single genome sequencing (SGS), to enumerate infecting HCV genomes (viruses), with detailed sexual and drug histories, we could gain insight into the routes of transmission among MSM. We used SGS to analyze blood specimens from eight HIV-infected MSM who had 10 episodes of acute (seronegative) or early HCV infections. Seven of eight men reported condomless receptive anal intercourse (CRAI), six with rectal exposure to semen, and all eight denied rectal trauma or bleeding. Of the 10 HCV infections, eight resulted from transmission of a single virus; one infection resulted from transmission of either one or a few (three or four) closely-related viruses; and one infection resulted from transmission of >10 distinct viruses. The participant infected by >10 viruses reported sharing injection equipment for methamphetamine during sex. Two other participants also injected methamphetamine during sex but they did not share injection equipment and were infected by a single virus. Conclusions: Most HCV infections of HIV-infected MSM without a history of either rectal trauma or bleeding or shared injection equipment were caused by a single virus. Intra-rectal exposure to semen during CRAI is therefore likely sufficient for HCV transmission among MSM. Conversely, rectal trauma or bleeding or shared injection equipment are not necessary for HCV transmission among MSM. These results help clarify routes of HCV transmission among MSM and can therefore help guide the design of much-needed behavioral and other interventions to prevent HCV transmission among MSM.
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Affiliation(s)
- Hui Li
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kristen M. Marks
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Andrew H. Talal
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Wouter O. van Seggelen
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Bisher Akil
- Chelsea Village Medical, New York, New York, United States of America
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York, United States of America
| | - Shirish Huprikar
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Andrea D. Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Shuyi Wang
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - George M. Shaw
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Daniel S. Fierer
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
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Trevisi L, Orav JE, Atwood S, Brown C, Curley C, King C, Muskett O, Sehn H, Nelson KA, Begay MG, Shin SS. Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation. Int J Equity Health 2019; 18:183. [PMID: 31771603 PMCID: PMC6880375 DOI: 10.1186/s12939-019-1097-9] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/18/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits. METHODS We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models. RESULTS Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group. CONCLUSION Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population. TRIAL REGISTRATION Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.
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Affiliation(s)
- Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - John E Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Christian Brown
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cameron Curley
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Caroline King
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Olivia Muskett
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Katrina A Nelson
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Sonya S Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
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Norris KC, Duru OK, Alicic RZ, Daratha KB, Nicholas SB, McPherson SM, Bell DS, Shen JI, Jones CR, Moin T, Waterman AD, Neumiller JJ, Vargas RB, Bui AAT, Mangione CM, Tuttle KR. Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD. BMC Nephrol 2019; 20:416. [PMID: 31747918 PMCID: PMC6868861 DOI: 10.1186/s12882-019-1558-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function. METHODS We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data. RESULTS The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials. DISCUSSION CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.
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Affiliation(s)
- Keith C Norris
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA.
- UCLA Department of Medicine, Division of General Internal Medicine, 1100 Glendon Ave. Suite 900, Los Angeles, CA, 90024, USA.
| | - O Kenrik Duru
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Radica Z Alicic
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Kenn B Daratha
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA
| | - Susanne B Nicholas
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Sterling M McPherson
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA
- Washington State University Elson S. Floyd College of Medicine, Spokane, Washington, USA
| | - Douglas S Bell
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Jenny I Shen
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Cami R Jones
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA
| | - Tannaz Moin
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
- VA Greater Los Angeles, Los Angeles, USA
| | - Amy D Waterman
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Joshua J Neumiller
- Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, USA
| | - Roberto B Vargas
- Charles R. Drew University of Medicine and Science, Los Angeles, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Alex A T Bui
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Carol M Mangione
- David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - Katherine R Tuttle
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
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Reed ME, Huang J, Brand RJ, Neugebauer R, Graetz I, Hsu J, Ballard DW, Grant R. Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal. PLoS One 2019; 14:e0217636. [PMID: 31216295 PMCID: PMC6583978 DOI: 10.1371/journal.pone.0217636] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/15/2019] [Indexed: 01/08/2023] Open
Abstract
Background For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits. Objective To examine the impact of portal access on the number of outpatient visits, emergency visits, and preventable hospitalizations. Design Observational study comparing patients’ visit rates with and without portal access, using marginal structural modeling with inverse probability weighting estimates to account for potential bias due to confounding and attrition. Setting Large integrated delivery system which implemented a patient portal (2006–2007). Patients We examined 165,447 patients with diabetes defined using clinical registries. Our study included both patients with diabetes-only and patients with multiple complex chronic conditions (diabetes plus asthma, congestive artery disease, congestive heart failure, or hypertension). Measurements We examined rates of outpatient office visits, emergency room visits, and preventable hospitalizations (for ambulatory care sensitive conditions). Results Access to a patient portal was associated with significantly higher rates of outpatient office visits, in both patients with diabetes only and in patients with multiple complex conditions (p<0.05). In patients with multiple complex chronic conditions, portal use was also associated with significantly fewer emergency room visits (3.9 fewer per 1,000 patients per month, p<0.05) and preventable hospital stays (0.8 fewer per 1,000 patients per month, p<0.05). In patients with only diabetes, the results were directionally consistent but not statistically significantly associated with emergency room visits and preventable hospital stays. Limitations Observational study in an integrated delivery system. Conclusion Access to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.
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Affiliation(s)
- Mary E. Reed
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
- * E-mail:
| | - Jie Huang
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
| | - Richard J. Brand
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
| | - Ilana Graetz
- University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - John Hsu
- Department of Health Care Policy, Morgan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dustin W. Ballard
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
- Kaiser Permanente San Rafael Medical Center, Kaiser Permanente, San Rafael, California, United States of America
| | - Richard Grant
- Division of Research, Kaiser Permanente, Oakland, California, United States of America
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Klann JG, Joss MAH, Embree K, Murphy SN. Data model harmonization for the All Of Us Research Program: Transforming i2b2 data into the OMOP common data model. PLoS One 2019; 14:e0212463. [PMID: 30779778 PMCID: PMC6380544 DOI: 10.1371/journal.pone.0212463] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The All Of Us Research Program (AOU) is building a nationwide cohort of one million patients' EHR and genomic data. Data interoperability is paramount to the program's success. AOU is standardizing its EHR data around the Observational Medical Outcomes Partnership (OMOP) data model. OMOP is one of several standard data models presently used in national-scale initiatives. Each model is unique enough to make interoperability difficult. The i2b2 data warehousing and analytics platform is used at over 200 sites worldwide, which uses a flexible ontology-driven approach for data storage. We previously demonstrated this ontology system can drive data reconfiguration, to transform data into new formats without site-specific programming. We previously implemented this on our 12-site Accessible Research Commons for Health (ARCH) network to transform i2b2 into the Patient Centered Outcomes Research Network model. METHODS AND RESULTS Here, we leverage our investment in i2b2 high-performance transformations to support the AOU OMOP data pipeline. Because the ARCH ontology has gained widespread national interest (through the Accrual to Clinical Trials network, other PCORnet networks, and the Nebraska Lexicon), we leveraged sites' existing investments into this standard ontology. We developed an i2b2-to-OMOP transformation, driven by the ARCH-OMOP ontology and the OMOP concept mapping dictionary. We demonstrated and validated our approach in the AOU New England HPO (NEHPO). First, we transformed into OMOP a fake patient dataset in i2b2 and verified through AOU tools that the data was structurally compliant with OMOP. We then transformed a subset of data in the Partners Healthcare data warehouse into OMOP. We developed a checklist of assessments to ensure the transformed data had self-integrity (e.g., the distributions have an expected shape and required fields are populated), using OMOP's visual Achilles data quality tool. This i2b2-to-OMOP transformation is being used to send NEHPO production data to AOU. It is open-source and ready for use by other research projects.
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Affiliation(s)
- Jeffrey G. Klann
- Research Information Science and Computing, Partners Healthcare, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Laboratory of Computer Science, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Matthew A. H. Joss
- Research Information Science and Computing, Partners Healthcare, Boston, Massachusetts, United States of America
| | - Kevin Embree
- Personalized Medicine, Partners Healthcare, Boston, Massachusetts, United States of America
| | - Shawn N. Murphy
- Research Information Science and Computing, Partners Healthcare, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Laboratory of Computer Science, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Minneci PC, Halleran DR, Lawrence AE, Fischer BA, Cooper JN, Deans KJ. Laser hair depilation for the prevention of disease recurrence in adolescents and young adults with pilonidal disease: study protocol for a randomized controlled trial. Trials 2018; 19:599. [PMID: 30382903 PMCID: PMC6211439 DOI: 10.1186/s13063-018-2987-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/13/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Laser hair depilation is a promising therapy in the management of pilonidal disease. However, the large controlled trials needed to demonstrate the effectiveness of this practice have not been performed. METHODS We designed a single-center randomized controlled trial that will enroll 272 patients with pilonidal disease. Patients will be randomized to receive laser hair depilation of the sacrococcygeal region or the best recommended standard of care. The primary outcome is the rate of recurrent pilonidal disease at 1 year, defined as development of a new pilonidal abscess, folliculitis, or draining sinus after treatment, which would require antibiotic treatment, additional surgical incision and drainage, or excision within 1 year of enrollment. Secondary outcomes include each of the following at 1 year: disability days of the patient, disability days of the caregiver, health-related quality of life, healthcare satisfaction, disease-related attitudes and perceived stigma, pilonidal disease-related complications, pilonidal disease-related procedures, surgical excision, postoperative complications, and compliance with recommended treatment. DISCUSSION This study will determine the effectiveness of laser hair depilation to reduce pilonidal disease recurrence in adolescents and young adults as compared to the best recommended standard of care. TRIAL REGISTRATION ClinicalTrials.gov, NCT03276065 . Registered on 8 September 2017.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - Devin R. Halleran
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - Amy E. Lawrence
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - Beth A. Fischer
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205 USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH USA
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Garland SN, Eriksen W, Song S, Dearing J, Barg FK, Gehrman P, Mao JJ. Factors that shape preference for acupuncture or cognitive behavioral therapy for the treatment of insomnia in cancer patients. Support Care Cancer 2018; 26:2407-2415. [PMID: 29423681 PMCID: PMC6158018 DOI: 10.1007/s00520-018-4086-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/29/2018] [Indexed: 01/18/2023]
Abstract
PURPOSE Patient preference is an essential component of patient-centered supportive cancer care; however, little is known about the factors that shape preference for treatment. This study sought to understand what factors may contribute to patient preference for two non-pharmacological interventions, acupuncture or cognitive behavioral therapy for insomnia (CBT-I). METHODS We conducted individual, open-ended, semi-structured interviews among cancer survivors who had completed active treatment and met the diagnostic criteria for insomnia disorder. Two forms of codes were used for analysis: a priori set of codes derived from the key ideas and a set of codes that emerged from the data. RESULTS Among 53 participants, the median age was 60.7 (range 27-83), 30 participants (56.6%) were female, and 18 (34%) were non-white. We identified three themes that contributed to an individual's treatment preference: perception of the treatment's evidence base, experience with the treatment, and consideration of personal factors. Participants gave preference to the treatment perceived as having stronger evidence. Participants also reflected on positive or negative experiences with both of the interventions, counting their own experiences, as well as those of trusted sources. Lastly, participants considered their own unique circumstances and factors such as the amount of work involved, fit with personality, or fit with their "type" of insomnia. CONCLUSIONS Knowledge of the evidence base, past experience, and personal factors shaped patient preference regardless of whether they accurately represent the evidence. Acknowledging these salient factors may help inform patient-centered decision-making and care.
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Affiliation(s)
- Sheila N Garland
- Departments of Psychology and Oncology, Memorial University of Newfoundland, St. John's, NL, Canada.
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Song
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Dearing
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Philip Gehrman
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jun J Mao
- The Bendheim Center for Integrative Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Mayo-Wilson E, Golozar A, Cowley T, Fusco N, Gresham G, Haythornthwaite J, Tolbert E, Payne JL, Rosman L, Hutfless S, Canner JK, Dickersin K. Methods to identify and prioritize patient-centered outcomes for use in comparative effectiveness research. Pilot Feasibility Stud 2018; 4:95. [PMID: 30026961 PMCID: PMC6047482 DOI: 10.1186/s40814-018-0284-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We used various methods for identifying and prioritizing patient-centered outcomes (PCOs) for comparative effectiveness research (CER). METHODS We considered potential PCOs ("benefits" and "harms") related to (1) gabapentin for neuropathic pain and (2) quetiapine for bipolar depression. Part 1 (April 2014 to March 2015): we searched for PCO research and core outcome sets (COSs). We conducted electronic searches of bibliographic databases and key websites and examined FDA prescribing information and reports of clinical trials and systematic reviews. We asked patient and clinician co-investigators to identify PCOs. Part 2 (not part of our original study protocol): in 2015, we surveyed members of The TMJ Association, Ltd., a patient group associated with temporomandibular disorders (4130 invitations sent). Participants prioritized (1) the importance of six potential benefits and (2) 21 potential harms selected by the investigators in part 1, using stated preference methods. We calculated descriptive statistics. RESULTS In part 1, we identified a COS for pain, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. The COS identified several important benefits, but it lacked specific recommendations about which potential harms to include in CER. We did not identify a COS for bipolar depression. Research reports, prescribing information, and patient co-investigators helped identify but not prioritize outcomes. We abandoned our electronic search for PCO research because we found it would be resource-intensive and yield few relevant reports. In part 2, surveying patients was useful for prioritizing PCOs. Members of The TMJ Association, Ltd., completed the survey (N = 746) and successfully prioritized both benefits and harms. Participants did not identify many benefits other than those we identified in part 1; several participants identified additional harms. CONCLUSIONS These exploratory results could inform future research about identifying and prioritizing PCOs. We found that stakeholder co-investigators and research reports contributed to identifying PCOs; surveying a patient group contributed to prioritizing PCOs. Prioritizing potential harms was particularly challenging because there are many more potential harms than potential benefits. Methods for identifying and prioritizing potential benefits for CER might not be appropriate for harms. Further research is needed to determine the generalizability of these results.
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Affiliation(s)
- Evan Mayo-Wilson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Asieh Golozar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Nicole Fusco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Gillian Gresham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Jennifer Haythornthwaite
- Center for Mind and Body Research, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | | | - Jennifer L. Payne
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Lori Rosman
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Susan Hutfless
- Department of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Joseph K. Canner
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD USA
| | - Kay Dickersin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Singh JA, Hossain A, Kotb A, Wells G. Risk of serious infections with immunosuppressive drugs and glucocorticoids for lupus nephritis: a systematic review and network meta-analysis. BMC Med 2016; 14:137. [PMID: 27623861 PMCID: PMC5022202 DOI: 10.1186/s12916-016-0673-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 08/10/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To perform a systematic review and network meta-analysis (NMA) to compare the risk of serious infections with immunosuppressive medications and glucocorticoids in lupus nephritis. METHODS A trained librarian performed two searches: (1) PubMed for all lupus nephritis trials from the end dates for the systematic review for the 2012 American College of Rheumatology (ACR) lupus nephritis treatment guidelines and the 2012 Cochrane Systematic Review on treatments for lupus nephritis, to September 2013; and (2) PubMed and SCOPUS for all lupus trials (excluding lupus nephritis) from inception to February 2014, to obtain additional trials for harms data in any lupus patient. The search was updated to May 2016. Duplicate title/abstract review and duplicate data abstractions by two abstractors independently was performed for all eligible studies, including those studies abstracted for the 2012 ACR lupus nephritis treatment guidelines and the 2012 Cochrane Systematic Review on lupus nephritis treatments. We performed a systematic review and a Bayesian NMA, including randomized controlled trials (RCTs) of immunosuppressive drugs or glucocorticoids in patients with lupus nephritis assessing serious infection risk. Markov chain Monte Carlo methods were used to model 95 % credible intervals (CrI). Sensitivity analyses examined the robustness of estimates. RESULTS A total of 32 RCTs with 2611 patients provided data. There were 26 two-arm, five three-arm, and one four-arm trials. We found that tacrolimus was associated with significantly lower risk of serious infections compared to glucocorticoids, cyclophosphamide (CYC), mycophenolate mofetil (MMF), and azathioprine (AZA) with odds ratios (95 % CrI) of 0.33 (0.12-0.88), 0.37 (0.15-0.87), 0.340 (0.18-0.81), and 0.32 (0.12-0.81), respectively. Conversely, CYC low dose (LD), CYC high dose (HD), and HD glucocorticoids were associated with higher odds of serious infections compared to tacrolimus, ranging from 4.84 to 12.83. We also found that MMF followed by AZA (MMF-AZA) was associated with significantly lower risk of serious infections as compared to CYC LD, CYC HD, CYC-AZA, or HD glucocorticoids with odds ratios (95 % CrI) of 0.09 (0.01-0.76), 0.07 (0.01-0.54), 0.14 (0.02-0.71), and 0.03 (0.00-0.56), respectively. Estimates were similar to pair-wise meta-analyses. Sensitivity analyses that varied estimate (odds ratio vs. Peto's odds ratio), method (random vs. fixed effects model), data (sepsis vs. serious infection data; exclusion of observational studies), treatment grouping (CYC and CYC HD as a combined treatment group vs. separate), made little/no difference to these estimates. CONCLUSIONS Tacrolimus and MMF-AZA combination were associated with lower risk of serious infections compared to other immunosuppressive drugs or glucocorticoids for lupus nephritis. In conjunction with comparative efficacy data, these data can help patients make informed decisions about treatment options for lupus nephritis. PROSPERO REGISTRATION CRD42016032965.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, 35233, USA.
- Department of Medicine at the School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294, USA.
- Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, AL, 35294, USA.
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA.
| | - Alomgir Hossain
- Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, K1Y 4W7, Canada
| | - Ahmed Kotb
- Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, K1Y 4W7, Canada
| | - George Wells
- Ottawa Heart Institute and the University of Ottawa, Ottawa, Ontario, K1Y 4W7, Canada
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Li J, Brock J, Jack B, Mittman B, Naylor M, Sorra J, Mays G, Williams MV. Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness. BMC Health Serv Res 2016; 16:70. [PMID: 26896024 PMCID: PMC4759940 DOI: 10.1186/s12913-016-1312-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/11/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors' offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated. METHODS/DESIGN Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. Using a mixed-methods approach for this evaluation, we will study historical (retrospective) and current and future (prospective) groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data. In this natural experiment observational study, we use a fractional factorial study design to specify comparators and estimate the individual and combined effects of key transitional care components. DISCUSSION Our study will determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings. Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. Finally, this work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities. TRIAL REGISTRATION Registered as NCT02354482 on clinicaltrials.gov on 1/29/2015.
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Affiliation(s)
- Jing Li
- Administrative Director of the Center for Health Services Research, Assistant Professor of Internal Medicine, University of Kentucky, Lexington, KY, USA.
| | - Jane Brock
- Care Transitions Theme Support Center, Telligen, Englewood, CO, USA.
| | - Brian Jack
- Family Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Brian Mittman
- Research Scientist, Research and Evaluation, Kaiser Permanente, Pasadena, CA, USA.
- US Department of Veterans Affairs Greater Los Angeles Healthcare System, VA Center for Implementation Practice and Research, Los Angeles, CA, USA.
- UCLA School of Medicine, UCLA Clinical Translational Science Institute, Los Angeles, CA, USA.
| | - Mary Naylor
- Director of NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | | | - Glen Mays
- National Coordinating Center for Public Health Services & Systems Research, University of Kentucky, Lexington, KY, USA.
| | - Mark V Williams
- Center for Health Services Research, Department of Internal Medicine, University of Kentucky, Kentucky Clinic J525, Lexington, KY, 40536-0284, USA.
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