Exploring Social Support Dynamics After Bariatric Surgery: Insights From Patients and Providers

INTRODUCTION

Weight loss after bariatric surgery is impacted by several factors, and social support is one of them. Our objective was to characterize patient and provider perceptions about social support after bariatric surgery.

METHODS

We reported a secondary analysis of qualitative data acquired from semi-structured interviews conducted from January-November 2020 with bariatric surgery patients and providers. Participants included primary care providers, health psychologists, registered dietitians, bariatric surgeons, and patients with at least 1 y of follow-up after their bariatric procedure. Interview guides were designed using a hybrid of Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Using directed content analysis, study team members generated codes, which were categorized into themes about social support pertaining to dietary habits, physical activity, and follow-up care.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White; mean age 50.6 ± 10.7 y) and 21 providers (six primary care providers, four health psychologists, five registered dieticians, and six bariatric surgeons). We identified four themes relating to social support affecting weight loss after surgery: (1) family involvement in helping patients adjust to the bariatric diet, (2) engagement in activities with partners/friends, (3) help with transportation to appointments, and (4) life stressors experienced by patients within their social relationships.

CONCLUSIONS

Continued assessment of interpersonal factors after bariatric surgery is essential for weight loss maintenance. Providers can contribute by reinforcing the facilitators of social support and making referrals that may help patients overcome barriers to social support for sustained weight loss after surgery.

Healthy Outcomes through Peer Educators: Feasibility of a peer support diabetes prevention programme for African-American grandmother caregivers

AIM

To assess the protocol feasibility and intervention acceptability of a community-based, peer support diabetes prevention programme (DPP) for African-American (AA) grandmother caregivers at risk for diabetes.

MATERIALS AND METHODS

Grandmother caregivers were randomized in a 2:1 ratio to DPP (active comparator) or DPP plus HOPE (Healthy Outcomes through Peer Educators; intervention). DPP + HOPE incorporated support from a peer educator who met with participants in person or by telephone every week during the 1-year intervention. Outcomes included: (1) recruitment rates, outcome assessment, and participation adherence rates assessed quantitatively; and (2) acceptability of the programme assessed through end-of-programme focus groups.

RESULTS

We successfully consented and enrolled 78% (n = 35) of the 45 AA grandmothers screened for eligibility. Eighty percent of participants (aged 64.4 ± 5.7 years) were retained up to Week 48 (74% for DPP [n = 17] and 92% for DPP + HOPE [n = 11]). All grandmothers identified social support, neighbourhood safety, and access to grocery stores as influences on their health behaviours. At Month 12, the active comparator (DPP) group and the intervention group (DPP + HOPE) had a mean change in body weight from baseline of -3.5 ± 5.5 (-0.68, -6.29) kg and - 4.4 ± 5.7 (-0.59, -8.2) kg, respectively.

CONCLUSIONS

This viable study met the aim of educating and equipping AA grandmothers with the practical and sustained support needed to work toward better health for themselves and their grandchildren, who may be at risk for diabetes. The intervention was both feasible and acceptable to participating grandmothers and their organizations.

A low-burden, self-weighing intervention to prevent weight gain in adults with obesity who do not enroll in comprehensive treatment

Background

For individuals who are eligible but unlikely to join comprehensive weight loss programs, a low burden self-weighing intervention may be a more acceptable approach to weight management.

Methods

This was a single-arm feasibility trial of a 12-month self-weighing intervention. Participants were healthcare patients with a BMI ≥25 kg/m2 with a weight-related comorbidity or a BMI >30 kg/m2 who reported lack of interest in joining a comprehensive weight loss program, or did not enroll in a comprehensive program after being provided program information. In the self-weighing intervention, participants were asked to weigh themselves daily on a cellular connected scale and were sent text messages every other week with tailored weight change feedback, including messages encouraging use of comprehensive programs if weight gain occurred.

Results

Of 86 eligible patients, 39 enrolled (45.3%) in the self-weighing intervention. Self-weighing occurred on average 4.6 days/week (SD = 1.4). At 12 months, 12 participants (30.8%) lost ≥3% baseline weight, 11 (28.2%) experienced weight stability (±3% baseline), 6 (15.4%) gained ≥3% of baseline weight, and 10 (25.6%) did not have available weight data to evaluate. Three participants reported joining a weight loss program during the intervention (7.7%). Participants reported high intervention satisfaction in quantitative ratings (4.1 of 5), and qualitative interviews identified areas of satisfaction (e.g., timing and content of text messages) and areas for improvement (e.g., increasing personalization of text messages).

Conclusion

A low-burden self-weighing intervention can reach adults with overweight/obesity who would be unlikely to engage in comprehensive weight loss programs; the efficacy of this intervention for preventing weight gain should be further evaluated in a randomized trial.

Small Monetary Incentives Lead to Greater Adherence in a Weight Loss Program

PURPOSE

Understand how weekly monetary incentives for dietary tracking and/or weight loss impact 6-month weight loss behavioral adherence.

DESIGN

Secondary analysis of participants randomized to one of four conditions in a behavioral weight loss intervention: incentives for dietary tracking, incentives for weight loss, both, or none.

SETTING

Participants were asked to self-weigh at least twice weekly, log food and drink in a mobile application five days weekly, and attend bi-weekly, group-based classes.

SAMPLE

Data from (n = 91) adults with obesity who completed a 24-week behavioral weight loss intervention of whom 88% were female and 74% Non-Hispanic White, were analyzed.

MEASURES

Non-adherence to weight and dietary self-monitoring was defined as the second week of not meeting criteria. Class attendance was also tracked.

ANALYSIS

Kaplan-Meier analyses were used to examine differences across the four conditions.

RESULTS

Participants incentivized for dietary self-monitoring had an average 15.8 weeks (SE:1.2) until the first non-adherent week compared to 5.9 weeks (SE:0.8) for those not incentivized for dietary self-monitoring (P < .01). Those incentivized for weight loss had an average 18.0 weeks (SE:1.02) of self-weighing until the first non-adherent week compared to 13.5 weeks (SE:1.3) for those not incentivized for weight loss (P = .02). No difference in class attendance was observed.

CONCLUSIONS

Incentivizing behaviors associated with weight loss improved adherence to those behaviors and does not appear to spill over to non-incentivized behaviors.

A review of implementation intentions as a tool to benefit high-need patients and healthcare systems: U.S. veterans affairs as an exemplar

Implementation intentions (if-then plans) are an evidence-based behavior change strategy designed to translate behavioral intentions into habits [1]. Despite extensive evidence of its potential utility, this behavior change strategy is underutilized and under-researched in high-need healthcare contexts within the United States (U.S.) which face high rates of chronic conditions and barriers to care such as rurality, lack of resources, and cognitive strain from mental health and neurological conditions [2,3]. Implementation intentions have demonstrated efficacy in promoting many health behaviors proven to mitigate chronic conditions, namely physical activity, healthy diet, and substance use reduction [4-6]. In addition, the accessible, adaptable, and self-driven nature of implementation intentions allow the technique to meet many of the individual and system-level priorities of these high-need care contexts. By being patient-driven, proactive, and personalized, implementation intentions can help these patients cultivate healthy habits as part of their everyday lives. At the systems-level, implementation intentions' inexpensiveness, scalability, and compatibility with telemedicine platforms allow them to be integrated easily into existing healthcare system infrastructure [7,8]. This review describes these concepts in detail, and uses the Veterans Affairs (VA) healthcare system as an exemplar to provide concrete examples of how and where implementation intentions could be integrated in a healthcare system, within some existing programs, to benefit both the system and individual patients.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Patient Perspectives of Barriers and Facilitators for the Uptake of Pharmacogenomic Testing in Veterans Affairs' Pharmacogenomic Testing for the Veterans (PHASER) Program

We applied implementation science frameworks to identify barriers and facilitators to veterans' acceptance of pharmacogenomic testing (PGx), which was made available as a part of clinical care at 25 VA medical centers. We conducted 30 min interviews with veterans who accepted (n = 14), declined (n = 9), or were contemplating (n = 8) PGx testing. Six team members coded one transcript from each participant group to develop the codebook and finalize definitions. Three team members coded the remaining 28 transcripts and met regularly with the larger team to reach a consensus. The coders generated a matrix of implementation constructs by testing status to identify the similarities and differences between accepters, decliners, and contemplators. All groups understood the PGx testing procedures and possible benefits. In the decision-making, accepters prioritized the potential health benefits of PGx testing, such as reducing side effects or the number of medications. In contrast, decliners prioritized the possibilities of data breach or the negative impact on healthcare insurance or Veterans Affairs benefits. Contemplators desired to speak to a provider to learn more before making a decision. Efforts to improve the clarity of data security and the impact on benefits may improve veterans' abilities to make more informed decisions about whether to undergo PGx testing.

Self-reported adherence and reasons for nonadherence among patients with low proportion of days covered for antihypertension medications

BACKGROUND: Incorporation of pharmacy fill data into the electronic health record has enabled calculations of medication adherence, as measured by proportion of days covered (PDC), to be displayed to clinicians. Although PDC values help identify patients who may be nonadherent to their medications, it does not provide information on the reasons for medication-taking behaviors. OBJECTIVE: To characterize self-reported adherence status to antihypertensive medications among patients with low refill medication adherence. Our secondary objective was to identify the most common reasons for nonadherence and examine the patient sociodemographic characteristics associated with these barriers. METHODS: Participants were adult patients seen in primary care clinics of a large, urban health system and on antihypertensive therapy with a PDC of less than 80% based on 6-month linked electronic health record-pharmacy fill data. We administered a validated medication adherence screener and a survey assessing reasons for antihypertensive medication nonadherence. We used descriptive statistics to characterize these data and logistic and Poisson regression models to assess the relationship between sociodemographic characteristics and adherence barriers. RESULTS: The survey was completed by 242 patients (57% female; 61.2% White; 79.8% not Latino/a or Hispanic). Of these patients, 45% reported missing doses of their medications in the last 7 days. In addition, 48% endorsed having at least 1 barrier to adherence and 38.4% endorsed 2 or more barriers. The most common barriers were being busy and having difficulty remembering to take medications. Compared with White participants, Black participants (incident rate ratio = 2.49; 95% CI = 1.93-3.22) and participants of other races (incident rate ratio = 2.16; 95% CI = 1.62-2.89) experienced a greater number of barriers. CONCLUSIONS: Nearly half of patients with low PDC reported nonadherence in the prior week, suggesting PDC can be used as a screening tool. Augmenting PDC with brief self-report tools can provide insights into the reasons for nonadherence. DISCLOSURES: Dr Kharmats, Ms Martinez, Dr Belli, Ms Zhao, Dr Mann, Dr Schoenthaler, and Dr Blecker received grants from the National Institute of Health/National Heart, Lung, Blood Institute. Dr Voils holds a license by Duke University for the DOSE-Nonadherence measure and is a consultant for New York University Grossman School of Medicine. This research was supported by the NIH (R01HL156355). Dr Kharmats received a postdoctoral training grant from the National Institutes of Health (5T32HL129953-04). Dr Voils was supported by a Research Career Scientist award from the Health Services Research & Development Service of the Department of Veterans Affairs (RCS 14-443). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the United States Government.

A Cluster Randomized Trial of a Family Health History Platform to Identify and Manage Patients at Increased Risk for Colorectal Cancer

BACKGROUND

Obtaining comprehensive family health history (FHH) to inform colorectal cancer (CRC) risk management in primary care settings is challenging.

OBJECTIVE

To examine the effectiveness of a patient-facing FHH platform to identify and manage patients at increased CRC risk.

DESIGN

Two-site, two-arm, cluster-randomized, implementation-effectiveness trial with primary care providers (PCPs) randomized to immediate intervention versus wait-list control.

PARTICIPANTS

PCPs treating patients at least one half-day per week; patients aged 40-64 with no medical conditions that increased CRC risk.

INTERVENTIONS

Immediate-arm patients entered their FHH into a web-based platform that provided risk assessment and guideline-driven decision support; wait-list control patients did so 12 months later.

MAIN MEASURES

McNemar's test examined differences between the platform and electronic medical record (EMR) in rates of increased risk documentation. General estimating equations using logistic regression models compared arms in risk-concordant provider actions and patient screening test completion. Referral for genetic consultation was analyzed descriptively.

KEY RESULTS

Seventeen PCPs were randomized to each arm. Patients (n = 252 immediate, n = 253 control) averaged 51.4 (SD = 7.2) years, with 83% assigned male at birth, 58% White persons, and 33% Black persons. The percentage of patients identified as increased risk for CRC was greater with the platform (9.9%) versus EMR (5.2%), difference = 4.8% (95% CI: 2.6%, 6.9%), p < .0001. There was no difference in PCP risk-concordant action [odds ratio (OR) = 0.7, 95% CI (0.4, 1.2; p = 0.16)]. Among 177 patients with a risk-concordant screening test ordered, there was no difference in test completion, OR = 0.8 [0.5,1.3]; p = 0.36. Of 50 patients identified by the platform as increased risk, 78.6% immediate and 68.2% control patients received a recommendation for genetic consultation, of which only one in each arm had a referral placed.

CONCLUSIONS

FHH tools could accurately assess and document the clinical needs of patients at increased risk for CRC. Barriers to acting on those recommendations warrant further exploration.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02247336 https://clinicaltrials.gov/ct2/show/NCT02247336.

Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience

OBJECTIVE

To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery.

BACKGROUND

COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown.

METHODS

Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis.

RESULTS

Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges.

CONCLUSIONS

COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BACKGROUND

Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.

METHODS

We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.

RESULTS

24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.

CONCLUSIONS

Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

Gender differences in social support for diabetes self-management: A qualitative study among veterans

OBJECTIVE

Describe the role of social support in veterans' diabetes self-management and examine gender differences.

METHODS

We conducted semi-structured interviews among veterans with diabetes from one Veterans Health Administration Health Care System. Participants described how support persons influenced their diabetes self-management and perspectives on a proposed self-management program incorporating a support person. We used thematic analysis to identify salient themes and examine gender differences.

RESULTS

Among 18 women and 18 men, we identified four themes: 1) women felt responsible for their health and the care of others; 2) men shared responsibility for managing their diabetes, with support persons often attempting to correct behaviors (social control); 3) whereas both men and women described receiving instrumental and informational social support, primarily women described emotional support; and 4) some women's self-management efforts were hindered by support persons. Regarding programs incorporating a support person, some participants endorsed including family/friends and some preferred programs including other individuals with diabetes.

CONCLUSIONS

Notable gender differences in social support for self-management were observed, with women assuming responsibility for their diabetes and their family's needs and experiencing interpersonal barriers.

PRACTICE IMPLICATIONS

Gender differences in the role of support persons in diabetes self-management should inform support-based self-management programs.

Provider-supported self-management cognitive behavioral therapy for insomnia (Tele-Self CBTi): Protocol for a randomized controlled trial

BACKGROUND

Cognitive Behavioral Therapy for Insomnia (CBTi) is recommended as first-line treatment for insomnia, yet patient access to CBTi is limited. Self-help CBTi could increase patient access. Self-help CBTI with provider sup]port is more effective and is preferred by patients. Self-help CBTi has not been evaluated in veterans; a population with greater medical and mental health morbidity and more severe sleep difficulties than non-veterans. Moreover, those with mental health conditions have been largely excluded from prior CBTi self-help trials. Stablishing the efficacy of provider-supported Self-help CBTi is an important first step for expanding veteran access to CBTi.

METHODS

In a 2-armed randomized controlled trial, a provider-supported self-help CBTi (Tele-Self CBTi) is compared to Health Education for improving insomnia severity (primary outcome) among treatment-seeking veterans with insomnia disorder. Tele-Self CBTi is comprised of two treatment components: self-help CBTi via a professionally designed manual developed using an iterative process of expert review and patient input; and 6 telephone-based support sessions lasting >20 min. Outcomes are assessed at baseline, 8 weeks, and 6 months after baseline. The primary outcome, insomnia severity, is measured using the Insomnia Severity Index. Secondary outcomes include self-reported and actigraphy-assessed sleep, fatigue, depression symptoms, and sleep-related quality of life.

CONCLUSION

Innovative approaches are essential to improving overall health among veterans; a population with highly prevalent insomnia disorder. If effective, Tele-Self CBTi may bridge the gap between unavailable resources and high demand for CBTi and serve as the entry level intervention in a stepped model of care.

CLINICAL TRIALS

GOV IDENTIFIER

NCT03727438.

What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study

BACKGROUND

Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making.

METHODS

We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses.

RESULTS

Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine.

CONCLUSION

Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.

Comparison of weight captured via electronic health record and cellular scales to the gold‐standard clinical method

Introduction

Obtaining body weights remotely could improve feasibility of pragmatic trials. This investigation examined whether weights collected via cellular scale or electronic health record (EHR) correspond to gold standard in-person study weights.

Methods

The agreement of paired weight measurements from cellular scales were compared to study scales from a weight loss intervention and EHR-collected weights were compared to study scales from a weight loss maintenance intervention. Differential weight change estimates between intervention and control groups using both pragmatic methods were compared to study collected weight. In the Log2Lose feasibility weight loss trial, in-person weights were collected bi-weekly and compared to weights collected via cellular scales throughout the study period. In the MAINTAIN weight loss maintenance trial, in-person weights were collected at baseline, 14, 26, 42 and 56 weeks. All available weights from the EHR during the study period were obtained.

Results

On average, in Log2Lose cellular scale weights were 0.6 kg (95% CI: -2.9, 2.2) lower than in-person weights; in MAINTAIN, EHR weights were 2.8 kg (SE: -0.5, 6.0) higher than in-person weights. Estimated weight change using pragmatic methods and study scales in both studies were in the same direction and of similar magnitude.

Conclusion

Both methods can be used as cost-effective and real-world surrogates within a tolerable variability for the gold-standard.

Trial registration

NCT02691260; NCT01357551.

The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer

BACKGROUND

The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations.

METHODS

A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test.

RESULTS

Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy.

CONCLUSION

Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.

Development and Initial Validation of a Systemic Lupus Erythematosus-Specific Measure of the Extent of and Reasons for Medication Nonadherence

OBJECTIVE

Medication nonadherence is common in patients with systemic lupus erythematosus (SLE) and negatively affects outcomes. To better recognize and address nonadherence in this population, there is a need for an easily implementable tool with interpretable scores. Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) is a measure that captures both extent of and reasons for nonadherence. We refined and evaluated DOSE-Nonadherence for patients with SLE.

METHODS

We refined the reasons for the nonadherence domain of DOSE-Nonadherence through rheumatologist feedback and patient cognitive interviewing. We then administered the refined instrument to patients prescribed oral SLE medications and compared the results to the Beliefs About Medicines Questionnaire (BMQ), the Medication Adherence Self-Report Inventory (MASRI), medication possession ratios (MPRs), and hydroxychloroquine (HCQ) blood levels using Pearson correlations.

RESULTS

Five rheumatologists provided feedback; 16 patients (median age 43 yrs, 100% female, 50% Black) participated in cognitive interviews and 128 (median age 49 yrs, 95% female, 49% Black, 88% on antimalarials, and 59% on immunosuppressants) completed the refined instrument. Items assessing extent of nonadherence produced reliable scores (α 0.89) and identified 47% as nonadherent. They showed convergent validity with MASRI (r = -0.57), HCQ blood levels (r = -0.55), to a lesser extent MPRs (r = -0.34 to -0.40), and discriminant validity with BMQ domains (r = -0.27 to 0.32). Nonadherent patients reported on average 3.5 adherence barriers, the most common being busyness/forgetting (62%), physical fatigue (38%), and pill fatigue (33%).

CONCLUSION

Our results support the reliability and validity of DOSE-Nonadherence for SLE medications. This refined instrument, DOSE-Nonadherence-SLE, can be used to identify, rigorously study, and guide adherence intervention development in SLE.

An Innovation to Expand the Reach of Peer Support: A Feasibility and Acceptability Study

INTRODUCTION

Peer support is a well-established part of veteran care and a cost-effective way to support individuals pursuing health behavior change. Common models of peer support, peer coaching, and mutual peer support have limitations that could be minimized by building on the strengths of each to increase the overall reach and effectiveness. We conducted a 12-week, proof-of-concept study to test the acceptability and feasibility of a hybrid model of peer support which supplements dyadic mutual peer support with as-needed peer coaching.

MATERIALS AND METHODS

We tested our novel peer support model within the context of cardiovascular disease (CVD) risk reduction as a support mechanism for the promotion of heart-healthy diet and exercise behaviors. We recruited peer buddies (participants who would be matched with each other to provide mutual support) with at least one uncontrolled CVD risk factor (i.e., blood pressure, weight, or diabetes) and peer coaches (individuals who would provide additional, as-needed support for peer buddies) with a recent history of CVD health behavior improvement. We aimed for 50% of peer buddies to be women to assess for potential gender differences in intervention engagement. Participants received didactic instruction during three group sessions, and peer dyads were instructed to communicate weekly with their peer buddy to problem-solve around action plans and behavioral goals. We tracked frequency of dyadic communication and conducted semi-structured interviews at the intervention's end to assess acceptability.

RESULTS

We recruited three peer coaches and 12 peer buddies. Ten buddies (five dyads) met at the first group session, and all were still in weekly contact with each other at week 12. Peer buddies had a mean of 8.75 out of 12 possible weekly peer buddy communications (range 6-15 in total). Peer coaches provided additional support to four participants over 12 weeks. Participants reported liking the intervention, including mixed-gender groups. Clarity and expectation setting around the role of peer coaches were important.

CONCLUSIONS

The supplementation of mutual peer support with as-needed peer coaching is an acceptable and feasible way to expand the potential reach and effectiveness of peer support for behavior change among veterans.

A Method to Deliver Automated and Tailored Intervention Content: 24-month Clinical Trial

Background

The use of digital technologies and software allows for new opportunities to communicate and engage with research participants over time. When software is coupled with automation, we can engage with research participants in a reliable and affordable manner. Research Electronic Data Capture (REDCap), a browser-based software, has the capability to send automated text messages. This feature can be used to automate delivery of tailored intervention content to research participants in interventions, offering the potential to reduce costs and improve accessibility and scalability.

Objective

This study aimed to describe the development and use of 2 REDCap databases to deliver automated intervention content and communication to index participants and their partners (dyads) in a 2-arm, 24-month weight management trial, Partner2Lose.

Methods

Partner2Lose randomized individuals with overweight or obesity and cohabitating with a partner to a weight management intervention alone or with their partner. Two databases were developed to correspond to 2 study phases: one for weight loss initiation and one for weight loss maintenance and reminders. The weight loss initiation database was programmed to send participants (in both arms) and their partners (partner-assisted arm) tailored text messages during months 1-6 of the intervention to reinforce class content and support goal achievement. The weight maintenance and reminder database was programmed to send maintenance-related text messages to each participant (both arms) and their partners (partner-assisted arm) during months 7-18. It was also programmed to send text messages to all participants and partners over the course of the 24-month trial to remind them of group classes, dietary recall and physical activity tracking for assessments, and measurement visits. All text messages were delivered via Twilio and were unidirectional.

Results

Five cohorts, comprising 231 couples, were consented and randomized in the Partner2Lose trial. The databases will send 53,518 automated, tailored text messages during the trial, significantly reducing the need for staff to send and manage intervention content over 24 months. The cost of text messaging will be approximately US $450. Thus far, there is a 0.004% known error rate in text message delivery.

Conclusions

Our trial automated the delivery of tailored intervention content and communication using REDCap. The approach described provides a framework that can be used in future behavioral health interventions to create an accessible, reliable, and affordable method for intervention delivery and engagement that requires minimal trial-specific resources and personnel time.

Trial Registration

ClinicalTrials.gov NCT03801174; https://clinicaltrials.gov/ct2/show/NCT03801174?term=NCT03801174

Promoting patient engagement during care transitions after surgery using mobile technology: Lessons learned from the MobiMD pilot study

BACKGROUND

Poorly coordinated transitions of care in complex abdominal surgery patients contribute to frequent hospital readmissions and inflated healthcare spending. Mobile health (mHealth) transitional care technologies may reduce surgical readmissions yet remain understudied in high-risk surgical populations.

METHODS

We conducted a single-group, prepost study of a mHealth transitional care app in 50 complex surgical patients. Eligible patients were adults undergoing complex abdominal surgery in the divisions of Surgical Oncology and Colorectal Surgery. The main outcome was app engagement, calculated by notification response rate (number of participant-entered datapoints divided by the total number of app-requested datapoints) over the 30-day postoperative period. Secondary outcomes included changes in engagement over time and by individual app feature.

RESULTS

A total of 85% (50/59) of eligible patients enrolled. Most participants were male (58%, n = 29), and mean age was 50 years (range 24-80 years). Overall notification response rate was 28%. Among the 58% of participants (29/50) who engaged with the app at least once after discharge (app users), the average notification response rate was 45%. The mean notification response rate among app users decreased over time from 50% to 32% between weeks 1 and 4 after hospital discharge. Engagement with individual app features ranged from 48-81%, with highest engagement for symptom reports and lowest engagement for wound care instructions.

CONCLUSION

mHealth transitional care is feasible in complex surgical patients using only patients' existing smart devices. Randomized controlled trials are required to determine the impact on hospital readmissions, surgical outcomes, patient satisfaction, and overall resource utilization.

Validation of the Turkish version of the DOSE-Nonadherence measure among patients with cardiometabolic conditions

WHAT IS KNOWN AND OBJECTIVE

There are no validated self-report measures to assess extent of and reasons for medication nonadherence in the Turkish language. The aim of this study is to evaluate validity and reliability of the Domains of Subjective Extent of Nonadherence Scale, which assesses extent of and reasons for nonadherence in Turkish patients with hypertension, diabetes mellitus and/or dyslipidaemia in community pharmacy settings.

METHODS

The Turkish version of the DOSE-Nonadherence scale was developed through translation and cultural adaption. Psychometric properties of the scale were evaluated in a cross-sectional study among 203 patients who visited six community pharmacies located in Istanbul, Turkey between November 2020 and March 2021. For the extent of nonadherence domain, reliability was estimated through Cronbach's alpha, and convergent validity was evaluated with Spearman's rank correlation with the validated Turkish version of the Medication Adherence Report Scale (MARS). Reasons for nonadherence were characterized among participants reporting nonadherence to the extent of nonadherence items. The measure was administered at baseline and 2 weeks later to 30 patients to estimate stability of extent scores using the Wilcoxon test and intraclass correlation coefficient. p < 0.05 was set as the level of statistical significance.

RESULTS

Among the 203 participants (65 male), the median (25th-75th percentiles) age was 59.0 years [51.0-67.0]. Cronbach's alpha for the extent of nonadherence scale was 0.86. A moderate negative correlation (r = -0.58; p < 0.001) was found between the extent of nonadherence scores and MARS, supporting convergent validity. The most common reasons for medication nonadherence were forgetfulness (22.5%) and mismatch between the patients' daily routine and medication taking (17.5%). The intraclass correlation coefficient was 0.97 for extent of nonadherence scores at baseline and 2 weeks (p < 0.001).

WHAT IS NEW AND CONCLUSION

The DOSE-Nonadherence Scale could be used to identify nonadherent patients and their reasons for nonadherence in Turkish patients with chronic cardiometabolic conditions. This scale can be used to evaluate clinical pharmacist-led services to reduce medication nonadherence. Nonadherence could be recorded longitudinally in electronic health records to provide a more accurate picture of medication use. Pharmacists or other providers could administer interventions tailored to patients' reasons for nonadherence.

Factors associated with non-adherence to insulin and non-insulin medications in patients with poorly controlled diabetes

OBJECTIVES

To evaluate differences in factors associated with self-reported medication non-adherence to insulin and non-insulin medications in patients with uncontrolled type 2 diabetes.

METHODS

In this secondary analysis of a randomized trial in patients with obesity and uncontrolled type 2 diabetes, multivariable logistic regression was used to evaluate associations between several clinical factors (measured with survey questionnaires at study baseline) and self-reported non-adherence to insulin and non-insulin medications.

RESULTS

Among 263 patients, reported non-adherence was 62% (52% for insulin, 55% for non-insulin medications). Reported non-adherence to non-insulin medications was less likely in white versus non-white patients (odds ratio (OR) = 0.42; 95%CI: 0.22,0.80) and with each additional medication taken (OR = 0.75; 95%CI: 0.61,0.93). Non-adherence to non-insulin medications was more likely with each point increase in a measure of diabetes medication intensity (OR = 1.43; 95%CI: 1.01,2.03), the Problem Areas in Diabetes (PAID) score (OR = 1.06; 95%CI: 1.02,1.12), and in men versus women (OR = 3.03; 95%CI: 1.06,8.65). For insulin, reporting non-adherence was more likely (OR = 1.02; 95%CI: 1.00,1.04) with each point increase in the PAID.

DISCUSSION

Despite similar overall rates of reported non-adherence to insulin and non-insulin medications, factors associated with reported non-adherence to each medication type differed. These findings may help tailor approaches to supporting adherence in patients using different types of diabetes medications.

Protocol for the MobiMD trial: A randomized controlled trial to evaluate the effect of a self-monitoring mobile app on hospital readmissions for complex surgical patients

BACKGROUND

Hospital readmissions are estimated to cost $17.4 billion per year in the Medicare population alone, with readmission rates as high as 30% for patients undergoing complex abdominal surgery. Improved transitional care and self-monitoring may reduce preventable readmissions for such high-risk populations. In this study, we will conduct a single-institution randomized controlled trial (RCT) to assess the effect of a novel transitional care mobile app, MobiMD, on hospital readmission in complex abdominal surgery patients.

METHODS

Three hundred patients will be randomized 1:1 to standard of care (SOC) versus SOC plus MobiMD app in a parallel, single-blinded, two-arm RCT. Eligible patients are those who undergo complex abdominal surgery in the division of Surgical Oncology, Colorectal Surgery or Transplant Surgery. The MobiMD app provides push notification reminders directly to the patient's smart device, prompting them to enter clinical data and patient-reported outcomes. Clinical data collected via the MobiMD app include vital signs, red flag symptoms, daily wound and surgical drain images, ostomy output, drain output, medication compliance, and wound care compliance. These data are reviewed daily by a physician. The primary outcome is the proportion of participants readmitted to the hospital within 30 days of surgery. Secondary outcomes are 90-day hospital readmission, emergency department and urgent care visits, complication severity, and total readmission cost.

DISCUSSION

If effective, mobile health apps such as MobiMD could be routinely integrated into surgical transitional care programs to minimize unnecessary hospital readmissions, emergency department visits and healthcare resource utilization. Clinical trials identifier: NCT04540315.

Validating a Self-Reported Medication Nonadherence Measure in the Context of Multiple Chronic Diseases and Routes of Medication Administration Among Patients with Type 2 Diabetes

INTRODUCTION

Patients with diabetes may take oral and injectable medications and often have comorbid chronic diseases. It is unclear whether to assess nonadherence for oral and injectable medications separately or combined and for comorbid conditions separately or combined.

RESEARCH DESIGN AND METHODS

We conducted two cognitive interview studies among patients with type 2 diabetes who were prescribed medications for oral or injectable diabetes medications (Study 1) or at least one diabetes, blood pressure, and cholesterol medication (Study 2). Participants completed the two-domain DOSE-Nonadherence measure, which assesses extent of nonadherence and reasons for nonadherence. We asked about interpretation of instructions and items, recall period, ability to respond accurately with separate versus combined versions, and comprehensiveness of reasons for nonadherence to injectable medications.

RESULTS

Based on Study 1 (n=14), nonadherence to injectable and oral medications should be assessed separately. Participants believe they can respond accurately to 7-day recall period for daily medications and a one-month recall period for weekly injectable medications. New reasons for nonadherence to injectable medications were perceived as relevant. Based on Study 2 (n-12), nonadherence to medications for diabetes, blood pressure, and cholesterol should be assessed separately.

CONCLUSION

Although separate versions increase response time, it may improve accuracy. Responses to the measure can facilitate conversations about nonadherence between providers and patients to inform clinical decision-making.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration

OBJECTIVE

To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers.

SUMMARY OF BACKGROUND DATA

Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration.

METHODS

We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use.

RESULTS

Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time.

CONCLUSIONS

Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Individual-level barriers to bariatric surgery from patient and provider perspectives: A qualitative study

BACKGROUND

Less than 1% adults in the United States who meet body mass index criteria undergo bariatric surgery. Our objective was to identify patient and provider perceptions of individual-level barriers to undergoing bariatric surgery.

METHODS

Adults with severe obesity and obesity care providers described their experiences with the bariatric surgery care process in semi-structured interviews. Using conventional content analysis, individual-level barriers were identified within Andersen's Behavioral Model of Health Services Use.

RESULTS

Of the 73 individuals interviewed, 36 (49%) were female, and 15 (21%) were non-white. Six individual-level barriers were identified: fear of surgery, fear of lifestyle change, perception that weight had not reached its "tipping point," concerns about dietary changes, lack of social support, and patient characteristics influencing referral.

CONCLUSIONS

Patient and provider education should address patient fears of surgery and the belief that surgery is a "last resort." Bariatric surgery programs should strengthen social support networks for patients.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Clinical associations of an updated medication effect score for measuring diabetes treatment intensity

OBJECTIVES

The medication effect score reflects overall intensity of a diabetes regimen by consolidating dosage and potency of agents used. Little is understood regarding how medication intensity relates to clinical factors. We updated the medication effect score to account for newer agents and explored associations between medication effect score and patient-level clinical factors.

METHODS

Cross-sectional analysis of baseline data from a randomized controlled trial involving 263 Veterans with type 2 diabetes and hemoglobin A1c levels ≥8.0% (≥7.5% if under age 50). Medication effect score was calculated for all patients at baseline, alongside additional measures including demographics, comorbid illnesses, hemoglobin A1c, and self-reported psychosocial factors. We used multivariable regression to explore associations between baseline medication effect score and patient-level clinical factors.

RESULTS

Our sample had a mean age of 60.7 (SD = 8.2) years, was 89.4% male, and 57.4% non-White. Older age and younger onset of diabetes were associated with a higher medication effect score, as was higher body mass index. Higher medication effect score was significantly associated with medication nonadherence, although not with hemoglobin A1c, self-reported hypoglycemia, diabetes-related distress, or depression.

DISCUSSION

We observed several expected associations between an updated medication effect score and patient-level clinical factors. These associations support the medication effect score as an appropriate measure of diabetes regimen intensity in clinical and research contexts.

The Influence of Emotions on Treatment Decisions About Low-Risk Thyroid Cancer: A Qualitative Study

Background: Little is known about the role of emotions in treatment decisions for thyroid cancer. We aimed to characterize the emotional content of patient-surgeon communication during decision-making about low-risk thyroid cancer treatment. Methods: We audio-recorded conversations about treatment for clinically low-risk thyroid cancer or biopsy suspicious for thyroid cancer between patients (n = 30) and surgeons (n = 9) in two diverse, academic hospitals in the United States. Inductive and deductive content analyses were used to characterize the emotional content in verbatim transcripts. Results: Patients' expression of emotion focused on primarily on their diagnosis and treatment outcomes. Patients commonly expressed negative emotions like fear and anxiety about "the C-word" and worried about the cancer growing or spreading. In response, most surgeons used education, as opposed to empathy or validation, to reassure patients, often highlighting low probabilities of adverse events. Surgeons emphasized the "slow-growing" nature and excellent prognosis of thyroid cancer compared with other malignancies. When discussing treatment options, surgeons often described alternatives in terms of their emotional outcomes. Some described total thyroidectomy as providing "peace of mind" or a "sense of completeness," warning that cancer or thyroid tissue remaining in the body with active surveillance or lobectomy might "worry" or "bother" patients. Surgeons supported deliberation by reassuring patients that there are "two right answers" and "no rush" to decide. Conclusions: Patients express negative emotions during treatment decision-making. In response, surgeons often miss opportunities to provide empathy in addition to education. Surgeons and patients both acknowledge patient fear and anxiety as a reason to choose thyroidectomy instead of active surveillance. Peace of mind gained by patients and surgeons as a result of thyroidectomy may lead to overtreatment of patients with low-risk thyroid cancer.

Patient experiences with a phone-based cardiovascular risk reduction intervention: Are there differences between women and men?

OBJECTIVES

To explore gender-based differences in experiences with a telehealth-delivered intervention for reduction of cardiovascular risk.

METHODS

We conducted 23 semi-structured qualitative interviews by telephone with 11 women and 12 men who received a 12-month, pharmacist-delivered, telephone-based medication and behavioral management intervention. We used content analysis to identify themes.

RESULTS

We identified three common themes for both men and women: ease and convenience of phone support, preference for proactive outreach, and need for trust building in the context of telehealth. While both genders appreciated the social support from the intervention pharmacist, women voiced appreciation for accountability whereas men generally spoke about encouragement.

CONCLUSIONS

Rapport building may differ between telehealth and in-person healthcare visits; our work highlights how men and women's experiences can differ with telehealth care and which can inform the development of future, purposeful rapport building activities to strengthen the clinician-patient interaction.

PRACTICE IMPLICATIONS

Clinicians should seek opportunities to provide frequent and routine support for patients with chronic disease. Telehealth interventions may benefit from gender-specific tailoring of social support.

Heterogeneity of Treatment Effects Among Patients With Type 2 Diabetes and Elevated Body Mass Index in a Study Comparing Group Medical Visits Focused on Weight Management and Medication Intensification

BACKGROUND

Illuminating heterogeneity of treatment effect (HTE) within trials is important for identifying target populations for implementation.

OBJECTIVE

The aim of this study was to examine HTE in a trial of group medical visits (GMVs) for patients with type 2 diabetes and elevated body mass index.

RESEARCH DESIGN AND MEASURES

Participants (n=263) were randomized to GMV-based medication management plus low carbohydrate diet-focused weight management (WM/GMV; n=127) or GMV-based medication management alone (GMV; n=136) for diabetes control. We used QUalitative INteraction Trees, a tree-based clustering method, to identify subgroups with greater improvement in hemoglobin A1c (HbA1c) and weight from either WM/GMV or GMV. Subgroup predictors included 32 baseline demographic, clinical, and psychosocial factors. Internal validation was conducted to estimate bias in the range of mean outcome differences between arms.

RESULTS

QUalitative INteraction Trees analyses indicated that for patients who had not previously attempted weight loss, WM/GMV resulted in better glycemic control than GMV (mean difference in HbA1c improvement=1.48%). For patients who had previously attempted weight loss and had lower cholesterol and blood urea nitrogen, GMV was better than WM/GMV (mean difference in HbA1c improvement=1.51%). No treatment-subgroup effects were identified for weight. Internal validation resulted in moderate corrections in mean HbA1c differences between arms; however, differences remained in the clinically significant range.

CONCLUSION

This work represents a novel step toward targeting care approaches for patients to maximize benefit based on individual patient characteristics.

Gulf War Era Veterans' perspectives on research: a qualitative study

AIMS

Many veterans of the 1990-1991 Gulf War Era (GWE) have experienced poorly understood health issues. In response to challenges recruiting this population for research, we conducted focus groups and semi-structured phone interviews with GWE veterans and subject matter experts (SMEs) to explore GWE veterans' perceptions about research.

MAIN METHODS

Transcribed discussions were content-analyzed. Participants discussed research-related motivators and barriers identified among other populations, and nuances that may be specific to GWE veterans.

KEY FINDINGS

Examples of motivating factors included: seeking answers about causes of and treatment for health issues; helping oneself; and helping other veterans. Examples of barriers included: distrust and dissatisfaction with federal entities; lack of research follow-through; and concerns about privacy and confidentiality.

SIGNIFICANCE

Researchers can use this information to better address GWE veterans' concerns and motivate them to participate in research. Inclusion of GWE veterans in research will allow researchers and clinicians to better understand and address health issues affecting this population.

Evaluation of the Veterans Affairs Pharmacogenomic Testing for Veterans (PHASER) clinical program at initial test sites

Aim: The first Plan-Do-Study-Act cycle for the Veterans Affairs Pharmacogenomic Testing for Veterans pharmacogenomic clinical testing program is described. Materials & methods: Surveys evaluating implementation resources and processes were distributed to implementation teams, providers, laboratory and health informatics staff. Survey responses were mapped to the Consolidated Framework for Implementation Research constructs to identify implementation barriers. The Expert Recommendation for Implementing Change strategies were used to address implementation barriers. Results: Survey response rate was 23-73% across personnel groups at six Veterans Affairs sites. Nine Consolidated Framework for Implementation Research constructs were most salient implementation barriers. Program revisions addressed these barriers using the Expert Recommendation for Implementing Change strategies related to three domains. Conclusion: Beyond providing free pharmacogenomic testing, additional implementation barriers need to be addressed for improved program uptake.

A randomized feasibility pilot trial of a financial incentives intervention for dietary self-monitoring and weight loss in adults with obesity

Financial incentives could be used to improve adherence to behavioral weight loss interventions, increasing their effectiveness. This Phase IIb randomized pilot study evaluated the feasibility and acceptability of a study protocol for providing financial incentives for dietary self-monitoring and/or weight loss. Community-dwelling adults with obesity were enrolled in a 24 week, group-based weight loss program. Participants were randomized in a 2 × 2 factorial design to receive financial incentives for both dietary self-monitoring and weekly weight loss, just one, or neither. Participants could earn up to $300, evolving from fixed weekly payments to intermittent, variable payments. The notice of reward was provided by text message. The study was conducted in three successive cohorts to evaluate study procedure changes, including dietary approach, recruitment and retention strategies, text messaging, and incentives. Descriptive statistics calculated separately for each cohort described study performance relative to predefined targets for recruitment, including minority representation; retention; adherence; and weight loss. Acceptability was assessed via postintervention qualitative interviews. In Cohort 1 (n = 34), a low-carbohydrate diet was used. Recruitment, retention, adherence, and weight loss were adequate, but minority representation was not. For Cohort 2 (n = 31), employing an additional recruitment method and switching to a reduced-calorie diet yielded adequate recruitment, minority representation, retention, and adherence but less weight loss. Returning to a low-carbohydrate diet in Cohort 3 (n = 28) yielded recruitment, minority representation, retention, adherence, and weight loss similar to Cohort 2. Participant feedback informed changes to text message timing and content and incentive amount. Through successive cohorts, we optimized recruitment and retention strategies and text messaging. An adequately powered trial is warranted to evaluate the efficacy of these incentive structures for reducing weight. The trial registration number is NCT02691260.

Measuring the multiple domains of medication nonadherence: findings from a Delphi survey of adherence experts

Consensus on a gold-standard measure of patient medication nonadherence has been elusive, in part because medication nonadherence involves multiple, distinct behaviors across three phases (initiation, implementation, and persistence). To assess these behaviors, multiple measurement approaches may be needed. The purpose of this study was to identify expert-recommended approaches to measuring nonadherence behaviors. Thirty medication nonadherence experts were e-mailed two consecutive surveys. In both, respondents rated their agreement with definitions of nonadherence behaviors and measurement approaches. In the second survey, respondents rated the suitability of each measurement approach for assessing each behavior and identified the optimal measurement approach for each behavior. Consensus was achieved for eight patient medication nonadherence behaviors: not filling initial prescription and not taking first dose (noninitiation); refilling prescription late, missing doses, taking extra doses, taking doses at wrong time, and improperly administering medication (incorrect implementation); and discontinuing medication early (nonpersistence). Consensus was achieved for seven measurement approaches: self-report, prescription fill data, pill count, drug levels, electronic drug monitoring (EDM), smart technology, and direct observation. Self-report questionnaires were most commonly rated "at least somewhat suitable" for measuring behaviors. EDM was rated as optimal for measuring missing doses, taking extra doses, and taking doses at the wrong time. Prescription fill data were rated as optimal for not filling initial prescription, refilling late, and discontinuing. Direct observation was rated as optimal for measuring improper administration. Suitable and optimal measurement approaches varied across nonadherence behaviors. Researchers should select the measurement approach best suited to assessing the behavior(s) targeted in their research.

Prevalence of High-Grade Anal Dysplasia and Anal Cancer in Veterans Living With HIV and CD4/CD8 Ratio as a Marker For Increased Risk: A Regional Retrospective Cohort Study

BACKGROUND

The Department of Veterans Affairs cares for the largest population of patients with HIV of any healthcare system in the United States. Screening for anal dysplasia/cancer is recommended for all veterans with HIV. Exams are invasive, burdensome, and resource intensive. We currently lack markers of disease to tailor screening.

OBJECTIVE

The purpose of this study was to establish the prevalence of advanced anal disease (high-grade dysplasia and anal cancer) and to determine whether CD4/CD8 ratio correlates with risk.

DESIGN

This was a retrospective regional cohort study of veterans with HIV.

SETTINGS

The study was conducted at eight medical centers between 2001 and 2019.

PATIENTS

Patients with advanced disease were compared with patients with nonadvanced anal pathology.

MAIN OUTCOME MEASURES

Logistic regression modeling was used to estimate adjusted odds of disease as a function of CD4/CD8. Lowest (nadir) CD4/CD8 and nearest CD4/CD8 ratio in each cohort were evaluated.

RESULTS

A total of 2267 veterans were included. Fifteen percent had anal pathology (112 with advanced disease (37 cancer and 75 high-grade), 222 with nonadvanced disease). Nadir and nearest ratio were lower in patients with advanced disease versus nonadvanced (0.24 vs 0.45 (p < 0.001) and 0.50 vs 0.88 (p < 0.001)). In adjusted models, a 1-unit increase in nadir or nearest ratio conferred decreased risk of advanced disease (OR = 0.19 (95% CI, 0.07-0.53); p < 0.001; OR = 0.22 (95% CI, 0.12-0.43); p < 0.001). Using a minimum sensitivity analysis, a cutoff nadir ratio of 0.42 or nearest ratio of 0.76 could be used to risk stratify.

LIMITATIONS

This was a retrospective analysis with a low screening rate.

CONCLUSIONS

In a regional cohort of veterans with HIV, 15% were formally assessed for anal dysplasia. Advanced anal disease was present in 33% of those screened, 5% of the HIV-positive population. A strong predictor of advanced disease in this cohort is the CD4/CD8 ratio, which is a promising marker to stratify screening practices. Risk stratification using CD4/CD8 has the potential to decrease burdensome invasive examinations for low-risk patients and to intensify examinations for those at high risk. See Video Abstract at http://links.lww.com/DCR/B528.

PREVALENCIA DE DISPLASIA ANAL DE ALTO GRADO Y CNCER ANAL EN VETERANOS QUE VIVEN CON EL VIH Y LA RELACIN CD / CD COMO MARCADOR DE MAYOR RIESGO UN ESTUDIO DE COHORTE REGIONAL RETROSPECTIVE

ANTECEDENTES:El Departamento de Asuntos de Veteranos atiende a la población más grande de pacientes con el virus de inmunodeficiencia humana (VIH) de cualquier sistema de salud en los Estados Unidos. Se recomienda la detección de displasia / cáncer anal para todos los veteranos con VIH. Los exámenes son invasivos, onerosos y requieren muchos recursos. Actualmente carecemos de marcadores de enfermedad para adaptar la detección.OBJETIVO:Establecer la prevalencia de enfermedad anal avanzada (displasia de alto grado y cáncer anal) y determinar si la relación CD4 / CD8 se correlaciona con el riesgo.DISEÑO:Estudio de cohorte regional retrospectivo de veteranos con VIH.AJUSTE:Ocho centros médicos entre 2001-2019.PACIENTES:Se comparó a pacientes con enfermedad avanzada con pacientes con patología anal no avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó un modelo de regresión logística para estimar las probabilidades ajustadas de enfermedad en función de CD4 / CD8. Se evaluó la relación CD4 / CD8 más baja (nadir) y la relación CD4 / CD8 más cercana en cada cohorte.RESULTADOS:Se incluyeron un total de 2267 veteranos. El 15% tenía patología anal (112 enfermedad avanzada (37 cáncer, 75 de alto grado), 222 enfermedad no avanzada). El nadir y el cociente más cercano fueron menores en los pacientes con enfermedad avanzada frente a los no avanzados (0,24 frente a 0,45 (p <0,001) y 0,50 frente a 0,88 (p <0,001)), respectivamente. En modelos ajustados, el aumento de una unidad en el nadir o el cociente más cercano confirió una disminución del riesgo de enfermedad avanzada (OR 0,19 (IC del 95%: 0,07, 0,53, p <0,001)) y (OR 0,22 (IC del 95%: 0,12, 0,43, p <0,001))), respectivamente. Utilizando un análisis de sensibilidad mínima, se podría utilizar un cociente del nadir de corte de 0,42 o el cociente más cercano de 0,76 para estratificar el riesgo.LIMITACIONES:Análisis retrospectivo con una tasa de detección baja.CONCLUSIONES:En una cohorte regional de veteranos con VIH, el 15% fueron evaluados formalmente por displasia anal. La enfermedad anal avanzada estuvo presente en el 33% de los examinados, el 5% de la población VIH +. Un fuerte predictor de enfermedad avanzada en esta cohorte es la relación CD4 / CD8, que es un marcador prometedor para estratificar las prácticas de detección. La estratificación del riesgo usando CD4 / CD8 tiene el potencial de disminuir los exámenes invasivos onerosos para los pacientes de bajo riesgo e intensificar los exámenes para los de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B528.

Protocol and short-term results for a feasibility randomized controlled trial of a video intervention for Veterans with obesity: The TOTAL (Teaching Obesity Treatment Options to Adult Learners) pilot study

Introduction

All three evidence-based treatment options for adults with severe obesity – behavioral weight management, weight management medications (WMM), and bariatric surgery – are underutilized in the Veterans Health Administration (VHA) system. Our objective in this study was to develop and pilot-test the TOTAL (Teaching Obesity Treatment Options to Adult Learners) intervention, which seeks to increase Veteran participation in obesity treatment.

Methods

In this single-site, parallel, pilot RCT, Veterans with severe obesity with an upcoming behavioral weight management visit were sent a recruitment letter after meeting inclusion/exclusion criteria via electronic health record screening. Eligible Veterans were randomized to TOTAL or usual care. TOTAL consisted of an 18-min video highlighting obesity health risks and treatment outcomes, eligibility criteria, and pros/cons of all three evidence-based obesity treatments. The primary outcomes were trial design feasibility (recruitment and retention rates) and acceptability to Veterans, which was assessed via semi-structured interviews with participants one week after randomization to TOTAL. Secondary outcomes included attitudes and self-efficacy to initiate treatment one week post-randomization and BMI change six months post-randomization (assessed via Cohen's d).

Results

Forty-two Veterans were randomized (recruitment rate = 47.2%), and 40/42 completed one-week assessments (retention rate = 95.2%). The mean participant age was 59.2 ± 11.9 years. Female and non-White participants comprised 14.3% and 11.9% of the cohort, respectively. Semi-structured interviews with all 20 participants who received TOTAL suggested that the delivery logistics and content of TOTAL were acceptable to Veterans. Attitudes toward behavioral weight management and bariatric surgery and weight loss improved in TOTAL vs. usual care patients (Cohen's d ranging from 0.3 to 0.6).

Conclusions

TOTAL was feasible to implement, acceptable to Veterans, and has the potential to increase obesity treatment participation in VHA. An adequately powered RCT is warranted to assess its impact on population-level weight loss.

Trial registration

ClinicalTrials.gov NCT03856320.

Two-year weight trajectories following completion of a behavioral weight loss maintenance intervention

Introduction

Long‐term effects of behavioral weight loss maintenance interventions need to be assessed in order to understand their durability of effects. This can be evaluated with the use of weights recorded in the electronic medical record. The goal of this study was to use electronic health record (EHR)‐recorded weight to examine outcomes 2 years beyond the completion of a trial in which participants were randomized to receive a weight maintenance intervention or usual care after required initial weight loss.

Methods

Weights collected in the Veteran's Affairs national EHR were obtained for 2 years following trial completion. Outliers and implausible weights were identified and removed prior to analysis. Mixed‐effects models with quadratic time were fit to estimate between‐arm differences in weight change.

Results

Model‐estimated weight at trial completion was 109.7 kg for usual care and 106.8 kg for intervention, estimated difference of −2.9 kg (95% confidence interval [CI]: −8.8, 3.0; p = 0.34). Two years later, estimated mean weight collected from (n = 211) participants with available EMR weights was 111.5 kg for usual care and 108.0 kg for intervention, estimated difference −3.4 kg (95% CI: −9.3, 2.4 kg; p = 0.35).

Conclusions

While not statistically significant, weights from the EHR suggest the possibility of a clinically meaningful difference that should be confirmed by future adequately powered studies.

Prenatal care experiences among pregnant women with obesity in Wisconsin, United States: a qualitative quality improvement assessment

BACKGROUND

Stigma and bias experienced during prenatal care can affect quality of care and, ultimately, the health of pregnant women with obesity and their infants. We sought to 1) better understand the bias and stigma that women with BMIs ≥40 kg/m2 experience while receiving prenatal care, 2) gauge women's interest in group prenatal education for women with obesity, and 3) gather feedback about their preferred weight-related terminology.

METHODS

We conducted and thematically content-analyzed 30 semi-structured interviews of women with BMIs ≥40 kg/m2 who received prenatal care at a university-affiliated teaching hospital in the Midwest region of the United States.

RESULTS

All women recalled positive experiences during their perinatal care during which they felt listened to and respected by providers. However, many also described a fear of weight-related bias or recalled weight-based discrimination. Women reacted favorably to a proposed group prenatal care option for pregnant women with obesity that focused on nutrition, physical activity, and weight management. Women rated "weight" and "BMI" as the most desirable terms for describing weight, while "large size" and "obesity" were rated least desirable.

CONCLUSIONS

Many pregnant women with BMIs ≥40 kg/m2 experience bias in the prenatal care setting. Potential steps to mitigate bias towards weight include improving provider awareness of the experiences and perspectives of this population, expanding prenatal care options targeted towards women with high BMIs, including group care, and using patient-preferred weight-related terminology. Through the remainder of this manuscript, wherever possible, the term "high BMI" will be used in place of the term "obesity" to describe women with BMI ≥ 30 kg/m2 in order to respect the preferred terminology of the women we interviewed.

A web-based intervention to increase weight loss treatment initiation: results of a cluster randomized feasibility and acceptability trial

Evidence-based behavioral weight loss treatment is under-utilized. To increase initiation of treatment, we developed a single-session, online, primary care-based intervention ("mobilization tool"). We evaluated the mobilization tool's acceptability for primary care patients with obesity, trial design feasibility, and signal of an effect of the tool on treatment initiation. In this cluster randomized feasibility trial, primary care providers (PCPs) were randomized to a mobilization tool or comparator tool arm. Patients with obesity and a scheduled appointment with a randomized PCP were assigned to complete the mobilization or comparator tool prior to their appointment. The online mobilization tool asks patients to answer questions about a variety of weight-related topics and then provides automated, tailored feedback that addresses psychosocial determinants of weight loss treatment initiation. The comparator tool provided a nontailored description of treatments. All participants were offered free enrollment in behavioral weight loss treatments. Six PCPs were randomized. Sixty patients (57% female; 66% white; aged 55 ± 13 years) participated in this study of 296 contacted for eligibility evaluation (20.2%). Six-month follow-up assessments were completed by 65% (22/34) of the mobilization and 73% (19/26) of comparator tool participants. Participants completing the acceptability survey reported that the mobilization tool was usable, enjoyable, informative, and useful. Weight loss treatment was initiated by 59% (n = 19) of mobilization and 33% (n = 8) of comparator tool participants. The mobilization tool shows promise for increasing treatment initiation among primary care patients, which may increase population weight loss. Trial Registration: Clinicaltrials.gov identifier: NCT02708121.

Comparison of the Perspectives of Medical Students and Residents on the Surgery Learning Environment

BACKGROUND

The learning environment plays a critical role in learners' satisfaction and outcomes. However, we often lack insight into learners' perceptions and assessments of these environments. It can be difficult to discern learners' expectations, making their input critical. When medical students and surgery residents are asked to evaluate their teachers, what do they focus on?

MATERIALS AND METHODS

Open-ended comments from medical students' evaluations of residents and attending surgeons and from residents' evaluations of attendings during the 2016-2017 academic year were analyzed. Content analysis was used, and codes derived from the data. A matrix of theme by learner role was created to distinguish differences between medical student and resident learners. Subthemes were grouped based on similarity into high-order themes.

RESULTS

Two overarching themes were Creating a positive environment for learning by modeling professional behaviors and Intentionally engaging learners in training and educational opportunities. Medical students and residents made similar comments for the subthemes of appropriate demeanor, tone and dialog, respect, effective direct instruction, feedback, debriefing, giving appropriate levels of autonomy, and their expectations as team members on a service. Differences existed in the subthemes of punctuality, using evidence, clinical knowledge, efficiency, direct interactions with patients, learning outcomes, and career decisions.

CONCLUSIONS

Faculty development efforts should target professional communication, execution of teaching skills, and relationships among surgeons, other providers, and patients. Attendings should make efforts to discuss their approach to clinical decision making and patient interactions and help residents and medical students voice their opinions and questions through trusting adult learner-teacher relationships.

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.

Identifying End Users' Preferences about Structuring Pharmacogenetic Test Orders in an Electronic Health Record System

Pharmacogenetics (PGx) testing can be used for detecting genetic variations that may affect an individual's anticipated metabolism of, or response to, medications. Although several studies have focused on developing tools for delivering results from PGx testing, there is a relative dearth of information about how to design provider-friendly electronic order-entry systems for PGx. The U.S. Department of Veterans Affairs (VA) is preparing to implement a new electronic health records system. In this study, VA PGx test end users were surveyed about their preferences for how electronic test orders for PGx should be structured, including the nomenclature that should be used to search for and identify PGx-test orders, whether to offer single- versus multigene tests, and whether information about test methodology should be included in the order name. Responses were analyzed systematically to identify areas of agreement and disagreement with the survey options, and areas where respondents' opinions diverged. End users endorsed preferences for flexible ways to identify and order PGx tests and multigene panel tests; opinions on whether test methodology should be included in the test name were divergent. The results could be used for both informing the VA's new electronic health records implementation (including how PGx tests are searched for and ordered) and for providing insights for other health systems implementing PGx-testing programs.

Protocol for Partner2Lose: A randomized controlled trial to evaluate partner involvement on long-term weight loss

Background

Behavioral interventions produce clinically significant weight reduction, with many participants regaining weight subsequently. Most interventions focus on an individual, but dietary and physical activity behaviors occur with, or are influenced by, domestic partners. According to interdependence theory, couples who approach behavior change as a problem to be tackled together versus independently are more likely to utilize communal coping processes to promote behavior change. We utilized interdependence theory to develop a partner-assisted intervention to increase long-term weight loss.

Methods

Community-dwelling individuals (index participants) cohabitating with a partner with 1) overweight and at least one obesity-related comorbidity or 2) obesity are randomized to participate in a standard weight management program alone or with their partner. The weight management program involves biweekly, in-person, group sessions focusing on weight loss for six months, followed by three group sessions and nine telephone calls focusing on weight loss maintenance for twelve months. In the partner-assisted arm, partners participate in half of the group sessions and telephone calls. Couples receive training in principles of cognitive behavioral therapy for couples, including sharing thoughts and feelings and joint problem solving, to increase communal coping. The primary outcome is participant weight loss at 24 months, with caloric intake and moderate-intensity physical activity as secondary outcomes. Partner weight and caloric intake will also be analyzed. Mediation analyses will examine the role of interdependence variables and social support.

Discussion

This trial will provide knowledge about effective ways to promote long-term weight loss and the role of interdependence constructs in weight loss.

Clinical trials identifier: NCT 03801174.

Enhancing reproducibility using interprofessional team best practices

The pervasive problem of irreproducibility of preclinical research represents a substantial threat to the translation of CTSA-generated health interventions. Key stakeholders in the research process have proposed solutions to this challenge to encourage research practices that improve reproducibility. However, these proposals have had minimal impact, because they either 1. take place too late in the research process, 2. focus exclusively on the products of research instead of the processes of research, and/or 3. fail to take into account the driving incentives in the research enterprise. Because so much clinical and translational science is team-based, CTSA hubs have a unique opportunity to leverage Science of Team Science research to implement and support innovative, evidence-based, team-focused, reproducibility-enhancing activities at a project's start, and across its evolution. Here, we describe the impact of irreproducibility on clinical and translational science, review its origins, and then describe stakeholders' efforts to impact reproducibility, and why those efforts may not have the desired effect. Based on team-science best practices and principles of scientific integrity, we then propose ways for Translational Teams to build reproducible behaviors. We end with suggestions for how CTSAs can leverage team-based best practices and identify observable behaviors that indicate a culture of reproducible research.

"Hopes and wishes": Goals of high-need, high-cost older patients and their caregivers

OBJECTIVE

Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers.

METHODS

Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers.

RESULTS

HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security.

CONCLUSION

Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers.

PRACTICE IMPLICATIONS

Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population.

From Overdiagnosis to Overtreatment of Low-Risk Thyroid Cancer: A Thematic Analysis of Attitudes and Beliefs of Endocrinologists, Surgeons, and Patients

Introduction: The optimal management for patients with small, low-risk thyroid cancer is often debated. We aimed to characterize the attitudes and beliefs of providers and patients about management of small, low-risk thyroid cancer and how they relate to overtreatment. Methods: We conducted 34 semi-structured interviews with surgeons (n = 12), endocrinologists (n = 12), and patients with <1.5 cm papillary thyroid cancer (n = 10). Interviews probed about diagnosis and treatment decision-making, including nonoperative options. We used thematic analysis to identify themes related to overtreatment and created concept diagrams to map observed relationships between themes. Results: When providers discussed management of small, low-risk thyroid cancer, most felt that overtreatment was a problem, and some brought it up without prompting. Providers often believed that overtreatment results from overdiagnosis and relayed how the process commonly starts with incidental discovery of a thyroid nodule on imaging. Providers viewed biopsy of the nodule as a reflexive or habitual action. They ascribed inappropriate biopsy to lack of adherence to or knowledge of guidelines, radiologist recommendations, and the desire of patients and physicians to minimize diagnostic uncertainty. Providers described subsequent cancer diagnosis as an event that "opens Pandora's box" and often provokes a strong instinctive, culturally rooted need to proceed with surgery-specifically total thyroidectomy. Consequently, most providers felt that it is easier to prevent overdiagnosis than overtreatment and recommended strategies such as improving guideline adherence, resetting patients' expectations, and engaging the media. In contrast, patients did not bring up or openly discuss overtreatment or overdiagnosis. Some patients described the seemingly automatic process from an incidental finding to surgery. Their statements confirmed that the "need to know" was a major motivation for biopsying their nodule. Patients felt that once they had a cancer diagnosis, surgery was a foregone conclusion. Patients admitted their knowledge about thyroid nodules and cancer was low, leaving room for education about the need for biopsy and less extensive treatment options. Conclusions: Surgeons' and endocrinologists' attitudes and beliefs about overtreatment focus on the automaticity of overdiagnosis. Both patients and providers are cognizant of the cascade of clinical events that propel patients from incidental discovery of a thyroid nodule to surgery.

Early-phase study of a telephone-based intervention to reduce weight regain among bariatric surgery patients

OBJECTIVE

This study describes early-phase development of a behavioral intervention to reduce weight regain following bariatric surgery. We utilized the Obesity-Related Behavioral Intervention Trials model to guide intervention development and evaluation. We sought to establish recruitment, retention, and fidelity monitoring procedures; evaluate feasibility of utilizing weight from the electronic medical record (EMR) as an outcome; observe improvement in behavioral risk factors; and evaluate treatment acceptability.

METHOD

The intervention comprised 4 weekly telephone calls addressing behavior change strategies for diet, physical activity, and nutrition supplement adherence and 5 biweekly calls addressing weight loss maintenance constructs. Veterans (N = 33) who received bariatric surgery 9-15 months prior consented to a 16-week, pre-post study. Self-reported outcomes were obtained by telephone at baseline and 16 weeks. Clinic weights were obtained from the EMR 6 months pre- and postconsent. Qualitative interviews were conducted at 16 weeks to evaluate treatment acceptability. We aimed to achieve a recruitment rate of ≥ 25% and retention rate of ≥ 80%, and have ≥ 50% of participants regain < 3% of their baseline weight.

RESULTS

Results supported the feasibility of recruiting (48%) and retaining participants (93% provided survey data; 100% had EMR weight). Pre-post changes in weight (73% with < 3% weight regain) and physical activity (Cohen's ds 0.38 to 0.52) supported the potential for the intervention to yield clinically significant results. Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability.

CONCLUSIONS

The intervention should be evaluated in an adequately powered randomized controlled trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comparison of Group Medical Visits Combined With Intensive Weight Management vs Group Medical Visits Alone for Glycemia in Patients With Type 2 Diabetes: A Noninferiority Randomized Clinical Trial

IMPORTANCE

Traditionally, group medical visits (GMVs) for persons with diabetes improved glycemia by intensifying medications, which infrequently led to weight loss. Incorporating GMVs with intensive dietary change could enable weight loss and improve glycemia while decreasing medication intensity.

OBJECTIVE

To examine whether a program of GMVs combined with intensive weight management (WM) is noninferior to GMVs alone for change in glycated hemoglobin (HbA1c) level at 48 weeks (prespecified margin of 0.5%) and superior to GMVs alone for hypoglycemic events, diabetes medication intensity, and weight loss.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial identified via the electronic medical record 2814 outpatients with type 2 diabetes, uncontrolled HbA1c, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 27 or higher from Veterans Affairs Medical Center clinics in Durham and Greenville, North Carolina. Between January 12, 2015, and May 30, 2017, 263 outpatients started the intervention.

INTERVENTIONS

Participants randomized to the GMV group (n = 136) received counseling about diabetes-related topics with medication optimization every 4 weeks for 16 weeks, then every 8 weeks (9 visits). Participants randomized to the WM/GMV group (n = 127) received low-carbohydrate diet counseling with baseline medication reduction and subsequent medication optimization every 2 weeks for 16 weeks followed by an abbreviated GMV intervention every 8 weeks (13 visits).

MAIN OUTCOMES AND MEASURES

Outcomes included HbA1c level, hypoglycemic events, diabetes medication effect score, and weight at 48 weeks analyzed using hierarchical generalized mixed models to account for clustering within group sessions.

RESULTS

Among 263 participants (mean [SD] age, 60.7 [8.2] years; 235 [89.4%] men; 143 [54.4%] black), baseline HbA1c level was 9.1% (1.3%) and BMI was 35.3 (5.1). At 48 weeks, HbA1c level was improved in both study arms (8.2% in the WM/GMV arm and 8.3% in the GMV arm; mean difference, -0.1%; 95% CI, -0.5% to 0.2%; upper 95% CI, <0.5% threshold; P = .44). The WM/GMV arm had lower diabetes medication use (mean difference in medication effect score, -0.5; 95% CI, -0.6 to -0.3; P < .001) and greater weight loss (mean difference, -3.7 kg; 95% CI, -5.5 to -1.9 kg; P < .001) than did the GMV arm at 48 weeks and approximately 50% fewer hypoglycemic events (incidence rate ratio, 0.49; 95% CI, 0.27 to 0.71; P < .001) during the 48-week period.

CONCLUSIONS AND RELEVANCE

In GMVs for diabetes, addition of WM using a low-carbohydrate diet was noninferior for lowering HbA1c levels compared with conventional medication management and showed advantages in other clinically important outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01973972.