Pilot RCT Testing A Mailing About Sleeping Pills and Cognitive Behavioral Therapy for Insomnia: Impact on Benzodiazepines and Z-Drugs

OBJECTIVES

The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans.

METHODS

Pilot randomized controlled trial consists of 2,009 veterans aged ≥ 65 years who received BZRA prescriptions from a Veterans Health Administration pharmacy (Colorado or Montana) during the prior 18 months. Active: Arm 1 was a mailed brochure about BZRA risks that also included information about a free, online cognitive behavioral therapy for the insomnia (CBTI) program. Arm 2 was a mailed brochure (same as arm 1) and telephone reinforcement call. Control: Arm 3 was a mailed brochure without insomnia treatment information. Active BZRA prescriptions at follow-up (6 and 12 months) were measured.

RESULTS

In logistic regression analyses, the odds of BZRA prescription at 6- and 12-month follow-ups were not significantly different for arm 1 or 2 (active) versus arm 3 (control), including models adjusted for demographics and prescription characteristics (p-values >0.36).

CONCLUSIONS

Although we observed no differences in active BZRA prescriptions, this pilot study provides guidance for conducting a future study, indicating a need for a more potent intervention. A full-scale trial testing an optimized program would provide conclusive results.

CLINICAL IMPLICATIONS

Mailing information about BZRA risks and CBTI did not affect BZRA prescriptions.

The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs

BACKGROUND

The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls.

OBJECTIVE

Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls.

DESIGN

Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs.

PARTICIPANTS

Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019.

INTERVENTION

The four-step TNP transitional care intervention.

MAIN MEASURES

Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls.

KEY RESULTS

Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)).

CONCLUSIONS

Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.

Understanding adaptations in the Veteran Health Administration's Transitions Nurse Program: refining methodology and pragmatic implications for scale-up

BACKGROUND

When complex health services interventions are implemented in real-world settings, adaptations are inevitable. Adaptations are changes made to an intervention, implementation strategy, or context prior to, during, and after implementation to improve uptake and fit. There is a growing interest in systematically documenting and understanding adaptations including what is changed, why, when, by whom, and with what impact. The rural Transitions Nurse Program (TNP) is a program in the Veterans Health Administration (VHA), designed to safely transition a rural veteran from a tertiary hospital back home. TNP has been implemented in multiple cohorts across 11 sites nationwide over 4 years. In this paper, we describe adaptations in five TNP sites from the first cohort of sites and implications for the scale-up of TNP and discuss lessons learned for the systematic documentation and analysis of adaptations.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) expanded version of the original Stirman framework to guide the rapid qualitative matrix analysis of adaptations. Adaptations were documented using multiple approaches: real-time database, semi-structured midpoint and exit interviews with implementors, and member checking with the implementation team. Interviews were recorded and transcribed. To combine multiple sources of adaptations, we used key domains from our framework and organized adaptations by time when the adaptation occurred (pre-, early, mid-, late implementation; sustainment) and categorized them as proactive or reactive.

RESULTS

Forty-one unique adaptations were reported during the study period. The most common type of adaptation was changes in target populations (patient enrollment criteria) followed by personnel changes (staff turnover). Most adaptations occurred during the mid-implementation time period and varied in number and type of adaptation. The reasons for this are discussed, and suggestions for future adaptation protocols are included.

CONCLUSIONS

This study demonstrates the feasibility of systematically documenting adaptations using multiple methods across time points. Implementors were able to track adaptations in real time across the course of an intervention, which provided timely and actionable feedback to the implementation team overseeing the national roll-out of the program. Longitudinal semi-structured interviews can complement the real-time database and elicit reflective adaptations.

An interdisciplinary postdoctoral fellowship model: Opportunities for nurse PhDs

Interdisciplinary postdoctoral fellowships can provide rich opportunities for nurses to receive additional training and develop diverse professional academic and research partnerships. They provide a structure for learning in which team science is emphasized and complex health issues are addressed. This paper presents an interdisciplinary postdoctoral fellowship model and highlights the development of one nurse fellow's network during the program. The fellowship curriculum is outlined and the three focus areas (education, research, and experience) are further explained. A social network analysis approach was used to illustrate the growth in one nurse fellow's network during a two-year postdoctoral fellowship. The first year of the fellowship showed an increase in the number of professional connections, while in the second year the relationships deepened as collaborations were established and strengthened.

Sleep and timing of death by suicide among U.S. Veterans 2006–2015: analysis of the American Time Use Survey and the National Violent Death Reporting System

Study Objectives

Suicide is a top public health priority, and U.S. Veterans are recognized to be at particularly elevated risk. Sleep disturbances are an independent risk factor for suicide; recent empirical data suggest that nocturnal wakefulness may be a key mechanism underlying this association. Given higher rates of sleep disturbances among U.S. Veterans compared with civilians, we examined associations between nocturnal wakefulness and timing of death by suicide in U.S. Veterans and civilians to determine whether temporal suicide patterns differed.

Methods

The American Time Use Survey and the National Violent Death Reporting System were analyzed (2006–2015) to determine whether sleep and temporal suicide patterns differed between age-stratified groups (18–39, 40–64, and ≥65) of U.S. Veterans and civilians. Observed temporal suicide patterns were reported and standardized incidence ratios (SIRs) calculated to compare the percentage of suicides observed with those expected, given the proportion of the population awake, across clock hours.

Results

The raw proportion of Veteran suicides peaks between the hours of 1000–1200; however, the peak prevalence of suicide after accounting for the population awake is between 0000 and 0300 hr (p < .00001, ϕ = .88). The highest SIR was at midnight; U.S. Veterans were eight times more likely to die by suicide than expected given the population awake (SIR = 8.17; 95% CI = 7.45–8.94).

Conclusions

Nocturnal wakefulness is associated with increased risk for suicide in U.S. Veterans. Overall patterns of observed suicides by clock hour were similar between U.S. Veterans and civilians. However, Veteran-specific SIRs suggest differences in magnitude of risk by clock hour across age groups. Future research examining female and Post-9/11 U.S. Veterans is warranted.

Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial

PURPOSE/OBJECTIVES

To examine the effect of cognitive-behavioral therapy for insomnia (CBTI) on sleep improvement, daytime symptoms, and quality of life (QOL) in breast cancer survivors (BCSs) after cancer treatment.

DESIGN

A prospective, longitudinal, randomized, controlled trial.

SETTING

Oncology clinics, breast cancer support groups, and communities in Colorado.

SAMPLE

56 middle-aged BCSs with chronic insomnia.

METHODS

Women were randomly assigned to CBTI or behavioral placebo treatment (BPT) and completed measures of sleep, QOL, functioning, fatigue, and mood at baseline, postintervention, and at three- and six-month follow-ups.

MAIN RESEARCH VARIABLES

Sleep outcomes (e.g., sleep efficiency, sleep latency, total sleep time, wake after sleep onset, number of nightly awakenings); secondary variables included sleep medication use, insomnia severity, QOL, physical function, cognitive function, fatigue, depression, anxiety, and sleep attitudes or knowledge.

FINDINGS

Sleep efficiency and latency improved more in the CBTI group than the BPT group; this difference was maintained during follow-up. Women in the CBTI group had less subjective insomnia, greater improvements in physical and cognitive functioning, positive sleep attitudes, and increased sleep hygiene knowledge. No group differences in improvement were noted relative to QOL, fatigue, or mood.

CONCLUSIONS

Nurse-delivered CBTI appears to be beneficial for BCSs' sleep latency/efficiency, insomnia severity, functioning, sleep knowledge, and attitudes more than active placebo, with sustained benefit over time.

IMPLICATIONS FOR NURSING

Oncology nurses are in a unique position to identify insomnia in cancer survivors. When sleep disturbances become chronic, nurses need to make recommendations and referrals.

Adherence to cognitive behavioral therapy for insomnia: a systematic review

Chronic insomnia is a significant public health problem worldwide, and insomnia has considerable personal and social costs associated with serious health conditions, greater healthcare utilization, work absenteeism, and motor-vehicle accidents. Cognitive behavioral therapy for insomnia (CBTI) is an efficacious treatment, yet attrition and suboptimal adherence may diminish its impact. Despite the increasing use of CBTI, surprisingly little attention has been devoted to understanding the role of adherence. This review describes a comprehensive literature search of adherence to CBTI. The search revealed 15 studies that evaluated adherence to CBTI in adults using valid and reliable measures of sleep, and measure of adherence other than study withdrawals. The primary purposes of this review were to 1) synthesize current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes. Strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the role of adherence as a factor and outcome of CBTI success. The importance of standardized adherence and outcome measures is discussed. In light of the importance of adherence to behavior change, this systematic review may better inform future intervention efforts.

Guidelines for nutrition therapy in critical illness: are not they all the same?

In general, clinical guidelines identify, summarize, and evaluate the most current data concerning prevention, diagnosis, prognosis, therapy and cost for a specific patient population. This paper will briefly describe the authors' point of view regarding controversial aspects of adult critical care nutrition therapy guidelines published by preeminent professional societies in the United States (US), Canada, and Europe. The US guidelines were developed by subject matter experts to offer recommendations for specialized nutrition therapy that are supported by review and analysis of the pertinent current literature, other national and international guidelines, and by a blend of expert opinion and clinical practicality. A similar strategy was used to compile all three guideline publications resulting in many areas of common agreement, but disparate substantive recommendations do exist regarding: indirect calorimetry versus predictive equations, prokinetics in the intensive care unit (ICU), arginine use in the ICU, probiotic use in the ICU, and acceptable gastric residual volumes in the ICU patient. All of the guidelines are based on high quality studies in patients with critical illness, but like any other therapeutic modality for an ICU patient, nutritional interventions require a multidisciplinary approach that incorporates institutional best practices, individual patient considerations, and above all, clinical judgment.

Comparison of the CardioWest total artificial heart, the novacor left ventricular assist system and the thoratec ventricular assist system in bridge to transplantation

BACKGROUND

Device selection has historically been supported by minimal comparative data. Since 1994, we have implanted 43 patients with the CardioWest Total Artificial Heart (CW), 23 with the Novacor Left Ventricular Assist System (N), and 26 with the Thoratec Ventricular Assist System (T). This experience provides a basis for our device selection criteria.

METHODS

We reviewed retrospectively the results for survival, stroke, and infection in the CW, N, and T groups. Statistical methods included the Student's t-test, chi2 analysis, and Kaplan-Meier actuarial survival curves.

RESULTS

The T group patients were younger and smaller sized than the CW or N group. The CW group had the highest mean central venous pressure (CVP) and lowest mean cardiac index. Survival to transplantation was 75% for CW, 57% for N, and 38% for T. Multiple organ failure postimplant caused most deaths in the CW and T groups. Right heart failure and stroke caused most N deaths. Linearized stroke rates (event/patient-month) were 0.03 for CW, 0.28 for N, and 0.08 for T. Serious infections were found in 20% of CW, 30% of N, and 8% of T patients, but linearized rates showed little difference and death from infection was rare.

CONCLUSIONS

The N device should be used in "stable" patients with body surface area (BSA) greater than 1.7 m2 and with minimal right heart failure. Unstable patients with biventricular failure should receive a CW if the BSA is greater than 1.7 m2 or a T if they are smaller.

Use of indirect calorimetry to optimize nutrition support and assess physiologic dead space in the mechanically ventilated ICU patient: a case study approach

Indirect calorimetry (IC) is an accurate method of estimating a patient's energy expenditure, particularly the complex critically ill patient who benefits most from an individualized regimen of nutritional support. This bedside technique measures variables related to gas exchange and replaces assumptions about physiologic stress. When indirect calorimetry data are augmented by an arterial blood gas analysis of carbon dioxide (PaCO2), the dead space to tidal volume ratio (VD/VT) can be determined for an individual patient. These data can be valuable to the healthcare team when checking reasons for weaning failure. A case study approach to a 69-year-old man with acute respiratory distress syndrome and biliary sepsis will demonstrate the utility of this measurement. Attention to precise nutritional support and optimal gas exchange can influence the outcome of critically ill mechanically ventilated patients. This discussion highlights the potential benefits of indirect calorimetry for critical care nurses.

Is it necessary to perform surveillance endomyocardial biopsies in heart transplant recipients?

BACKGROUND

Routine surveillance endomyocardial biopsies to diagnose unsuspected rejection are performed at 3- to 12-month intervals after heart transplantation. From 1979 to 1989, surveillance biopsies were routinely performed as a part of the yearly evaluation.

METHODS

A retrospective analysis of the follow-up data showed that "routine surveillance biopsies" had an extremely low yield, and, on the basis of the results of this study, we discontinued to perform surveillance biopsies beyond 6 months after transplantation. To validate these results, we compared the outcome of two groups of patients who had similar demographics and identical immunosuppression, except that in one group the surveillance biopsies were not performed.

RESULTS

No difference was found in either actuarial survival rate or freedom from late rejection between the two groups.

CONCLUSIONS

These findings confirm that routine surveillance heart biopsies beyond 6 months after transplantation are not necessary and they should be performed only if there is clinical suspicion of rejection or as part of a research protocol.

Clinical significance of weight difference between donor and recipient in heart transplantation

A standard and important criterion for donor acceptance is to match the donor's body weight to within 20% of the recipient's body weight. However, to meet the increasing demand of patients who need heart transplantation, frequently a heart that is below the standard criteria for donation is accepted. Of the 200 consecutive patients who underwent heart transplantation at the University of Arizona, 27 patients received a heart from a smaller donor with a weight difference of more than 30% (range 30% to 46%). The early mortality and late survival of these 27 patients were not different when compared with those of the patients who received transplants from donors with a weight difference of less than 30%. The probability of freedom from rejection and infection and postoperative ejection fraction were also similar between the two groups. Therefore, we believe that the widely accepted donor-recipient weight-match criterion of 20% can be safely extended.

The effect of ascorbic acid on copper-induced oxidative changes in the erythrocytes of rats, sheep, and normal humans

Rats, sheep, and normal humans displayed a comparable sensitivity to copper acetate (3 mM)-induced changes in reduced glutathione (GSH) levels in vitro. However, the human erythrocytes were more sensitive than either animal to methemoglobin (METHB) formation with the rat being least sensitive. Ascorbic acid incubation markedly enhanced the occurrence of copper acetate-induced increases in METHB and decreases in GSH in the sheep and humans. However, ascorbic acid incubation reduced the occurrence of copper acetate-induced increases in METHB, while not effecting changes in GSH in rats.

The effect of ascorbic acid on nitrite-induced methemoglobin formation in rats, sheep, and normal human erythrocytes

Interspecies differences were demonstrated with respect to the occurrence of sodium nitrite-induced methemoglobin (METHB) in the erythrocytes of rats, dorset sheep, and normal humans, with the rats displaying approximately 25-33% of the sensitivity of sheep and human erythrocytes. Ascorbic acid incubation along with the nitrite was able to significantly reduce METHB formation in a dose-dependent manner in both rats and humans but not in sheep.

The effect of ascorbic acid on sodium nitrite-induced methemoglobin formation in glucose-6-phosphate dehydrogenase-deficient erythrocytes

Ascorbic acid significantly reduced the occurrence of sodium nitrite-induced methemoglobin (METHB) formation in a dose-dependent manner in erythrocytes from glucose-6-phosphate dehydrogenase (G-6-PD)-deficient humans in vitro. The ascorbic acid treatment, however, also decreased levels of reduced GSH in a dose-dependent manner, a response indicative of oxidant stress to the erythrocyte membrane. The latter findings are inconsistent with the hypothesis that ascorbic acid supplementation in G-6-PD-deficient humans may help compensate for inherently low levels of erythrocyte GSH. Finally, the ascorbic acid-induced reduction of METHB values, while of statistical significance, does not appear to be of clinical significance.