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Haber Y, Fu SS, Rogers E, Richter K, Tenner C, Dognin J, Goldfeld K, Gold HT, Sherman SE. A novel opt-in vs opt-out approach to referral-based treatment of tobacco use in Veterans Affairs (VA) primary care clinics: A provider-level randomized controlled trial protocol. Contemp Clin Trials 2022; 116:106716. [PMID: 35276337 DOI: 10.1016/j.cct.2022.106716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation. Trial Registration:Clinicaltrials.govIdentifierNCT03477435.
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Affiliation(s)
- Yaa Haber
- VA New York Harbor Healthcare System, New York, NY, USA; Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA.
| | - Steven S Fu
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin Rogers
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Kim Richter
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Craig Tenner
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA
| | - Joanna Dognin
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA; Department of Psychology, VA New York Harbor Healthcare System, New York, NY, USA
| | - Keith Goldfeld
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Heather T Gold
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY, USA; NYU Grossman School of Medicine, Department of Population Health, New York, NY, USA; NYU Grossman School of Medicine, Department of Medicine, New York, NY, USA
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Wittleder S, Smith S, Wang B, Beasley JM, Orstad SL, Sweat V, Squires A, Wong L, Fang Y, Doebrich P, Gutnick D, Tenner C, Sherman SE, Jay M. Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care. BMJ Open 2021; 11:e043013. [PMID: 33637544 PMCID: PMC7919589 DOI: 10.1136/bmjopen-2020-043013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m2) or obese range (≥30 kg/m2). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3). METHODS AND ANALYSIS We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms. ETHICS AND DISSEMINATION The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders. TRIAL REGISTRATION NUMBER NCT03163264; Pre-results.
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Affiliation(s)
- Sandra Wittleder
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Shea Smith
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Binhuan Wang
- Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - Jeannette M Beasley
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Stephanie L Orstad
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Victoria Sweat
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Allison Squires
- Rory Meyers College of Nursing, New York University, New York City, New York, USA
| | - Laura Wong
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Yixin Fang
- Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - Paula Doebrich
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
| | - Damara Gutnick
- Department of Epidemiology & Population Health, Department of Family & Social Medicine, Department of Psychiatry & Behavioral Sciences, The Albert Einstein College of Medicine, Bronx, New York, USA
| | - Craig Tenner
- Department of Medicine, New York University School of Medicine, New York City, New York, USA
- Veterans Affairs New York Harbor Healthcare System, Veterans Health Administration, New York City, New York, USA
| | - Scott E Sherman
- Veterans Affairs New York Harbor Healthcare System, Veterans Health Administration, New York City, New York, USA
- Department of Population Health, Department of Medicine, Department of Psychiatry, New York University School of Medicine, New York City, New York, USA
| | - Melanie Jay
- Veterans Affairs New York Harbor Healthcare System, Veterans Health Administration, New York City, New York, USA
- Department of Medicine, Department of Population Health, New York University School of Medicine, New York City, New York, USA
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Pendse J, Vallejo-García F, Parziale A, Callanan M, Tenner C, Alemán JO. Obesity Pharmacotherapy is Effective in the Veterans Affairs Patient Population: A Local and Virtual Cohort Study. Obesity (Silver Spring) 2021; 29:308-316. [PMID: 33491308 PMCID: PMC8112812 DOI: 10.1002/oby.23075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/24/2020] [Accepted: 10/24/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Obesity is a major public health challenge, and the US military veteran population is disproportionately affected. Using deidentified records from a local weight management clinic and a national clinical data repository, obesity pharmacotherapy use and effectiveness for weight loss and obesity comorbidities in this vulnerable population were assessed. METHODS During the initial year of the local clinic, 43 records with monthly follow-up of MOVE! lifestyle intervention augmented by obesity pharmacotherapy were found. Nationally, more than 2 million records of prescribed obesity pharmacotherapy compared with metformin as control were identified. Records with detailed documentation of weight trends from 1 year before to 1 year after the prescription date for further analysis were selected for review. RESULTS The most commonly prescribed medications in the local clinic were metformin, liraglutide, and combination phentermine/topiramate. On average, weight loss of -4.0 ± 2.1 kg over the initial 6-month intervention was observed. In the national cohort, 577,491 records with an obesity or control metformin prescription and adequate weight documentation were identified. The most effective pharmacotherapy in the national cohort was phentermine/topiramate (-0.0931 ± 0.0198 kg/wk difference), followed by liraglutide, lorcaserin, and orlistat. CONCLUSIONS Obesity pharmacotherapy is effective in achieving clinically meaningful weight loss in veterans as part of an integrated care approach.
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Affiliation(s)
- Jay Pendse
- Division of Endocrinology, Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
- Division of Endocrinology, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
- Laboratory of Translational Obesity Research, New York University Grossman School of Medicine, New York, New York, USA
| | - Franco Vallejo-García
- Division of Endocrinology, Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
- Division of Endocrinology, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
- Laboratory of Translational Obesity Research, New York University Grossman School of Medicine, New York, New York, USA
| | - Andrew Parziale
- Division of Endocrinology, Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
- Division of Endocrinology, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
- Laboratory of Translational Obesity Research, New York University Grossman School of Medicine, New York, New York, USA
| | - Mae Callanan
- Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
| | - Craig Tenner
- Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
| | - José O Alemán
- Division of Endocrinology, Department of Medicine, Manhattan Campus of the VA New York Harbor Healthcare System, New York, New York, USA
- Division of Endocrinology, Department of Medicine, New York University Langone Medical Center, New York, New York, USA
- Laboratory of Translational Obesity Research, New York University Grossman School of Medicine, New York, New York, USA
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Rogers ES, Wysota C, Prochaska JJ, Tenner C, Dognin J, Wang B, Sherman SE. A behavioral economic intervention to increase psychiatrist adherence to tobacco treatment guidelines: a provider-randomized study protocol. Implement Sci Commun 2020; 1. [PMID: 32617528 PMCID: PMC7331951 DOI: 10.1186/s43058-020-00011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background People with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a 'no treatment' default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3A's (ask, advise, assist) tobacco treatment model in outpatient psychiatry. Methods We will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of two groups: (1) Opt-In Treatment Approach: Psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; or (2) Opt-Out Treatment Approach: Psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-hour training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study's primary outcomes: 1) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3 A's approach and patient perceptions of the opt-out system. At six months, we will survey the clustered patient sample again to evaluate the study's secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the opt-out approach. Discussion This study will produce important data on the potential of opt-out systems to overcome barriers in implementing tobacco use treatment in outpatient psychiatry. Trial registration Clinicaltrials.gov Identifier NCT04071795 (registered August 28, 2019). https://www.clinicaltrials.gov/ct2/show/NCT04071795.
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Affiliation(s)
- Erin S Rogers
- NYU School of Medicine, Department of Population Health, 180 Madison Avenue, New York, NY 10016
| | - Christina Wysota
- NYU School of Medicine, Department of Population Health, 180 Madison Avenue, New York, NY 10016
| | - Judith J Prochaska
- Stanford University, Department of Medicine, Stanford Prevention Research Center, 1265 Welch Road St, Stanford, California 94305
| | - Craig Tenner
- VA NY Harbor Healthcare System, 423 East 23 Street, New York, NY 10010
| | - Joanna Dognin
- VA NY Harbor Healthcare System, 423 East 23 Street, New York, NY 10010
| | - Binhuan Wang
- NYU School of Medicine, Department of Population Health, 180 Madison Avenue, New York, NY 10016
| | - Scott E Sherman
- NYU School of Medicine, Department of Population Health, 180 Madison Avenue, New York, NY 10016; VA NY Harbor Healthcare System, 423 East 23 Street, New York, NY 10010
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Abstract
Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the establishment of a Diabetes Prevention Clinic for veterans with prediabetes.
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Affiliation(s)
| | | | - Craig Tenner
- New York University School of Medicine, New York, NY
| | - Karin Katz
- New York University School of Medicine, New York, NY
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Pendse J, Vallejo-García F, Parziale A, Griffin M, Callanan M, Tenner C, Diaz JOA. MON-601 Obesity Pharmacotherapy Is Effective in the United States Veterans Affairs Patient Population: A Local and Virtual Cohort Study. J Endocr Soc 2020. [PMCID: PMC7208056 DOI: 10.1210/jendso/bvaa046.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Overweight and obesity are major health burdens, and the military veteran population may be disproportionately affected. Multiple new pharmacologic agents and combinations have been approved by the FDA for use in medical weight management. Using deidentified records from our local interdisciplinary weight management clinic and a national clinical data repository, we assessed obesity pharmacotherapy use and its real-world effectiveness for weight loss and improvement of comorbid metabolic parameters in this vulnerable population. Methods: During the initial year of the local weight management clinic, we found over 50 records with monthly followup of lifestyle intervention augmented by obesity pharmacotherapy. In the national clinical data repository, we identified over 2 million records for unique individuals prescribed bupropion-naltrexone, liraglutide, lorcaserin, orlistat, or phentermine-topiramate, and metformin considered as a control prescription. We selected records with detailed documentation of weight trends from 1 year before to 1 year after first prescription date for further analysis. Results: The most commonly prescribed medications in our local weight management clinic were metformin, liraglutide, orlistat, and combination phentermine/topiramate. On average, we observed −4.0 ± 2.1 kg weight loss over the initial 6-month intervention in records that completed at least 3 visits within this period. In the national database, over 800,000 records for an obesity or control metformin prescription provided adequate weight documentation to compare weight slopes during the year before and after the prescription start date. Records for metformin prescriptions showed −0.04 ± 0.008 kg/week difference in weight slope over one year before versus after the prescription start date. The greatest difference in weight slope was seen with phentermine-topiramate (−0.13 ± 0.03 kg/week), followed by lorcaserin, liraglutide, bupropion-naltrexone, and orlistat. Conclusions: Our data suggests that veterans with obesity experience weight loss at 1 year follow-up when engaged with our interdisciplinary weight management clinic. Nationally, veterans with obesity experience modest weight loss when prescribed pharmacotherapy. Taken together, our two data sources provide complementary perspectives to help guide obesity pharmacotherapy in veterans with obesity.
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Affiliation(s)
- Jay Pendse
- Veterans Affairs New York Harbor, Manhattan Campus + New York University, New York, NY, USA
| | - Franco Vallejo-García
- Veterans Affairs New York Harbor, Manhattan Campus + New York University, New York, NY, USA
| | - Andrew Parziale
- Veterans Affairs New York Harbor, Manhattan Campus + New York University, New York, NY, USA
| | - Megan Griffin
- Veterans Affairs New York Harbor, Manhattan Campus + New York University, New York, NY, USA
| | - Mae Callanan
- Veterans Affairs New York Harbor, Manhattan Campus, New York, NY, USA
| | - Craig Tenner
- Veterans Affairs New York Harbor, Manhattan Campus + New York University, New York, NY, USA
| | - Jose Orlando Aleman Diaz
- Veterans Affairs New York Harbor, Manhattan Campus + New York University Medical Center, New York, NY, USA
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Parziale A, Vallejo-Garcia F, McCloskey K, Callanan M, Tenner C, Alemán J. SAT-102 Self-efficacy As A Predictor Of Weight Loss In Veterans With Obesity Participating In Medical Weight Management. J Endocr Soc 2019. [PMCID: PMC6551665 DOI: 10.1210/js.2019-sat-102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Overweight and obesity are major health burdens in veterans, occurring at higher rates than the general population (78% vs 69%) and associate with chronic disease development. Self-efficacy is a person's ability to overcome the difficulties inherent in performing a specific task in a particular situation such as smoking cessation. We evaluated if a simple self-efficacy score may serve as a predictor of weight control in de-identified records of veterans with obesity undergoing a weight loss intervention consisting of lifestyle modification with pharmacotherapy through a VA weight management clinic. Methods We reviewed deidentified records for 22 obese (BMI ≥ 30) participants (17 males, 5 females, age range = 43–69, race/ethnicity 45% Black, 32% White, 18% Latino, and 5% Asian) in the VA weight management clinic. As part of the intake assessment, we used 2 validated questions to assess participants’ confidence in their ability to lose weight. Individuals were asked: “How ready are you to commit time, energy and resources to weight loss therapy?" and "How confident are you in your ability to lose weight?" Answers were rated from 1 (not ready or not confident) to 3 (ready or confident). Self-efficacy was scored as high (5-6), intermediate (3-4) or low (0-2). Results: Participants were on average 56 years old with weight of 275±49 lb at baseline. Eight records were classified as having high self-efficacy, 7 had moderate self-efficacy, and 3 had low self-efficacy. After 3 months of lifestyle plus pharmacotherapy intervention, weight loss in the high self-efficacy group was 8.8 ± 4.6 lb vs -0.4 ± 1.2 lb (mean±SE, p = 0.088) in the non-high self-efficacy group. Excess body weight in high vs non-high self-efficacy groups at 3 months was 3.08% ± 0.02% vs -0.26% ± 0.01 (p = 0.094). Conclusions: Our data suggests that veterans with obesity and high self-efficacy may lose more weight than those with lower self-efficacy. This simple tool may serve as an important first screen for weight management clinical practice. References -Diabetes Prevention Program Research, G., et al., 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet, 2009. 374(9702): p. 1677-86. -Tsai et al. Readiness Redefined: A Behavioral Task during Screening Predicted 1-Year Weight Loss in the Look AHEAD Study. Obesity (Silver Spring). 2014 April ; 22(4): 1016–1023. doi:10.1002/oby.20648.
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Affiliation(s)
- Andrew Parziale
- Manhattan Campus, VA New York Harbor Healthcare System, New York, NY, United States
| | | | - Karen McCloskey
- Manhattan Campus, VA New York Harbor Healthcare System, New York, NY, United States
| | - Mae Callanan
- Manhattan Campus, VA New York Harbor Healthcare System, New York, NY, United States
| | - Craig Tenner
- Manhattan Campus, VA New York Harbor Healthcare System, New York, NY, United States
| | - José Alemán
- Manhattan Campus, VA New York Harbor Healthcare System, New York, NY, United States
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Viglione C, Bouwman D, Rahman N, Fang Y, Beasley JM, Sherman S, Pi-Sunyer X, Wylie-Rosett J, Tenner C, Jay M. A technology-assisted health coaching intervention vs. enhanced usual care for Primary Care-Based Obesity Treatment: a randomized controlled trial. BMC Obes 2019; 6:4. [PMID: 30766686 PMCID: PMC6360675 DOI: 10.1186/s40608-018-0226-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022]
Abstract
Background Goals for Eating and Moving (GEM) is a technology-assisted health coaching intervention to improve weight management in primary care at the Veterans Health Administration (VHA) that we designed through prior rigorous formative studies. GEM is integrated within the patient-centered medical home and utilizes student health coach volunteers to counsel patients and encourage participation in VHA’s intensive weight management program, MOVE!. The primary aim of this study was to determine the feasibility and acceptability of GEM when compared to Enhanced Usual Care (EUC). Our secondary aim was to test the impact of GEM on weight, diet and physical activity when compared to EUC. Methods Veterans with a Body Mass Index ≥30 kg/m2 or 25–29.9 kg/m2 with comorbidities (n = 45) were recruited in two phases and randomized to GEM (n = 22) or EUC (n = 23). We collected process measures (e.g. number of coaching calls completed, number and types of lifestyle goals, counseling documentation) and qualitative feedback on quality of counseling and acceptability of call duration. We also measured weight and behavioral outcomes. Results GEM participants reported receiving high quality counseling from health coaches and that call duration and frequency were acceptable. They received 5.9 (SD = 3.7) of 12 coaching calls on average, and number of coaching calls completed was associated with greater weight loss at 6-months in GEM participants (Spearman Coefficient = 0.71, p < 0.001). Four participants from GEM and two from EUC attended the MOVE! program. PCPs completed clinical reminders in 12% of PCP visits with GEM participants. Trends show that GEM participants (n = 21) tended to lose more weight at 3-, 6-, and 12-months as compared to EUC, but this was not statistically significant. There were no significant differences in diet or physical activity. Conclusions We found that a technology assisted health coaching intervention delivered within primary care using student health coaches was feasible and acceptable to Veteran patients. This pilot study helped elucidate challenges such as low provider engagement, difficulties with health coach continuity, and low patient attendance in MOVE! which we have addressed and plan to test in future studies. Trial registration NCT03006328 Retrospectively registered on December 30, 2016. Electronic supplementary material The online version of this article (10.1186/s40608-018-0226-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clare Viglione
- 1Veteran Affairs New York Harbor Healthcare System & NYU School of Medicine, New York, USA
| | - Dylaney Bouwman
- 2NYU School of Medicine & Veteran Affairs New York Harbor Healthcare System, New York, USA
| | - Nadera Rahman
- 3NYU Langone Health & Veteran Affairs New York Harbor Healthcare System, New York, USA
| | - Yixin Fang
- 4New Jersey Institute of Technology, New York, USA
| | | | - Scott Sherman
- 1Veteran Affairs New York Harbor Healthcare System & NYU School of Medicine, New York, USA
| | | | | | - Craig Tenner
- 1Veteran Affairs New York Harbor Healthcare System & NYU School of Medicine, New York, USA
| | - Melanie Jay
- 1Veteran Affairs New York Harbor Healthcare System & NYU School of Medicine, New York, USA
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Mateo KF, Berner NB, Ricci NL, Seekaew P, Sikerwar S, Tenner C, Dognin J, Sherman SE, Kalet A, Jay M. Development of a 5As-based technology-assisted weight management intervention for veterans in primary care. BMC Health Serv Res 2018; 18:47. [PMID: 29378584 PMCID: PMC5789563 DOI: 10.1186/s12913-018-2834-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/09/2018] [Indexed: 12/04/2022] Open
Abstract
Background Obesity is a worldwide epidemic, and its prevalence is higher among Veterans in the United States. Based on our prior research, primary care teams at a Veterans Affairs (VA) hospital do not feel well-equipped to deliver effective weight management counseling and often lack sufficient time. Further, effective and intensive lifestyle-based weight management programs (e.g. VA MOVE! program) are underutilized despite implementation of systematic screening and referral at all VA sites. The 5As behavior change model (Assess, Advise, Agree, Assist, Arrange) is endorsed by the United States Preventive Service Task Force for use in counseling patients about weight management in primary care and reimbursed by Medicare. In this paper, we describe the iterative development of a technology-assisted intervention designed to provide primary care-based 5As counseling within Patient-Centered Medical Homes without overburdening providers/healthcare teams. Methods Thematic analyses of prior formative work (focus groups with patients [n = 54] and key informant interviews with staff [n = 25]) helped to create a technology-assisted, health coaching intervention called Goals for Eating and Moving (GEM). To further develop the intervention, we then conducted two rounds of testing with previous formative study participants (n = 5 for Round 1, n = 5 for Round 2). Each session included usability testing of prototypes of the online GEM tool, pilot testing of 5As counseling by a Health Coach, and a post-session open-ended interview. Results Three main themes emerged from usability data analyses: participants’ emotional responses, tool language, and health literacy. Findings from both rounds of usability testing, pilot testing, as well as the open-ended interview data, were used to finalize protocols for the full intervention in the clinic setting to be conducted with Version 3 of the GEM tool. Conclusions The use of qualitative research methods and user-centered design approaches enabled timely detection of salient issues to make iterative improvements to the intervention. Future studies will determine whether this intervention can increase enrollment in intensive weight management programs and promote clinically meaningful weight loss in both Veterans and in other patient populations and health systems.
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Affiliation(s)
- Katrina F Mateo
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Natalie B Berner
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Natalie L Ricci
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Pich Seekaew
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Sandeep Sikerwar
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Craig Tenner
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Joanna Dognin
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA
| | - Scott E Sherman
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA.,New York University School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Adina Kalet
- New York University School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Melanie Jay
- VA NY Harbor Healthcare System, Manhattan Campus 423 East 23rd Street, New York, NY, 10010, USA. .,New York University School of Medicine, 550 1st Avenue, New York, NY, 10016, USA.
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Chang K, Yokose C, Tenner C, Oh C, Donnino R, Choy-Shan A, Pike VC, Shah BD, Lorin JD, Krasnokutsky S, Sedlis SP, Pillinger MH. Association Between Gout and Aortic Stenosis. Am J Med 2017; 130:230.e1-230.e8. [PMID: 27720853 PMCID: PMC5357081 DOI: 10.1016/j.amjmed.2016.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/14/2016] [Accepted: 09/15/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND An independent association between gout and coronary artery disease is well established. The relationship between gout and valvular heart disease, however, is unclear. The aim of this study was to assess the association between gout and aortic stenosis. METHODS We performed a retrospective case-control study. Aortic stenosis cases were identified through a review of outpatient transthoracic echocardiography (TTE) reports. Age-matched controls were randomly selected from patients who had undergone TTE and did not have aortic stenosis. Charts were reviewed to identify diagnoses of gout and the earliest dates of gout and aortic stenosis diagnosis. RESULTS Among 1085 patients who underwent TTE, 112 aortic stenosis cases were identified. Cases and nonaortic stenosis controls (n = 224) were similar in age and cardiovascular comorbidities. A history of gout was present in 21.4% (n = 24) of aortic stenosis subjects compared with 12.5% (n = 28) of controls (unadjusted odds ratio 1.90, 95% confidence interval 1.05-3.48, P = .038). Multivariate analysis retained significance only for gout (adjusted odds ratio 2.08, 95% confidence interval 1.00-4.32, P = .049). Among subjects with aortic stenosis and gout, gout diagnosis preceded aortic stenosis diagnosis by 5.8 ± 1.6 years. The age at onset of aortic stenosis was similar among patients with and without gout (78.7 ± 1.8 vs 75.8 ± 1.0 years old, P = .16). CONCLUSIONS Aortic stenosis patients had a markedly higher prevalence of precedent gout than age-matched controls. Whether gout is a marker of, or a risk factor for, the development of aortic stenosis remains uncertain. Studies investigating the potential role of gout in the pathophysiology of aortic stenosis are warranted and could have therapeutic implications.
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Affiliation(s)
- Kevin Chang
- Section of Rheumatology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Rheumatology, Department of Medicine, New York University School of Medicine; TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine
| | - Chio Yokose
- Section of Rheumatology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Rheumatology, Department of Medicine, New York University School of Medicine; TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine
| | - Craig Tenner
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Primary Care, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Primary Care, Department of Medicine, New York University School of Medicine
| | - Cheongeun Oh
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Department of Biostatistics, New York University
| | - Robert Donnino
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Cardiology, Department of Medicine, New York University School of Medicine; Department of Radiology, New York University School of Medicine
| | - Alana Choy-Shan
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Cardiology, Department of Medicine, New York University School of Medicine
| | - Virginia C Pike
- Section of Rheumatology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Rheumatology, Department of Medicine, New York University School of Medicine; TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine
| | - Binita D Shah
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Cardiology, Department of Medicine, New York University School of Medicine
| | - Jeffrey D Lorin
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Cardiology, Department of Medicine, New York University School of Medicine
| | - Svetlana Krasnokutsky
- Section of Rheumatology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Rheumatology, Department of Medicine, New York University School of Medicine; TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine
| | - Steven P Sedlis
- TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine; Section of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Cardiology, Department of Medicine, New York University School of Medicine
| | - Michael H Pillinger
- Section of Rheumatology, Department of Medicine, Veterans Affairs New York Harbor Healthcare System; Division of Rheumatology, Department of Medicine, New York University School of Medicine; TRIAD (Translational Research in Inflammation and Atherosclerotic Disease), New York University School of Medicine.
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Bang D, Xu J, Keenan R, Pike V, Lehmann R, Tenner C, Crittenden D, Pillinger M, Krasnokutsky S. Cardiovascular Disease Prevalence in Patients with Osteoarthritis, Gout, or Both. Bull Hosp Jt Dis (2013) 2016; 74:113-118. [PMID: 27281314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Osteoarthritis (OA) and gout have each been associated with increased cardiovascular disease (CVD), but their relative impact is unknown. We compared CVD rates among patients with gout versus patients with OA and no gout (OA-only). METHODS We identified male patients at the VA New York Harbor Healthcare System with gout (with or without concur - rent OA) and with OA-only between August 2007 and August 2008. For each group, we collected baseline demographic data and CVD risk factors. The primary outcome was a composite index (CV4) of any diagnosis of coronary artery disease (CAD), angina, myocardial infarction (MI), or coro- nary bypass surgery (CABG). Secondary outcomes included individual diagnoses within the CV4, CHF, and death. We subsequently divided the gout patients into those who did versus did not have concurrent diagnoses of OA (gout-only; gout+OA). Logistic regression was used to compare the associations of OA-only, gout-only, and gout+OA with CV outcomes. RESULTS 1,280 gout subjects met inclusion criteria (983 gout- only and 297 gout+OA), along with 1,231 OA-only subjects. Gout subjects overall had more CVD risk factors at baseline, including hypertension, hyperlipidemia, and chronic kidney disease, versus OA-only. Compared with OA-only, gout subjects overall had increased rates of all outcomes except MI. Both the gout-only and gout+OA subgroups also had increased risk for all outcomes except MI, and CABG in the case of gout+OA subjects. After adjusting for traditional CVD risk factors, both gout-only and gout+OA subjects continued to have increased risk for multiple CVD outcomes. Gout+OA did not impart ad- ditional risk over gout-only for any outcome studied. CONCLUSION Our data suggest that gout is associated with higher risk of CVD compared with OA, and that OA does not impart any additive CVD risk to patients who also have gout. Significance and Innovations: • In our dataset, gout subjects both with and without con- comitant OA had more cardiovascular disease (CVD) risk factors at baseline, and higher prevalence of CVD outcomes, than patients with OA only. • After adjusting for traditional CVD risk factors, gout-only and gout+OA subjects continued to have increased rates of multiple CVD outcomes, suggesting an intrinsic CVD risk to the diagnosis of gout, compared with OA. • These observations underline that gout patients represent a group at increased CVD risk, for whom both rheumatic disease management and CVD prevention need to be addressed.
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Savarimuthu SM, Jensen AE, Schoenthaler A, Dembitzer A, Tenner C, Gillespie C, Schwartz MD, Sherman SE. Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA. BMC Fam Pract 2013; 14:176. [PMID: 24261337 PMCID: PMC3840588 DOI: 10.1186/1471-2296-14-176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/14/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. METHODS We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. RESULTS Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas - continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. CONCLUSIONS Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. TRIAL REGISTRATION ClinicalTrials.gov, NCT01677533.
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Affiliation(s)
- Stella M Savarimuthu
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Ashley E Jensen
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | | | - Anne Dembitzer
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Craig Tenner
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Colleen Gillespie
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Mark D Schwartz
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
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Abstract
BACKGROUND Beta-blockers reduce mortality in patients with systolic chronic heart failure (CHF), yet prescription rates have remained low among primary care providers. OBJECTIVE To determine the beta-blocker prescription rate among patients with systolic CHF at primary care Veterans Affairs (VA) clinics, its change over time; and to determine factors associated with nonprescription. DESIGN Retrospective chart review. SUBJECTS Seven hundred and forty-five patients with diagnostic codes for CHF followed in primary care clinics at 3 urban VA Medical Centers. MEASUREMENTS Rate of beta-blocker prescription and comparison of patient characteristics between those prescribed versus those not prescribed beta-blockers. RESULTS Only 368 (49%) had documented systolic CHF. Eighty-two percent (303/368) of these patients were prescribed a beta-blocker. The prescription rate rose steadily over 3 consecutive 2-year time periods. Patients with more severely depressed ejection fractions were more likely to be on a beta-blocker than patients with less severe disease. Independent predictors of nonprescription included chronic obstructive pulmonary disease, asthma, depression, and age. Patients under 65 years old were 12 times more likely to receive beta-blockers than those over 85. CONCLUSION Primary care providers at VA Medical Centers achieved high rates of beta-blocker prescription for CHF patients. Subgroups with relative contraindications had lower prescription rates and should be targeted for quality improvement initiatives.
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Affiliation(s)
- Sanjai Sinha
- Department of Medicine, Bronx VA Medical Center, Bronx, NY, USA.
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Sänger T, Tenner C. [Not Available]. Wurzbg Medizinhist Mitt 2001; 2:19-28. [PMID: 11631087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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