A Randomized Controlled Trial of Animal-assisted Activities for Pediatric Oncology Patients: Psychosocial and Microbial Outcomes

INTRODUCTION

Evidence about the effectiveness and safety of dog visits in pediatric oncology is limited.

METHOD

We conducted a randomized controlled trial (n=26) of dog visits versus usual care among pediatric oncology inpatients. Psychological functioning and microbial load from hand wash samples were evaluated. Parental anxiety was a secondary outcome.

RESULTS

We did not observe a difference in the adjusted mean present functioning score (-3.0; 95% confidence interval [CI], -12.4 to 6.4). The difference in microbial load on intervention versus control hands was -0.04 (95% CI, -0.60 to 0.52) log10 CFU/mL, with an upper 95% CI limit below the prespecified noninferiority margin. Anxiety was lower in parents of intervention versus control patients.

DISCUSSION

We did not detect an effect of dog visits on functioning; however, our study was underpowered by low recruitment. Visits improved parental anxiety. With hand sanitization, visits did not increase hand microbial levels.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT03471221.

"What Will Happen If I Say Yes?" Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms

OBJECTIVE

Addressing firearm access is recommended when patients are identified as being at risk of suicide. However, the practice of assessing firearm access is controversial, and no national guidelines exist to inform practice. This study qualitatively explored patient perspectives on a routine question about firearm access to optimize the patient centeredness of this practice in the context of suicide risk.

METHODS

Electronic health record data were used to identify primary care patients reporting depressive symptoms, including suicidal thoughts, within 2 weeks of sampling. Participants completed a semistructured telephone interview (recorded and transcribed), which focused broadly on the experience of being screened for suicidality and included specific questions to elicit beliefs and opinions about being asked a standard firearm access question. Directive (deductive) and conventional (inductive) content analysis was used to analyze responses to the portion of the interview focused on firearm assessment and disclosure.

RESULTS

Thirty-seven patients in Washington State ages 20-95 completed the qualitative interview by phone. Organizing themes included apprehensions about disclosing access to firearms related to privacy, autonomy, and firearm ownership rights; perceptions regarding relevance of the firearm question, informed by experiences with suicidality and common beliefs and misconceptions about the inevitability of suicide; and suggestions for connecting questions about firearms and other lethal means to suicide risk.

CONCLUSIONS

Clarifying the purpose and use of routine firearm access assessment, contextualizing firearm questions within injury prevention broadly, and addressing misconceptions about suicide prevention may help encourage disclosure of firearm access and increase the patient centeredness of this practice.

"You Actually View Us as the Experts in Our Own System": Indigenous-Academic Community Partnership

BACKGROUND

The literature on community-engaged research provides important principles to guide research partnerships, but concrete descriptions of the complexities involved in developing, navigating, and maintaining such partnerships are lacking.

OBJECTIVES

To describe and assess a longstanding, complex research partnership between Indigenous and academic pharmacogenetic research partners, with attention to co-learning and capacity building lessons learned.

METHODS

Descriptive thematic analysis of 11 semistructured interviews with interdisciplinary research partners situated at Indigenous and academic settings.

RESULTS

Lessons learned included the need for explicit negotiation around mentoring expectations, and discussion on advisory and staff roles. Partners need to be aware not only of the structures, policies, and hierarchies within each partner institution, but also the tacit value commitments and understandings entailed in their different missions.

CONCLUSIONS

This study highlights that the concept of "bidirectional" learning as it is usually presented in the literature fails to capture the complexity of how partnerships work.

Systematic Multi-Domain Alzheimer's Risk Reduction Trial (SMARRT): Study Protocol

This article describes the protocol for the Systematic Multi-domain Alzheimer's Risk Reduction Trial (SMARRT), a single-blind randomized pilot trial to test a personalized, pragmatic, multi-domain Alzheimer's disease (AD) risk reduction intervention in a US integrated healthcare delivery system. Study participants will be 200 higher-risk older adults (age 70-89 years with subjective cognitive complaints, low normal performance on cognitive screen, and ≥ two modifiable risk factors targeted by our intervention) who will be recruited from selected primary care clinics of Kaiser Permanente Washington, oversampling people with non-white race or Hispanic ethnicity. Study participants will be randomly assigned to a two-year Alzheimer's risk reduction intervention (SMARRT) or a Health Education (HE) control. Randomization will be stratified by clinic, race/ethnicity (non-Hispanic white versus non-white or Hispanic), and age (70-79, 80-89). Participants randomized to the SMARRT group will work with a behavioral coach and nurse to develop a personalized plan related to their risk factors (poorly controlled hypertension, diabetes with evidence of hyper or hypoglycemia, depressive symptoms, poor sleep quality, contraindicated medications, physical inactivity, low cognitive stimulation, social isolation, poor diet, smoking). Participants in the HE control group will be mailed general health education information about these risk factors for AD. The primary outcome is two-year cognitive change on a cognitive test composite score. Secondary outcomes include: 1) improvement in targeted risk factors, 2) individual cognitive domain composite scores, 3) physical performance, 4) functional ability, 5) quality of life, and 6) incidence of mild cognitive impairment, AD, and dementia. Primary and secondary outcomes will be assessed in both groups at baseline and 6, 12, 18, and 24 months.

Perceptions of alcohol misuse among Alaska native health care system stakeholders: A qualitative exploration

Although alcohol misuse is a priority for health care systems serving Alaska Native and American Indian (ANAI) people, stakeholders' perceptions of misuse are understudied. Patients (n = 34), providers (n = 20), and leaders (n = 16) at a Tribally owned and operated health care system reported that alcohol misuse results from the interaction of factors, including colonization, structural factors, social alienation, social norms about overdrinking introduced at the time of colonizing contact, coping with emotions, and beliefs about ANAI people and alcohol. Childhood exposure to alcohol misuse leads some ANAI people to avoid alcohol altogether, shedding light on the high levels of abstinence observed in ANAI communities.

Mechanisms for the testing effect on patient-reported outcomes

The testing effect is when patient-reported outcomes (PRO) improve with repeated administration without intervention. The testing effect can confound interpretation of clinical trials using PROs as endpoints. This study investigated potential mechanisms. The parent study (n = 302) investigated a self-management intervention for depression. We qualitatively analyzed exit interview feedback from the 89 control group participants completing the last assessment. Participants reported several perceived benefits from control group participation including novel mechanisms (study participation was meaningful, emotional support, appreciating outreach), a possible negative testing effect and mechanisms previously identified (behavioral change).

The impact of primary care behavioral health services on patient behaviors: A randomized controlled trial

INTRODUCTION

Greater understanding of the impact of low intensity psychosocial interventions delivered by behavioral health clinicians (BHCs) working in an integrated care program (ICP) may promote better depression care.

METHOD

In a randomized controlled trial, 153 participants identified as depressed by their primary care provider (PCP) were assigned to ICP or usual care (UC, management by PCP, including specialty referral). In the ICP condition, BHCs worked collaboratively with PCPs and liaison psychiatrists.

RESULTS

ICP participants with lower and higher severity symptoms reported significantly greater use of coping strategies than UC participants at the 1-month follow up (lower: p = .002; higher: p = .016). ICP participants with lower severity continued to report significantly greater use of coping strategies than UC participants at the 4-month (p = .024), and 7-month (p = .012) follow ups. ICP participants were more likely to be following relapse preventions plans at the 4-month follow up (lower: 89.5% vs. 50%, p = .0.000; higher 74.1% vs. 33%, p = .0001). ICP participants also reported use of antidepressant medications on more days than UC participants at the 4-month follow up (lower: 21.27 vs. 14.49 days, p = .049; higher: 24.61 vs. 17.08 days, p = .035). Patient retention in the ICP was high, and ICP participants were significantly more satisfied with depression care than UC participants at follow-up assessments.

DISCUSSION

Delivery of low intensity psychosocial interventions by BHCs was associated with improvements to behavior charge targets. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effect of a Care Management Intervention on 12-Month Drinking Outcomes Among Patients With and Without DSM-IV Alcohol Dependence at Baseline

BACKGROUND

The CHOICE care management intervention did not improve drinking relative to usual care (UC) for patients with frequent heavy drinking at high risk of alcohol use disorders. Patients with alcohol dependence were hypothesized to benefit most. We conducted preplanned secondary analyses to test whether the CHOICE intervention improved drinking relative to UC among patients with and without baseline DSM-IV alcohol dependence.

METHODS

A total of 304 patients reporting frequent heavy drinking from 3 VA primary care clinics were randomized (stratified by DSM-IV alcohol dependence, sex, and site) to UC or the patient-centered, nurse-delivered, 12-month CHOICE care management intervention. Primary outcomes included percent heavy drinking days (%HDD) using 28-day timeline follow-back and a "good drinking outcome" (GDO)-abstaining or drinking below recommended limits and no alcohol-related symptoms on the Short Inventory of Problems at 12 months. Generalized estimating equation binomial regression models (clustered on provider) with interaction terms between dependence and intervention group were fit.

RESULTS

At baseline, 59% of intervention and UC patients had DSM-IV alcohol dependence. Mean drinking outcomes improved for all subgroups. For participants with dependence, 12-month outcomes did not differ for intervention versus UC patients (%HDD 37% versus 38%, p = 0.76 and GDO 16% versus 16%, p = 0.77). For participants without dependence, %HDD did not differ between intervention (41%) and UC (31%) patients (p = 0.12), but the proportion with GDO was significantly higher among UC participants (26% versus 13%, p = 0.046). Neither outcome was significantly modified by dependence (interaction p values 0.19 for %HDD and 0.10 for GDO).

CONCLUSIONS

Among participants with frequent heavy drinking, care management had no benefit relative to UC for patients with dependence, but UC may have had benefits for those without dependence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01400581.

If You Listen, I Will Talk: the Experience of Being Asked About Suicidality During Routine Primary Care

BACKGROUND

Routine population-based screening for depression is an essential part of evolving health care models integrating care for mental health in primary care. Depression instruments often include questions about suicidal thoughts, but how patients experience these questions in primary care is not known and may have implications for accurate identification of patients at risk.

OBJECTIVES

To explore the patient experience of routine population-based depression screening/assessment followed, for some, by suicide risk assessment and discussions with providers.

DESIGN

Qualitative, interview-based study.

PARTICIPANTS

Thirty-seven patients from Kaiser Permanente Washington who had recently screened positive for depression on the 2-item Patient Health Questionnaire [PHQ] and completed the full PHQ-9.

APPROACH

Criterion sampling identified patients who had recently completed the PHQ-9 ninth question which asks about the frequency of thoughts about self-harm. Patients completed semi-structured interviews by phone, which were recorded and transcribed. Directive and conventional content analyses were used to apply knowledge from prior research and elucidate new information from interviews; thematic analysis was used to organize key content overall and across groups based on endorsement of suicide ideation.

KEY RESULTS

Four main organizing themes emerged from analyses: (1) Participants believed being asked about suicidality was contextually appropriate and valuable, (2) some participants described a mismatch between their lived experience and the PHQ-9 ninth question, (3) suicidality disclosures involved weighing hope for help against fears of negative consequences, and (4) provider relationships and acts of listening and caring facilitated discussions about suicidality.

CONCLUSIONS

All participants believed being asked questions about suicidal thoughts was appropriate, though some who disclosed suicidal thoughts described experiencing stigma and sometimes distanced themselves from suicidality. Direct communication with trusted providers, who listened and expressed empathy, bolstered comfort with disclosure. Future research should consider strategies for reducing stigma and encouraging fearless disclosure among primary care patients experiencing suicidality.

Integration of screening, assessment, and treatment for cannabis and other drug use disorders in primary care: An evaluation in three pilot sites

BACKGROUND

This pilot study evaluated whether use of evidence-based implementation strategies to integrate care for cannabis and other drug use into primary care (PC) as part of Behavioral Health Integration (BHI) increased diagnosis and treatment of substance use disorders (SUDs).

METHODS

Patients who visited the three pilot PC sites were eligible. Implementation strategies included practice coaching, electronic health record decision support, and performance feedback (3/2015-4/2016). BHI introduced annual screening for past-year cannabis and other drug use, a Symptom Checklist for DSM-5 SUDs, and shared decision-making about treatment options. Main analyses tested whether the proportions of PC patients diagnosed with, and treated for, new cannabis or other drug use disorders (CUDs and DUDs, respectively), differed significantly pre- and post-implementation.

RESULTS

Of 39,599 eligible patients, 57% and 59% were screened for cannabis and other drug use, respectively. Among PC patients reporting daily cannabis use (2%) or any drug use (1%), 51% and 37%, respectively, completed an SUD Symptom Checklist. The proportion of PC patients with newly diagnosed CUD increased significantly post-implementation (5 v 17 per 10,000 patients, p < 0.0001), but not other DUDs (10 vs 13 per 10,000, p = 0.24). The proportion treated for newly diagnosed CUDs did not increase post-implementation (1 vs 1 per 10,000, p = 0.80), but did for those treated for newly diagnosed other DUDs (1 vs 3 per 10,000, p = 0.038).

CONCLUSIONS

A pilot implementation of BHI to increase routine screening and assessment for SUDs was associated with increased new CUD diagnoses and a small increase in treatment of new other DUDs.

Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study

OBJECTIVE

The authors sought to understand why patients may not report suicidal ideation at a health care visit prior to a suicide attempt.

METHODS

Electronic health record data from Kaiser Permanente Washington were used to identify patients who reported having no suicidal ideation on question 9 of the nine-item Patient Health Questionnaire and who subsequently made a suicide attempt (≤60 days). Semistructured interviews were audio-recorded, transcribed, and analyzed by using a combination of directed (deductive) and conventional (inductive) content analysis to validate and further explore reasons why patients may not report suicidal ideation prior to a suicide attempt.

RESULTS

Of 42 adults sampled, 26 agreed to be interviewed, of whom about half were women (N=15) and a majority was white (N=20), with ages ranging from 18 to 63. Key themes were that patients who attempted suicide after having reported no thoughts of self-harm were either not experiencing suicidal ideation at the time of screening or feared the outcome of disclosure, including stigma, overreaction, and loss of autonomy. An additional theme that emerged from the interviews included reports of heavy episodic drinking at the time of the suicide attempt, particularly when suicide was completely unplanned. Patients also identified important aspects of interactions with health care system providers that may facilitate disclosure about suicidal ideation.

CONCLUSIONS

Nonjudgmental listening and expressions of caring without overreaction among providers may help patients overcome fear of reporting suicidal ideation. Screening for heavy episodic drinking may help identify individuals who make unplanned suicide attempts.

Impact of initiatives to reduce prescription opioid risks on medically attended injuries in people using chronic opioid therapy

PURPOSE

The purpose of the study is to determine whether initiatives to improve the safety of opioid prescribing decreased injuries in people using chronic opioid therapy (COT).

METHODS

We conducted an interrupted time series analysis using data from Group Health (GH), an integrated health care delivery system in the United States. In 2007, GH implemented initiatives which substantially reduced daily opioid dose and increased patient monitoring. Among GH members age 18 or older receiving COT between 2006 and 2014, we compared injury rates for patients in GH's integrated group practice (IGP; exposed to the initiatives) vs patients cared for by contracted providers (not exposed). Injuries were identified using a validated algorithm. We calculated injury incidence during the baseline (preintervention) period from 2006 to 2007; the dose reduction period, 2008 to 2010; and the risk stratification and monitoring period, 2010 to 2014. Using modified Poisson regression, we estimated adjusted relative risks (RRs) representing the relative change per year in injury rates.

RESULTS

Among 21 853 people receiving COT in the IGP and 8260 in contracted care, there were 2679 injuries during follow-up. The baseline injury rate was 1.0% per calendar quarter in the IGP and 0.9% in contracted care. Risk reduction initiatives did not decrease injury rates: Within the IGP, the RR in the dose reduction period was 1.01 (95% CI, 0.95-1.07) and in the risk stratification and monitoring period, 0.99 (95% CI, 0.95-1.04). Injury trends did not differ between the two care settings.

CONCLUSIONS

Risk reduction initiatives did not decrease injuries in people using COT.

Parents' attitudes toward consent and data sharing in biobanks: A multisite experimental survey

BACKGROUND

The factors influencing parents' willingness to enroll their children in biobanks are poorly understood. This study sought to assess parents' willingness to enroll their children, and their perceived benefits, concerns, and information needs under different consent and data-sharing scenarios, and to identify factors associated with willingness.

METHODS

This large, experimental survey of patients at the 11 eMERGE Network sites used a disproportionate stratified sampling scheme to enrich the sample with historically underrepresented groups. Participants were randomized to receive one of three consent and data-sharing scenarios.

RESULTS

In total, 90,000 surveys were mailed and 13,000 individuals responded (15.8% response rate). 5737 respondents were parents of minor children. Overall, 55% (95% confidence interval 50-59%) of parents were willing to enroll their youngest minor child in a hypothetical biobank; willingness did not differ between consent and data-sharing scenarios. Lower educational attainment, higher religiosity, lower trust, worries about privacy, and attitudes about benefits, concerns, and information needs were independently associated with less willingness to allow their child to participate. Of parents who were willing to participate themselves, 25% were not willing to allow their child to participate. Being willing to participate but not willing to allow one's child to participate was independently associated with multiple factors, including race, lower educational attainment, lower annual household income, public health care insurance, and higher religiosity.

CONCLUSIONS

Fifty-five percent of parents were willing to allow their youngest minor child to participate in a hypothetical biobank. Building trust, protecting privacy, and addressing attitudes may increase enrollment and diversity in pediatric biobanks.

Impact of Chronic Opioid Therapy Risk Reduction Initiatives on Opioid Overdose

We assessed the effects of opioid dose and risk reduction initiatives on opioid overdose rates among patients on chronic opioid therapy (COT). Using an interrupted time series design, we compared trends in overdose rates. We compared patients on COT in settings that implemented a COT dose reduction initiative and then a COT risk stratification/monitoring initiative to similar patients on COT from control settings. From 2006 to 2014, 31,142 patients on COT (22,673 intervention, 8,469 control) experienced 311 fatal or nonfatal opioid overdoses. In primary analyses, changes in opioid overdose rates among patients on COT did not differ significantly between intervention and control settings with the implementation of either dose reduction or risk stratification/monitoring. In planned secondary analyses, overdose rates decreased significantly (17% per year) during the dose reduction initiative among patients on COT in intervention settings (relative annual change, 0.83; 95% confidence interval, 0.70-0.99), but not in control settings (0.98. 95% confidence interval, 0.70-1.39). We conclude that overdose rates among patients on COT were not decreased by risk stratification and monitoring initiatives. Results were inconsistent for COT dose reduction, with no significant difference between intervention and control settings (primary hypothesis test), but a significant decrease in overdose rates within the intervention setting during dose reduction (secondary hypothesis test). PERSPECTIVE: Risk stratification/monitoring interventions among patients on COT did not decrease opioid overdose rates. The effects of COT dose reduction on opioid overdose rates were inconsistent. Greater decreases in COT dose, a larger control group, or both may have been needed to identify conclusive reductions in opioid overdose rates.

Balancing Hope and Risk Among Adolescent and Young Adult Cancer Patients with Late-Stage Cancer: A Qualitative Interview Study

PURPOSE

Previous studies have called for further research to explore adolescent and young adult (AYA) decision-making in the context of advanced cancer to understand the perspectives of this understudied population. We conducted a qualitative study with patients and providers to better understand the decision-making experience of AYA patients with advanced stages of cancer.

METHODS

Semistructured qualitative telephone interviews were conducted from April 2016 to October 2016. English-speaking AYAs and healthcare providers were recruited through the social media sites Twitter and Facebook. AYAs were eligible if they were aged 18-39 years at diagnosis and self-reported having metastatic cancer; any provider who worked with AYAs with metastatic cancer was eligible. Researchers with expertise in qualitative methods conducted inductive thematic content analysis of transcribed interviews. The analyzed data were used to formulate recommendations for clinicians.

RESULTS

Twelve AYA patients with self-reported stage IV cancer and five clinicians who care for AYAs with advanced stages of cancer were enrolled and shared their experience about AYA medical decision-making. Four primary themes emerged: (1) AYAs describe receiving unclear prognosis, (2) AYAs balance concepts of hope and risk, (3) AYAs choose aggressive treatment options, and (4) AYAs want support facing mortality. Recommendations for clinicians include clear communication about prognosis and side effects and concerted efforts to elicit patient values.

CONCLUSION

AYA patients and clinicians provided insights into the experiences and decision-making processes of AYA patients choosing to continue or discontinue treatment and into the areas for improvement in patient-centered oncology care. Taken together, these data provide important suggestions for clinicians caring for this vulnerable population.

Alcohol-Related Nurse Care Management in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Experts recommend that alcohol use disorders (AUDs) be managed in primary care, but effective approaches are unclear.

OBJECTIVE

To test whether 12 months of alcohol care management, compared with usual care, improved drinking outcomes among patients with or at high risk for AUDs.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 3 Veterans Affairs (VA) primary care clinics. Between October 11, 2011, and September 30, 2014, the study enrolled 304 outpatients who reported heavy drinking (≥4 drinks per day for women and ≥5 drinks per day for men).

INTERVENTIONS

Nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner-prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The comparison was usual primary care.

MAIN OUTCOMES AND MEASURES

Primary outcomes, assessed by blinded telephone interviewers at 12 months, were percentage of heavy drinking days in the prior 28 days measured by timeline follow-back interviews and a binary good drinking outcome, defined as abstinence or drinking below recommended limits in the prior 28 days (according to timeline follow-back interviews) and no alcohol-related symptoms in the past 3 months as measured by the Short Inventory of Problems.

RESULTS

Of 304 participants, 275 (90%) were male, 206 (68%) were white, and the mean (SD) age was 51.4 (13.8) years. At baseline, both the CHOICE intervention (n = 150) and usual care (n = 154) groups reported heavy drinking on 61% of days (95% CI, 56%-66%). During the 12-month intervention, 137 of 150 patients in the intervention group (91%) had at least 1 nurse visit, and 77 of 150 (51%) had at least 6 nurse visits. A greater proportion of patients in the intervention group than in the usual care group received alcohol-related care: 42% (95% CI, 35%-49%; 63 of 150 patients) vs 26% (95% CI, 19%-35%; 40 of 154 patients). Alcohol-related care included more AUD medication use: 32% (95% CI, 26%-39%; 48 of 150 patients in the intervention group) vs 8% (95% CI, 5%-13%; 13 of 154 patients in the usual care group). No significant differences in primary outcomes were observed at 12 months between patients in both groups. The percentages of heavy drinking days were 39% (95% CI, 32%-47%) and 35% (95% CI, 28%-42%), and the percentages of patients with a good drinking outcome were 15% (95% CI, 9%-22%; 18 of 124 patients) and 20% (95 % CI, 14%-28%; 27 of 134 patients), in the intervention and usual care groups, respectively (P = .32-.44). Findings at 3 months were similar.

CONCLUSIONS AND RELEVANCE

The CHOICE intervention did not decrease heavy drinking or related problems despite increased engagement in alcohol-related care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01400581.

Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics

BACKGROUND

Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely.

OBJECTIVE

This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications.

DESIGN

Qualitative, interview-based study.

PARTICIPANTS

Twenty-four providers from five VA PC clinics.

APPROACH

Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review.

KEY RESULTS

Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have.

CONCLUSIONS

We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives

BACKGROUND

To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care.

OBJECTIVE

To identify what patients with multiple chronic conditions describe as most important to their well-being and health.

DESIGN

We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory.

PARTICIPANTS

A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state.

APPROACH

Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation.

KEY RESULTS

Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation.

CONCLUSIONS

The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Firearm Storage Practices in Households of Adolescents With and Without Mental Illness

PURPOSE

Safe firearm storage practices are associated with a lower risk of self-inflicted injury and death. Whether such practices and relevant beliefs differ between households of adolescents with and without mental illness is unknown.

METHODS

We used survey and administrative data to perform a two-stage cross-sectional study of parents/guardians of adolescents who were 11-17 years, enrolled in a managed care plan in 2004 and living in a household with a firearm. Multivariable Poisson models compared the prevalence of three firearm storage practices between households of adolescents with (depression or bipolar disorder) and without mental illness (no psychiatric or substance use disorder), including whether all firearms were locked, any firearms were loaded, and all firearms were locked and unloaded. We used chi-square tests to compare responses to Likert items assessing beliefs relevant to storage practices between households.

RESULTS

Adolescents with mental illness were present in 141 (50.5%) of 279 study households. Their mean age was 14.5 years, and 54.8% were male. The mean age of parent/guardian respondents was 47.0 years, and 17.9% were male. Respondents from nearly 70% of households reported that all household firearms were stored locked and unloaded. In unadjusted and adjusted analyses, there were no significant differences in the prevalence of three firearm storage practices or in beliefs relevant to those practices between households of adolescents with and without mental illness.

CONCLUSIONS

These findings add to a growing body of evidence suggesting that firearm storage practices do not differ based on household mental health risk factors for self-harm.

Factor Structure and Sensitivity to Change of the Recovery Assessment Scale

The focus on recovery, not just symptom reduction, in mental health care brings a need for psychometrically sound measures of recovery. This study examined the factor structure and sensitivity to change of a common measure of mental health recovery, the Recovery Assessment Scale (RAS). We conducted a secondary data analysis from a randomized clinical trial of self-management for depression (n = 302). We tested both bifactor and the previously found five-factor model. Sensitivity to change was examined three ways: (1) between the intervention and control group; (2) across time in the intervention group; and (3) in those whose depression remitted. The previous five-factor model was supported. One subscale, no domination by symptoms, was particularly sensitive to change and showed sensitivity to change whereas the subscale reliance on others did not show change in any of the comparisons. Results suggest that the subscales of the RAS should be examined separately in future studies of recovery.

Design and Implementation of a Physician Coaching Pilot to Promote Value-Based Referrals to Specialty Care

INTRODUCTION

Referral rates to specialty care from primary care physicians vary widely. To address this variability, we developed and pilot tested a peer-to-peer coaching program for primary care physicians.

OBJECTIVES

To assess the feasibility and acceptability of the coaching program, which gave physicians access to their individual-level referral data, strategies, and a forum to discuss referral decisions.

METHODS

The team designed the program using physician input and a synthesis of the literature on the determinants of referral. We conducted a single-arm observational pilot with eight physicians which made up four dyads, and conducted a qualitative evaluation.

RESULTS

Primary reasons for making referrals were clinical uncertainty and patient request. Physicians perceived doctor-to-doctor dialogue enabled mutual learning and a pathway to return joy to the practice of primary care medicine. The program helped physicians become aware of their own referral data, reasons for making referrals, and new strategies to use in their practice. Time constraints caused by large workloads were cited as a barrier both to participating in the pilot and to practicing in ways that optimize referrals. Physicians reported that the program could be sustained and spread if time for mentoring conversations was provided and/or nonfinancial incentives or compensation was offered.

CONCLUSION

This physician mentoring program aimed at reducing specialty referral rates is feasible and acceptable in primary care settings. Increasing the appropriateness of referrals has the potential to provide patient-centered care, reduce costs for the system, and improve physician satisfaction.

Public Attitudes toward Consent and Data Sharing in Biobank Research: A Large Multi-site Experimental Survey in the US

Individuals participating in biobanks and other large research projects are increasingly asked to provide broad consent for open-ended research use and widespread sharing of their biosamples and data. We assessed willingness to participate in a biobank using different consent and data sharing models, hypothesizing that willingness would be higher under more restrictive scenarios. Perceived benefits, concerns, and information needs were also assessed. In this experimental survey, individuals from 11 US healthcare systems in the Electronic Medical Records and Genomics (eMERGE) Network were randomly allocated to one of three hypothetical scenarios: tiered consent and controlled data sharing; broad consent and controlled data sharing; or broad consent and open data sharing. Of 82,328 eligible individuals, exactly 13,000 (15.8%) completed the survey. Overall, 66% (95% CI: 63%-69%) of population-weighted respondents stated they would be willing to participate in a biobank; willingness and attitudes did not differ between respondents in the three scenarios. Willingness to participate was associated with self-identified white race, higher educational attainment, lower religiosity, perceiving more research benefits, fewer concerns, and fewer information needs. Most (86%, CI: 84%-87%) participants would want to know what would happen if a researcher misused their health information; fewer (51%, CI: 47%-55%) would worry about their privacy. The concern that the use of broad consent and open data sharing could adversely affect participant recruitment is not supported by these findings. Addressing potential participants' concerns and information needs and building trust and relationships with communities may increase acceptance of broad consent and wide data sharing in biobank research.

Improving Services for Women with Depression in Primary Care Settings

Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early stages of mental illness and to provide evidence-based treatments, but this potential is largely unfulfilled because of significant system-level barriers inherent in primary care. Recent effectiveness research provides an excellent framework for cost-effectively improving care of depression using stepped care principles and strategies effective for improving care of other chronic conditions. Psychologists have the potential to help implement stepped care models by providing training, consultation and ongoing quality assurance, as well as by delivering collaborative care models of acute-phase treatment and relapse prevention interventions.

Conducting a large, multi-site survey about patients' views on broad consent: challenges and solutions

Background

As biobanks play an increasing role in the genomic research that will lead to precision medicine, input from diverse and large populations of patients in a variety of health care settings will be important in order to successfully carry out such studies. One important topic is participants’ views towards consent and data sharing, especially since the 2011 Advanced Notice of Proposed Rulemaking (ANPRM), and subsequently the 2015 Notice of Proposed Rulemaking (NPRM) were issued by the Department of Health and Human Services (HHS) and Office of Science and Technology Policy (OSTP). These notices required that participants consent to research uses of their de-identified tissue samples and most clinical data, and allowing such consent be obtained in a one-time, open-ended or “broad” fashion. Conducting a survey across multiple sites provides clear advantages to either a single site survey or using a large online database, and is a potentially powerful way of understanding the views of diverse populations on this topic.

Methods

A workgroup of the Electronic Medical Records and Genomics (eMERGE) Network, a national consortium of 9 sites (13 separate institutions, 11 clinical centers) supported by the National Human Genome Research Institute (NHGRI) that combines DNA biorepositories with electronic medical record (EMR) systems for large-scale genetic research, conducted a survey to understand patients’ views on consent, sample and data sharing for future research, biobank governance, data protection, and return of research results.

Results

Working across 9 sites to design and conduct a national survey presented challenges in organization, meeting human subjects guidelines at each institution, and survey development and implementation. The challenges were met through a committee structure to address each aspect of the project with representatives from all sites. Each committee’s output was integrated into the overall survey plan. A number of site-specific issues were successfully managed allowing the survey to be developed and implemented uniformly across 11 clinical centers.

Conclusions

Conducting a survey across a number of institutions with different cultures and practices is a methodological and logistical challenge. With a clear infrastructure, collaborative attitudes, excellent lines of communication, and the right expertise, this can be accomplished successfully.

Population-based outreach versus care as usual to prevent suicide attempt: study protocol for a randomized controlled trial

BACKGROUND

Suicide remains the 10th-ranked most frequent cause of death in the United States, accounting for over 40,000 deaths per year. Nonfatal suicide attempts lead to over 200,000 hospitalizations and 600,000 emergency department visits annually. Recent evidence indicates that responses to the commonly used Patient Health Questionnaire (PHQ9) can identify outpatients who are at risk of suicide attempt and suicide death and that specific psychotherapy or Care Management programs can prevent suicide attempts in high-risk patients. Motivated by these developments, the NIMH-funded Mental Health Research Network has undertaken a multisite trial of two outreach programs to prevent suicide attempts among outpatients identified by routinely administered PHQ9 questionnaires.

METHODS/DESIGN

Outpatients who are at risk of suicide attempt are automatically identified using data from electronic health records (EHRs). Following a modified Zelen design, all those identified are assigned to continued usual care (i.e., no contact) or to be offered one of two population-based outreach programs. A Care Management intervention includes systematic outreach to assess suicide risk, EHR-based tools to implement risk-based care pathways, and care management to facilitate recommended follow-up. A Skills Training intervention includes interactive online training in Dialectical Behavior Therapy skills, supported by reminder and reinforcement messages from a skills coach. Each intervention supplements, rather than replaces, usual care; participants may receive any other services normally available. Interventions are delivered primarily by secure messaging through EHR patient portals. Suicide attempts and deaths following randomization are identified using state vital statistics data and health system EHR and insurance claim data. Primary evaluation will compare risk of suicide attempt or death over 18 months according to the initial assignment, regardless of intervention participation. Recruitment is underway in three health systems (Group Health Cooperative, HealthPartners, and Kaiser Permanente Colorado). Over 2500 participants have been randomized as of 1 March 2016, with enrollment averaging approximately 100 per week.

DISCUSSION

Assessing the effectiveness of population-based suicide prevention requires adherence to the principles of pragmatic trials: population-based enrollment, accepting variable treatment participation, assessing outcomes using health record data, and analyses based on intent-to-treat.

TRIAL REGISTRATION

ClinicalTrials.gov registration # NCT02326883 , registered on 23 December 2014.

Allocation of Resources to Communication of Research Result Summaries

Researchers and policymakers recommend communicating summary research results to biobank participants when feasible. To date, however, there have been few explorations of participant preferences for dedicating resources to this activity. Fifteen semi-structured interviews were conducted with participants of a genetic medicine biobank. Participants were interviewed by phone about their motivation for participation, and opinions about the allocation of resources to communicating summary results. De-identified transcripts were used for a directed content analysis. Most biobank participation was altruistic. All participants were not only interested in receiving summary results but also expressed a clear preference for allocating limited funds to conducting additional genetic research. The results suggest that participants have a nuanced view about the allocation of biobank resources to returning summary results, and asking their opinion is a valuable exercise. Researchers may benefit from transparency about research goals and involving biobank participants in decisions about return of summary results.

Proactive telephone counseling for adolescent smokers: Comparing regular smokers with infrequent and occasional smokers on treatment receptivity, engagement, and outcomes

BACKGROUND

Adolescent smoking cessation efforts to date have tended to focus on regular smokers. Consequently, infrequent and occasional smokers' receptivity and response to smoking cessation interventions is unknown. To address this gap, this study examines data from the Hutchinson Study of High School Smoking-a randomized trial that examined the effectiveness of a telephone-delivered smoking cessation intervention for a large, population-based cohort of adolescent smokers proactively recruited in an educational setting.

METHODS

The study population included 1837 proactively identified high school smokers. Intervention receptivity, engagement, and outcomes were examined among adolescent infrequent (1-4days/month) and occasional (5-19days/month) smokers and compared with regular smokers (20 or more days/month).

RESULTS

With regard to treatment receptivity, intervention recruitment did not differ by smoking frequency. For engagement, intervention completion rates were higher for infrequent smokers (80.5%) compared with occasional (63.8%) and regular smokers (61.5%, p<0.01). Intervention effect sizes were not statistically different across groups.

CONCLUSIONS

Adolescent infrequent and occasional smokers are at least as receptive to a proactively delivered smoking cessation intervention as regular smokers and can benefit just as much from it. Including these adolescent smokers in cessation programs and research-with the goal of interrupting progression of smoking before young adulthood-should help reduce the high smoking prevalence among young adults.

Does Effectiveness of Adolescent Smoking-Cessation Intervention Endure Into Young Adulthood? 7-Year Follow-Up Results from a Group-Randomized Trial

BACKGROUND

The Hutchinson Study of High School Smoking was the first randomized trial to show effectiveness of a smoking cessation intervention on 6-months prolonged smoking abstinence at one year post-intervention in a large population-based sample of adolescent smokers. An important question remains: Do the positive effects from teen smoking cessation interventions seen at up to 12 months post-intervention endure into young adulthood? This study examines for the first time whether such positive early effects from teen smoking cessation intervention can endure into young adulthood in the absence of additional intervention.

METHODS

High school smokers (n = 2,151) were proactively recruited into the trial from fifty randomly selected Washington State high schools randomized to the experimental (Motivational Interviewing + Cognitive Behavioral Skills Training telephone counseling intervention) or control (no intervention) condition. These smokers were followed to 7 years post high school to ascertain rates of six-year prolonged smoking abstinence in young adulthood. All statistical tests are two-sided.

RESULTS

No evidence of intervention impact at seven years post high school was observed for the main endpoint of six-year prolonged abstinence, neither among all smokers (14.2% in the experimental condition vs. 13.1% in the control condition, difference = +1.1%, 95% confidence interval (CI) = -3.4 to 5.8, p = .61), nor among the subgroups of daily smokers and less-than-daily smokers, nor among other a priori subgroups. But, observed among males was some evidence of an intervention impact on two endpoints related to progress towards quitting: reduction in number of days smoked in the past month, and increase in the length of the longest quit attempt in the past year.

CONCLUSIONS

There was no evidence from this trial among adolescent smokers that positive effectiveness of the proactive telephone intervention for smoking abstinence, observed previously at one year post-intervention, was sustained for the long-term into young adulthood. In light of the positive short-term effectiveness consistently observed from this and other trials for teen smokers, together with the lack of evidence from this study that such short-term impact can endure into young adulthood, sustained interventions that continue into young adulthood should be developed and tested for long-term impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00115882.

Organized Self-Management Support Services for Chronic Depressive Symptoms: A Randomized Controlled Trial

OBJECTIVE

This study aimed to determine whether a self-management support service was more effective than treatment as usual in reducing depressive symptoms and major depressive episodes and increasing personal recovery among individuals with chronic or recurrent depressive symptoms.

METHODS

The study was a randomized controlled trial of a self-management support service consisting of depression self-management training, recovery coaching, and care coordination. The 18-month intervention included regular telephone or in-person contacts with a care manager and a structured group program co-led by a professional therapist and a trained peer specialist. Intervention (N=150) and control (N=152) participants ages ≥ 18 with chronic or recurrent depressive symptoms were recruited from five clinics in Seattle, Washington. Outcome measures included the Hopkins Symptom Checklist depression scale, the Recovery Assessment Scale, the Patient-Rated Global Improvement scale, and the percentage of participants with a major depressive episode. Interviewers were masked to treatment condition.

RESULTS

Repeated-measures estimates of the long-term effect of the intervention versus usual care (average of the six-, 12-, and 18-month outcomes adjusted for age, gender, and site) indicated that intervention participants had less severe symptoms (p=.002) and higher recovery scores (p=.03), were less likely to be depressed (odds ratio [OR]=.52, p=.001), and were more likely to be much improved (OR=1.96, p=.001).

CONCLUSIONS

These findings support providing regular outreach care management and a self-care group offering a combined behavioral and recovery-oriented approach for people with chronic or recurrent depressive symptoms.

Perspectives in Implementing a Primary Care-Based Intervention to Reduce Alcohol Misuse

In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended screening followed by brief behavioral counseling to reduce alcohol misuse. Our study, Options Regarding Consumption of Alcohol (ORCA), was one of the studies included in an evidence review that comprised 23 RCTs. ORCA was designed to test whether a primary care-based intervention would reduce alcohol misuse among patients who screened positive for risky or hazardous drinking. Data collection occurred between 1995 and 1999; data analysis was conducted in 2000-2002. Study design and implementation built from a behavioral counseling research paradigm with four components: (1) population-based screening; (2) centralized delivery of intervention components; (3) involvement of primary care practitioners to motivate and reinforce behavior change; and (4) personalization of intervention components. In this paper, we assess the study features using the Pragmatic-Explanatory Continuum Indicator Summary Model domains. As a randomized trial, the study included some explanatory features (e.g., standardized follow-up surveys administered by study personnel); however, several aspects of the study were highly pragmatic. Practicable recruitment and training of providers, embedding population-based screening in pre-visit surveys, and keeping the delivery of the primary care intervention components consistent with the tempo and competing priorities of practice are three key features that contributed to the study's success and relevance to the USPSTF.

Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study

BACKGROUND

Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics.

OBJECTIVE

We aimed to understand factors that might contribute to low sensitivity of alcohol screening.

DESIGN

This was an observational, qualitative study.

PARTICIPANTS

Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S.

APPROACH

Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes.

KEY RESULTS

We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort.

CONCLUSIONS

This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.

Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff

BACKGROUND AND OBJECTIVE

Population-based alcohol screening, followed by brief intervention for patients who screen positive for unhealthy alcohol use, is widely recommended for primary care settings and considered a top prevention priority, but is challenging to implement. However, new policy initiatives in the U.S., including the Affordable Care Act, may help launch widespread implementation. While the nationwide Veterans Health Administration (VA) has achieved high rates of documented alcohol screening and brief intervention, research has identified quality problems with both. We conducted a qualitative key informant study to describe local implementation of alcohol screening and brief intervention from the perspectives of frontline adopters in VA primary care in order to understand the process of implementation and factors underlying quality problems.

METHODS

A purposive snowball sampling method was used to identify and recruit key informants from 5 VA primary care clinics in the northwestern U.S. Key informants completed 20-30 minute semi-structured interviews, which were recorded, transcribed, and qualitatively analyzed using template analysis.

RESULTS

Key informants (N=32) included: clinical staff (n=14), providers (n=14), and administrative informants (n=4) with varying participation in implementation of and responsibility for alcohol screening and brief intervention at the medical center. Ten inter-related themes (5 a priori and 5 emergent) were identified and grouped into 3 applicable domains of Greenhalgh's conceptual framework for dissemination of innovations, including values of adopters (theme 1), processes of implementation (themes 2 and 3), and post-implementation consequences in care processes (themes 4-10). While key informants believed alcohol use was relevant to health and important to address, the process of implementation (in which no training was provided and electronic clinical reminders "just showed up") did not address critical training and infrastructure needs. Key informants lacked understanding of the goals of screening and brief intervention, believed referral to specialty addictions treatment (as opposed to offering brief intervention) was the only option for following up on a positive screen, reported concern regarding limited availability of treatment resources, and lacked optimism regarding patients' interest in seeking help.

CONCLUSIONS

Findings suggest that the local process of implementing alcohol screening and brief intervention may have inadequately addressed important adopter needs and thus may have ultimately undermined, instead of capitalized on, staff and providers' belief in the importance of addressing alcohol use as part of primary care. Additional implementation strategies, such as training or academic detailing, may address some unmet needs and help improve the quality of both screening and brief intervention. However, these strategies may be resource-intensive and insufficient for comprehensively addressing implementation barriers.

Community dissemination and genetic research: moving beyond results reporting

The community-based participatory research (CBPR) literature notes that researchers should share study results with communities. In the case of human genetic research, results may be scientifically interesting but lack clinical relevance. The goals of this study were to learn what kinds of information community members want to receive about genetic research and how such information should be conveyed. We conducted eight focus group discussions with Yup'ik Alaska Native people in southwest Alaska (N = 60) and 6 (N = 61) with members of a large health maintenance organization in Seattle, Washington. Participants wanted to receive genetic information they "could do something about" and wanted clinically actionable information to be shared with their healthcare providers; they also wanted researchers to share knowledge about other topics of importance to the community. Although Alaska Native participants were generally less familiar with western scientific terms and less interested in web-based information sources, the main findings were the same in Alaska and Seattle: participants wished for ongoing dialogue, including opportunities for informal, small-group conversations, and receiving information that had local relevance. Effective community dissemination is more than a matter of presenting study results in lay language. Community members should be involved in both defining culturally appropriate communication strategies and in determining which information should be shared. Reframing dissemination as a two-way dialogue, rather than a one-way broadcast, supports the twin aims of advancing scientific knowledge and achieving community benefit.

Do depressed newly diagnosed cancer patients differentially benefit from nurse navigation?

OBJECTIVE

To examine whether the effects of a nurse navigator intervention for cancer vary with baseline depressive symptoms.

METHOD

Participants were enrolled in a randomized controlled trial of a nurse navigation intervention for patients newly diagnosed with lung, breast or colorectal cancer (N=251). This exploratory analysis used linear regression models to estimate the effect of a nurse navigator intervention on patient experience of care. Models estimated differential effects by including interactions between randomization group and baseline depressive symptoms. Baseline scores on the 9-item Patient Health Questionnaire (PHQ) were categorized into 3 groups: no depression (PHQ=0-4, N=138), mild symptoms of depression (PHQ=5-9, N=76) and moderate to severe symptoms (PHQ=10 or greater, N=34). Patient experience outcomes were measured by subscales of the Patient Assessment of Chronic Illness Care (PACIC) and subscales from an adaptation of the Picker Institute's patient experience survey at 4-month follow-up.

RESULTS

With the exception of the PACIC subscale of delivery system/practice design, interaction terms between randomization group and PHQ-9 scores were not statistically significant.

CONCLUSIONS

The intervention was broadly useful; we found that it was equally beneficial for both depressed patients and patients who were not significantly depressed in the first 4 months postdiagnosis. However, because of the small sample size, we cannot conclude with certainty that patients with depressive symptoms did not differentially benefit from the intervention.

A differential item function analysis of somatic symptoms of depression in people with cancer

BACKGROUND

The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer.

METHODS

People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment.

RESULTS

Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months.

LIMITATIONS

The sample size was small for DIF and consisted of mostly women with breast cancer.

CONCLUSIONS

Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.

Factors associated with successful discontinuation of hormone therapy

BACKGROUND

Careful management of symptoms, particularly sleep and mood disturbances, may assist women in discontinuing hormone therapy (HT). We sought to describe characteristics associated with successful HT cessation in women who attempted to discontinue estrogen pills/patches with or without progestin.

METHODS

We invited 2,328 women, aged 45-70, enrolled January 1, 2005, to May 31, 2006, at Group Health in Washington State and Harvard Vanguard Medical Associates in Massachusetts, to participate in a telephone survey about HT practices. For the sample, we selected 2,090 women with estrogen dispensings (pharmacy data) during the study period, 200 women without HT dispensing after January 2005, and 240 women with no estrogen dispensings; 1,358 (58.3%) completed the survey. These analyses are based on survey responses.

RESULTS

Among 802 women who attempted HT discontinuation, the mean age was 50 years, 93% were postmenopausal, 90% were white, 30% had had a hysterectomy, and 75% experienced hot flashes after discontinuation. Those who did not succeed had greater trouble sleeping (74% vs. 57%) and mood disturbances (51% vs. 34%) than those who succeeded. In multivariable analyses, factors associated with successful discontinuation included doctor advice (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.68-4.08), lack of symptom improvement (OR 4.21, CI 1.50-12.17), vaginal bleeding (OR 5.96, CI 1.44-24.6), and learning to cope with symptoms (OR 3.36, CI 2.21-5.11). Factors associated with unsuccessful HT discontinuation included trouble sleeping (OR 0.40, CI 0.26-0.61) and mood swings or depression (OR 0.63, CI 0.42-0.92).

CONCLUSIONS

Doctor advice is strongly associated with successful HT discontinuation. Symptom management, particularly sleep and mood disturbances, may help women discontinue HT.

Nurse navigators in early cancer care: a randomized, controlled trial

PURPOSE

To determine whether a nurse navigator intervention improves quality of life and patient experience with care for people recently given a diagnosis of breast, colorectal, or lung cancer.

PATIENTS AND METHODS

Adults with recently diagnosed primary breast, colorectal, or lung cancer (n = 251) received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133) in a two-group cluster randomized, controlled trial with primary care physicians as the units of randomization. Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life scale, three subscales of the Patient Assessment of Chronic Illness Care (PACIC), and selected subscales from a cancer adaptation of the Picker Institute's patient experience survey. Self-report measures were collected at baseline, 4 months, and 12 months. Automated administrative data were used to assess time to treatment and total health care costs.

RESULTS

There were no significant differences between groups in FACT-G scores. Nurse navigator patients reported significantly higher scores on the PACIC and reported significantly fewer problems with care, especially psychosocial care, care coordination, and information, as measured by the Picker instrument. Cumulative costs after diagnosis did not differ significantly between groups, but lung cancer costs were $6,852 less among nurse navigator patients.

CONCLUSION

Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.

Population targeting and durability of multimorbidity collaborative care management

OBJECTIVES

A patient-centered collaborative care program for depression and uncontrolled diabetes and/or coronary heart disease (CHD) demonstrated improved clinical outcomes relative to usual care. We report clinically stratified analyses of patient outcomes to inform the duration and targeting of care management services for complex patients with multimorbidity.

METHODS

A 12-month randomized controlled trial of a multimorbidity collaborative care program followed patients at 6, 12, 18, and 24 months for diabetes (glycated hemoglobin [A1C]), blood pressure (systolic; SBP), low-density lipoprotein (LDL) cholesterol, and depression (Symptoms Check List-20 score). Depressed patients with less favorable medical control (Patient Health Questionnaire-9 score > 10, A1C > 8.0 %, SBP > 140 mm Hg, and LDL cholesterol > 120 mg/dL) were compared with depressed patients with more favorable medical control to describe differential intervention benefits over time.

RESULTS

In contrast to patients with more favorable baseline control, patients with depression and unfavorable control of A1C, SBP, and LDL at baseline showed improved outcomes as early as the 6-month follow-up assessment. Clinical benefits in the intervention group were largely sustained over the 24-month follow-up, except for some deterioration of glycemic control in intervention patients and trends toward improvement among controls over time. Among patients with depression and more favorable medical control at baseline, there were minimal between-group differences in medical disease outcomes.

CONCLUSIONS

Clinical benefits of a multimorbidity collaborative care management program occurred early, and were only found among patients with poor control of baseline diabetes and CHD risk factors. Targeting may maximize reach and improve affordability of complex care management.

Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?

OBJECTIVE As use of standard depression questionnaires in clinical practice increases, clinicians will frequently encounter patients reporting thoughts of death or suicide. This study examined whether responses to the Patient Health Questionnaire for depression (PHQ-9) predict subsequent suicide attempt or suicide death. METHODS Electronic records from a large integrated health system were used to link PHQ-9 responses from outpatient visits to subsequent suicide attempts and suicide deaths. A total of 84,418 outpatients age ≥13 completed 207,265 questionnaires between 2007 and 2011. Electronic medical records, insurance claims, and death certificate data documented 709 subsequent suicide attempts and 46 suicide deaths in this sample. RESULTS Cumulative risk of suicide attempt over one year increased from .4% among outpatients reporting thoughts of death or self-harm "not at all" to 4% among those reporting thoughts of death or self-harm "nearly every day." After adjustment for age, sex, treatment history, and overall depression severity, responses to item 9 of the PHQ-9 remained a strong predictor of suicide attempt. Cumulative risk of suicide death over one year increased from .03% among those reporting thoughts of death or self-harm ideation "not at all" to .3% among those reporting such thoughts "nearly every day." Response to item 9 remained a moderate predictor of subsequent suicide death after the same factor adjustments. CONCLUSIONS Response to item 9 of the PHQ-9 for depression identified outpatients at increased risk of suicide attempt or death. This excess risk emerged over several days and continued to grow for several months, indicating that suicidal ideation was an enduring vulnerability rather than a short-term crisis.

An oncology nurse navigator program designed to eliminate gaps in early cancer care

Although the burden of a cancer diagnosis for patients is profound, healthcare systems often fail to address patients' and families' psychosocial, information, and care coordination needs. The authors of this article designed an oncology nurse navigator program to proactively address these care gaps and tested the program's effectiveness in providing high-quality cancer care through a randomized, controlled trial. The program's model was informed by research synthesizing the perspectives of patients, families, clinicians, and experts throughout the country. The authors systematically incorporated feedback from participating clinical departments to improve the effectiveness of the program. This article details the intervention to help inform other systems interested in implementing an oncology nurse navigator program.

Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes

PURPOSE

Although psychosocial and clinical factors have been found to be associated with hypoglycemic episodes in patients with diabetes, few studies have examined the association of depression with severe hypoglycemic episodes. This study examined the prospective association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization.

METHODS

In a longitudinal cohort study, a sample of 4,117 patients with diabetes enrolled between 2000 and 2002 were observed from 2005 to 2007. Meeting major depression criteria on the Patient Health Questionnaire-9 was the exposure of interest, and the outcome of interest was an International Classification of Disease, Ninth Revision code for a hypoglycemic episode requiring an emergency department visit or hospitalization. Proportional hazard models were used to analyze the association of baseline depression and risk of one or more severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes.

RESULTS

After adjusting for sociodemographic, clinical measures of diabetes severity, non-diabetes-related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared with nondepressed patients who had diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95% CI, 1.03-1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95% CI, 1.03-1.74).

CONCLUSION

Depression was significantly associated with time to first severe hypoglycemic episode and number of hypoglycemic episodes. Research assessing whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes is needed.

Improving confidence for self care in patients with depression and chronic illnesses

The aim of this study was to examine whether patients who received a multicondition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy, and whether greater knowledge and self-efficacy was positively associated with improved target outcomes. A randomized controlled trial with 214 patients with comorbid depression and poorly controlled diabetes and/or coronary heart disease tested a 12-month team-based intervention that combined self-management support and collaborative care management. At 6 and 12 month outcomes the intervention group showed significant improvements over the usual care group in confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress. Improvements in self care-efficacy were significantly related to improvements in depression, and early improvements in confidence to maintain lifestyle changes even during times of stress explained part of the observed subsequent improvements in depression.

Building a community-academic partnership: implementing a community-based trial of telephone cognitive behavioral therapy for rural latinos

Concerns about the appropriate use of EBP with ethnic minority clients and the ability of community agencies to implement and sustain EBP persist and emphasize the need for community-academic research partnerships that can be used to develop, adapt, and test culturally responsive EBP in community settings. In this paper, we describe the processes of developing a community-academic partnership that implemented and pilot tested an evidence-based telephone cognitive behavioral therapy program. Originally demonstrated to be effective for urban, middle-income, English-speaking primary care patients with major depression, the program was adapted and pilot tested for use with rural, uninsured, low-income, Latino (primarily Spanish-speaking) primary care patients with major depressive disorder in a primary care site in a community health center in rural Eastern Washington. The values of community-based participatory research and community-partnered participatory research informed each phase of this randomized clinical trial and the development of a community-academic partnership. Information regarding this partnership may guide future community practice, research, implementation, and workforce development efforts to address mental health disparities by implementing culturally tailored EBP in underserved communities.