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Sayer NA, Maieritsch KP, Yamokoski CA, Orazem RJ, Clothier BA, Noorbaloochi S. Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report. BMJ Open Qual 2024; 13:e002449. [PMID: 38216294 PMCID: PMC10806576 DOI: 10.1136/bmjoq-2023-002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/07/2023] [Indexed: 01/14/2024] Open
Abstract
Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.
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Affiliation(s)
- Nina A Sayer
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kelly P Maieritsch
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Cynthia A Yamokoski
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Robert J Orazem
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | | | - Siamak Noorbaloochi
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Polusny MA, Marquardt CA, Hubbling M, Campbell EH, Arbisi PA, Davenport ND, Lim KO, Lissek S, Schaefer JD, Sponheim SR, Masten AS, Noorbaloochi S. Adaptation in Young Military Recruits: Protocol for the Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study. JMIR Res Protoc 2023; 12:e51235. [PMID: 37792432 PMCID: PMC10585449 DOI: 10.2196/51235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Military services provide a unique opportunity for studying resilience, a dynamic process of successful adaptation (ie, doing well in terms of functioning and symptoms) in response to significant adversity. Despite the tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding the neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential for enhancing the resilience of military service members. OBJECTIVE The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize the trajectories of positive adaptation among young military recruits in response to basic combat training (BCT), a well-defined, uniform, and 10-week period of intense stress (aim 1), and identify promotive and protective processes contributing to individual variations in resilience (aim 2). The secondary objective is to investigate the pathways by which neurobehavioral markers of self-regulation assessed using electroencephalography and magnetic resonance imaging contribute to adaptive trajectories (aim 3). METHODS ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped out for BCT. Participants (N=1201) are assessed at 5 time points over the initial >2 years of military service beginning before BCT (baseline) and followed up at 2 weeks and 6, 12, and 18 months after BCT. Participants complete web-based questionnaires assessing vulnerability and protective factors, mental health, and socioemotional functioning at each time point and a battery of neurocognitive tests at time 0. A subset of participants also complete structured diagnostic interviews and additional self-report measures and perform neurobehavioral tasks before and after BCT during electroencephalography sessions and before BCT only during magnetic resonance imaging sessions. RESULTS This UG3/UH3 project was initially funded in August 2017, with the UG3 pilot work completed at the end of 2018. The UH3 phase of the project was funded in March 2019. Study enrollment for the UH3 phase began on April 14, 2019, and ended on October 16, 2021. A total of 1201 participants are enrolled in the study. Follow-up data collection for the UH3 phase is ongoing and projected to continue through February 2024. We will disseminate the findings through conferences, webinars, open access publications, and communications with participants and stakeholders. CONCLUSIONS The ARMOR study provides a rich data set to identify the predictors and mechanisms of resilient and nonresilient outcomes in the context of military stressors, which are intended to empirically inform the development of prevention and intervention strategies to enhance the resilience of military trainees and potentially other young people facing significant life challenges. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51235.
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Affiliation(s)
- Melissa A Polusny
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Craig A Marquardt
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Michelle Hubbling
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Emily Hagel Campbell
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Minneapolis, MN, United States
| | - Paul A Arbisi
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Nicholas D Davenport
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Kelvin O Lim
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Shmuel Lissek
- Department of Psychology, University of Minnesota-Twin Cities, Minneapolis, MN, United States
| | - Jonathan D Schaefer
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Scott R Sponheim
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Psychology, University of Minnesota-Twin Cities, Minneapolis, MN, United States
| | - Ann S Masten
- Institute of Child Development, University of Minnesota-Twin Cities, Minneapolis, MN, United States
| | - Siamak Noorbaloochi
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
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Ackland PE, Kenny ME, Clothier BA, Salameh HA, Boening N, Gordon AJ, Noorbaloochi S, Gustavson AM, Miller W, Hagedorn HJ. What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities. J Gen Intern Med 2023; 38:2647-2654. [PMID: 37037986 PMCID: PMC10088728 DOI: 10.1007/s11606-023-08116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability. OBJECTIVE We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing. DESIGN Convergent mixed-methods design. PARTICIPANTS Thirty-nine providers and leaders from eight VHA facilities. APPROACH Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period. KEY RESULTS Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access. CONCLUSIONS Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA.
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Marie E Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Barbara A Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Hope A Salameh
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Natassia Boening
- ORD Strategic Initiative for Research and EHR Synergy (OSIRES), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Hildi J Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Centers of Excellence in Substance Addiction Treatment and Education, Puget Sound VAHCS/Philadelphia VAHCS, Seattle, WA, USA
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Garcia CC, Bounthavong M, Gordon AJ, Gustavson AM, Kenny ME, Miller W, Esmaeili A, Ackland PE, Clothier BA, Bangerter A, Noorbaloochi S, Harris AHS, Hagedorn HJ. Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder. Implement Sci Commun 2023; 4:91. [PMID: 37563672 PMCID: PMC10413546 DOI: 10.1186/s43058-023-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/29/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.
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Affiliation(s)
- Carla C Garcia
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mark Bounthavong
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
- UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, San Diego, CA, USA.
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS, Salt Lake City Veterans Affairs Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Allison M Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marie E Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Aryan Esmaeili
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Princess E Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Barbara A Clothier
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Ann Bangerter
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
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Polusny MA, Marquardt CA, Hubbling S, Campbell EH, Arbisi PA, Davenport ND, Lim KO, Lissek S, Schaefer JD, Sponheim SR, Masten AS, Noorbaloochi S. Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study of Adaptation in Young Military Recruits: Protocol and rationale for methods and measures. medRxiv 2023:2023.07.07.23292348. [PMID: 37502945 PMCID: PMC10370239 DOI: 10.1101/2023.07.07.23292348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background Military service provides a unique opportunity for studying resilience, a dynamic process of successful adaptation (i.e., doing well in terms of functioning and symptoms) in response to significant adversity. Despite tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential to enhance the resilience of military service members. Objectives The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize trajectories of positive adaptation among young military recruits in response to Basic Combat Training (BCT), a well-defined, uniform, 10-week period of intense stress (Aim 1) and identify promotive and protective processes contributing to individual variations in resilience (Aim 2). The secondary objective is to investigate pathways by which neurobehavioral markers of self-regulation assessed by electroencephalography (EEG) and magnetic resonance imaging (MRI) contribute to adaptive trajectories (Aim 3). Methods ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped for BCT. Participants (N=1,201) are assessed at five timepoints over the initial 2+ years of military service beginning before BCT (baseline) and followed up at 2 weeks, 6, 12, and 18 months post-BCT. At each time point, participants complete online questionnaires assessing vulnerability and protective factors, mental health and social-emotional functioning, and, at Time 0 only, a battery of neurocognitive tests. A subset of participants also complete structured diagnostic interviews, additional self-report measures, and perform neurobehavioral tasks before and after BCT during EEG sessions, and, at pre-BCT only, during MRI sessions. Results Study enrollment began April 14, 2019 and ended in October 16, 2021. A total of 1,201 participants are enrolled in the study (68.9% male; mean age = 18.9, SD = 3.0). Follow-up data-collection is ongoing and projected to continue through March 2024. We will disseminate findings through conferences, webinars, open access publications, and communications with participants and stakeholders. Conclusions Results are expected to elucidate how young military recruits adapt to military stressors during the initial years of military service. Understanding positive adaptation of military recruits in the face of BCT has implications for developing prevention and intervention strategies to enhance resilience of military trainees and potentially other young people facing significant life challenges.
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Affiliation(s)
- Melissa A Polusny
- Minneapolis VA Health Care System, Minneapolis, MN
- Center for Care Delivery Outcomes Research, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
| | - Craig A Marquardt
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
| | - Shelly Hubbling
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
| | - Emily Hagel Campbell
- Minneapolis VA Health Care System, Minneapolis, MN
- Center for Care Delivery Outcomes Research, Minneapolis, MN
| | - Paul A Arbisi
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
- Department of Psychology, University of Minnesota, Minneapolis, MN
| | - Nicholas D Davenport
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
| | - Kelvin O Lim
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
| | - Shumel Lissek
- Department of Psychology, University of Minnesota, Minneapolis, MN
| | | | - Scott R Sponheim
- Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School
- Department of Psychology, University of Minnesota, Minneapolis, MN
| | - Ann S Masten
- Institute of Child Development, University of Minnesota, Minneapolis, MN
| | - Siamak Noorbaloochi
- Minneapolis VA Health Care System, Minneapolis, MN
- Center for Care Delivery Outcomes Research, Minneapolis, MN
- Department of Medicine, University of Minnesota Medical School
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Miller WA, Gordon AJ, Clothier BA, Ackland PE, Bounthavong M, Garcia C, Kenny ME, Noorbaloochi S, Hagedorn HJ. Co-occurring implementation strategies: The effects of academic detailing for opioid use disorder campaign on the advancing pharmacological treatments for opioid use disorder (ADaPT-OUD) study. Implement Res Pract 2023; 4:26334895231199463. [PMID: 37790176 PMCID: PMC10504828 DOI: 10.1177/26334895231199463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD. Methods This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach. Results There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites. Conclusion Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted.
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Affiliation(s)
- Wendy A. Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Barbara A. Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mark Bounthavong
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA, USA
| | - Carla Garcia
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
| | - Marie E. Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Centers of Excellence in Substance Addiction Treatment and Education, Puget Sound VAHCS, Seattle, WA & Philadelphia VAHCS, Philadelphia, PA, USA
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Murdoch M, Clothier BA, Kehle-Forbes S, Vang D, Noorbaloochi S. Impact of different cover letter information and incentives on Veterans' emotional responses to an unsolicited mailed survey about military traumas: a randomized, 3x2x2 factorial trial. BMC Med Res Methodol 2022; 22:308. [PMID: 36456912 PMCID: PMC9714177 DOI: 10.1186/s12874-022-01783-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Altering cover letter information to reduce non-response bias in trauma research could inadvertently leave survey participants unprepared for potentially upsetting questions. In an unsolicited, mailed survey, we assessed participants' change in affect post-survey after altering key cover letter information and promising different incentives. We tested direct and indirect effects of participants carefully reading the cover letter on changes in their affect post-survey. METHODS In a 3X2X2 randomized, factorial trial, 480 male and 480 female, nationally representative Veterans who were applying for posttraumatic stress disorder disability benefits were randomized to receive one of 12 different cover letters. The cover letters provided general versus more explicit information about the survey's trauma content and how their names were selected for study; we also promised different incentives for returning the survey. The main outcome was change in affect post-survey. We examined five potential moderators: combat or military sexual trauma exposure, posttraumatic stress disorder or serious mental illness diagnosis, and recency of military service. Mediators between reading the cover letter carefully and post-survey affect included how participants rated the cover letters' information and whether they thought the cover letters prepared them for the survey's content. A Bonferroni corrected alpha of 0.003 was the threshold for statistical significance. RESULTS One hundred ninety men and 193 women reported their pre-and post-survey affect. Across all study conditions, out of 16 possible points, the net change in affect post-survey was less than a quarter-point for men and women. Mean changes in post-survey affect did not differ statistically significantly across any of the study factors (ps > 0.06); nor were there statistically significant interactions between any of the study factors and the 5 moderators after accounting for multiple comparisons (ps > 0.02). After controlling for pre-survey affect, reading the cover letter carefully had small effects on changes in post-survey affect, with larger associations seen in the women compared to men. Mediators' effects were often in opposite directions for men and women. CONCLUSION General descriptions of a survey's trauma content appear ethically defensible. Research on cover letters' impacts on survey participants' emotional reactions and how those impacts differ by gender is needed.
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Affiliation(s)
- Maureen Murdoch
- grid.410394.b0000 0004 0419 8667Section of General Internal Medicine, Minneapolis VA Health Care System, One Veterans Drive (111-0), Minneapolis, MN 55417 USA ,grid.410394.b0000 0004 0419 8667Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417 USA ,grid.17635.360000000419368657Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455 USA
| | - Barbara A Clothier
- grid.410394.b0000 0004 0419 8667Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417 USA
| | - Shannon Kehle-Forbes
- grid.410394.b0000 0004 0419 8667Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417 USA ,grid.17635.360000000419368657Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455 USA ,grid.410370.10000 0004 4657 1992National Center for, PTSD Women’s Health Sciences Division, VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130 USA
| | - Derek Vang
- grid.480845.50000 0004 0629 5065Minneapolis Heart Institute Foundation, 920 E 28th St #100, Minneapolis, MN 55407 USA
| | - Siamak Noorbaloochi
- grid.410394.b0000 0004 0419 8667Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417 USA ,grid.17635.360000000419368657Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455 USA
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8
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Hagedorn HJ, Gustavson AM, Ackland PE, Bangerter A, Bounthavong M, Clothier B, Harris AHS, Kenny ME, Noorbaloochi S, Salameh HA, Gordon AJ. Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities. J Gen Intern Med 2022; 37:3594-3602. [PMID: 34981352 PMCID: PMC8722660 DOI: 10.1007/s11606-021-07274-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. OBJECTIVE Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. DESIGN Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. PARTICIPANTS VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. INTERVENTION External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. MAIN MEASURES Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. KEY RESULTS Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. CONCLUSIONS Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.
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Affiliation(s)
- Hildi J. Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Allison M. Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Princess E. Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Ann Bangerter
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Mark Bounthavong
- Health Economics Resource Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94025 USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA 92093 USA
| | - Barbara Clothier
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Alex H. S. Harris
- Center for Innovation To Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94025 USA
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA 94305 USA
| | - Marie E. Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Hope A. Salameh
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS, Salt Lake City Veterans Affairs Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148 USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84148 USA
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9
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Topless R, Noorbaloochi S, Merriman TR, Singh JA. Change in serum urate level with urate-lowering therapy initiation associates in the immediate term with patient-reported outcomes in people with gout. Semin Arthritis Rheum 2022; 56:152057. [PMID: 35835008 DOI: 10.1016/j.semarthrit.2022.152057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/25/2022] [Accepted: 06/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the associations of changes in serum urate (SU) with health-related quality of life (HRQOL) in gout. METHODS We used the first 6-months of data from four interventional trials and one observational, open-label study of urate-lowering therapy (ULT) use. HRQOL were assessed at baseline and every 3-months, and SU was measured monthly. Primary outcome measures were Short-form 36 physical and mental component summary scores, Health Assessment Questionnaire Disability Index (HAQ-DI), Sheehan Disability Scale (SDS), Patient Global Assessment, and pain scores in the last week. Linear mixed models for each outcome were adjusted as appropriate for current SU, change in urate in the last month, number of flare-affected days in the last month, baseline BMI, age, comorbidities, sex, ethnicity, trial/study and treatment combination, and tophi status (fixed effects); subject, and the trial/study month were random effects. RESULTS Higher current SU correlated with reduced physical and mental HRQOL, and increased SDS and pain but not with HAQ-DI score. In the first 6-months of new/escalating ULT use, absolute change in SU levels associated with poorer outcomes on the HAQ-DI scale (β (95% CI) = 0.013 (0.007-0.019)) and poorer outcomes on SDS, SF-36 MCS, patient global and pain scales. Reduction of SU associated with poorer outcomes in all six measures. CONCLUSION High SU levels were associated with poorer HRQOL, pain and Sheehan disability score. Recent SU level fluctuations are associated with poorer outcomes, primarily driven by a reduction in SU. Clinical emphasis on slow rather than fast SU reduction and the routine use of effective, anti-inflammatory medications at ULT initiation/escalation may avoid short-term poor outcomes.
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Affiliation(s)
- Ruth Topless
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Siamak Noorbaloochi
- Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand; Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294, USA
| | - Jasvinder A Singh
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294, USA; Medicine Service, VA Medical Center, 510, 20th street South, FOT 805B, Birmingham, AL 35233, USA; Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
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10
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Murdoch M, Clothier BA, Beebe TJ, Bangerter AK, Noorbaloochi S. Impact of different cover letter content and incentives on non-response bias in a sample of Veterans applying for Department of Veterans Affairs disability benefits: a randomized, 3X2X2 factorial trial. BMC Med Res Methodol 2022; 22:61. [PMID: 35249535 PMCID: PMC8898515 DOI: 10.1186/s12874-022-01531-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 11/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. Methods A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey’s topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans’ names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents’ and sampling frame’s characteristics on 8 administrative variables, including Veterans’ receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. Results Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men’s variance and 0.6 to 30.5% of women’s variance in combat non-response bias and 10.2 to 43.0% of men’s variance and 0.4 to 31.9% of women’s variance in military sexual trauma non-response bias. Non-random assumptions showed that men’s self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women’s self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. Conclusions Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01531-x.
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11
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Polusny MA, Marquardt CA, Campbell EH, Filetti CR, Noël VV, Disner SG, Schaefer JD, Davenport N, Lissek S, Noorbaloochi S, Sponheim SR, Erbes CR. Advancing Research on Mechanisms of Resilience (ARMOR) Longitudinal Cohort Study of New Military Recruits: Results from a Feasibility Pilot Study. Res Hum Dev 2021; 18:212-229. [PMID: 34887706 DOI: 10.1080/15427609.2021.1964898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Psychological resilience as a longitudinal process is highly relevant for understanding the functioning outcomes of military populations. Here, we review the extant literature on resilience among military service members, focusing on National Guard Soldiers. Our specific project (Advancing Research on Mechanisms of Resilience, "ARMOR") aims to develop a comprehensive model of resilience using a multilevel perspective. We report results from our prospective pilot study (n = 103) conducted in preparation for our large-scale longitudinal cohort study of Basic Combat Training (BCT) and its impact on military recruits' wellbeing. Results support feasibility of the larger study, evidence for a new measure of BCT stressor exposure, and demonstrate preliminary associations with BCT-related stressors and longitudinal changes in adaptive functioning. Future directions for our larger study will utilize data from survey responses, structured clinical interviews, neurobehavioral tasks, and neurobiological measures (functional and structural MRI and electroencephalography [EEG]) to examine individual differences in self-regulation as a predictor of resilience-related processes. ARMOR is well positioned to elucidate mechanisms that could be targeted for promoting wellbeing, preventing psychopathology, and facilitating long-term recovery.
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Affiliation(s)
- Melissa A Polusny
- Minneapolis VA Health Care System, Minneapolis, MN.,Center for Care Delivery and Outcomes Research, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Craig A Marquardt
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Emily Hagel Campbell
- Center for Care Delivery and Outcomes Research, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Clarissa R Filetti
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Valentin V Noël
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Seth G Disner
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | | | - Nicholas Davenport
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Shmuel Lissek
- Department of Psychology, University of Minnesota - Twin Cities
| | - Siamak Noorbaloochi
- Minneapolis VA Health Care System, Minneapolis, MN.,Center for Care Delivery and Outcomes Research, Minneapolis, MN.,Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Scott R Sponheim
- Minneapolis VA Health Care System, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
| | - Christopher R Erbes
- Minneapolis VA Health Care System, Minneapolis, MN.,Center for Care Delivery and Outcomes Research, Minneapolis, MN.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN
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12
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Shafie K, Faridrohani MR, Noorbaloochi S, Moradi Rekabdarkolaee H. A Global Bayes Factor for Observations on an Infinite-Dimensional Hilbert Space, Applied to Signal Detection in fMRI. AJS 2021. [DOI: 10.17713/ajs.v50i3.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Functional Magnetic Resonance Imaging (fMRI) is a fundamental tool in advancing our understanding of the brain's functionality. Recently, a series of Bayesian approaches have been suggested to test for the voxel activation in different brain regions. In this paper, we propose a novel definition for the global Bayes factor to test for activation using the Radon-Nikodym derivative. Our proposed method extends the definition of Bayes factor to an infinite dimensional Hilbert space. Using this extended definition, a Bayesian testing procedure is introduced for signal detection in noisy images when both signal and noise are considered as an element of an infinite dimensional Hilbert space. This new approach is illustrated through a real data analysis to find activated areas of Brain in an fMRI data.
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13
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Koffel E, Kats AM, Kroenke K, Bair MJ, Gravely A, DeRonne B, Donaldson MT, Goldsmith ES, Noorbaloochi S, Krebs EE. Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial. Pain Med 2021; 21:1162-1167. [PMID: 31529104 DOI: 10.1093/pm/pnz221] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy. DESIGN Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120). METHODS We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups. RESULTS The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164). CONCLUSIONS Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.
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Affiliation(s)
- Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Allyson M Kats
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana
| | - Matthew J Bair
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Center for Health Information and Communication, Roudebush Veterans Affairs Medical, Center, Indianapolis, Indiana
| | - Amy Gravely
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,University of Minnesota Medical School, Minneapolis, Minnesota, USA
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14
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Meis LA, Noorbaloochi S, Hagel Campbell EM, Erickson EPG, Velasquez TL, Leverty DM, Thompson K, Erbes C. A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments. J Trauma Stress 2021; 34:440-453. [PMID: 33200475 DOI: 10.1002/jts.22620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/25/2020] [Accepted: 09/16/2020] [Indexed: 11/10/2022]
Abstract
Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs = .19-.38; treatment completion, rs = .21-.25; practical treatment barriers, rs = -.19 to -.24; and therapeutic alliance, rs = .39-.57.
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Affiliation(s)
- Laura A Meis
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Emily M Hagel Campbell
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Emily P G Erickson
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Tina L Velasquez
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - David M Leverty
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Katie Thompson
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Christopher Erbes
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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15
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Murdoch M, Spoont MR, Sayer NA, Kehle-Forbes SM, Noorbaloochi S. Reversals in initially denied Department of Veterans Affairs' PTSD disability claims after 17 years: a cohort study of gender differences. BMC Womens Health 2021; 21:70. [PMID: 33593337 PMCID: PMC7885341 DOI: 10.1186/s12905-021-01214-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND In 2011, the Department of Veterans Affairs (VA) strengthened its disability claims processes for military sexual trauma, hoping to reduce gender differences in initial posttraumatic stress disorder (PTSD) disability awards. These process improvements should also have helped women reverse previously denied claims and, potentially, diminished gender discrepancies in appealed claims' outcomes. Our objectives were to examine gender differences in reversals of denied PTSD claims' outcomes after 2011, determine whether disability awards (also known as "service connection") for other disorders offset any PTSD gender discrepancy, and identify mediating confounders that could explain any persisting discrepancy. METHODS From a nationally representative cohort created in 1998, we examined service connection outcomes in 253 men and 663 women whose initial PTSD claims were denied. The primary outcome was PTSD service connection as of August 24, 2016. Secondary outcomes were service connection for any disorder and total disability rating. The total disability rating determines the generosity of Veterans' benefits. RESULTS 51.4% of men and 31.3% of women were service connected for PTSD by study's end (p < 0.001). At inception, 54.2% of men and 63.2% of women had any service connection-i.e., service connection for disorders other than PTSD (p = 0.01) and similar total disability ratings (p = 0.50). However, by study's end, more men than women had any service connection (88.5% versus 83.5%, p = 0.05), and men's mean total disability rating was substantially greater than women's (77.1 ± 26.2 versus 66.8 ± 30.7, p < 0.001). History of military sexual assault had the largest effect modification on men's versus women's odds of PTSD service connection. CONCLUSION Even after 2011, cohort men were more likely than the women to reverse initially denied PTSD claims, and military sexual assault history accounted for much of this difference. Service connection for other disorders initially offset women's lower rate of PTSD service connection, but, ultimately, men's total disability ratings exceeded women's. Gender discrepancies in service connection should be monitored beyond the initial claims period.
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Affiliation(s)
- Maureen Murdoch
- Section of General Internal Medicine, Minneapolis VA Health Care System, One Veterans Drive (111-0), Minneapolis, MN, 55417, USA. .,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA. .,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | - Michele Roxanne Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.,National Centers for PTSD, Pacific Islands Division, Department of Veterans Affairs, 3375 Koapaka Street, Suite I-560, Honolulu, HI, 96819, USA.,Department of Psychiatry, University of Minnesota Medical School, F282/2A West Building, 2450 Riverside Avenue S, Minneapolis, MN, 55454, USA
| | - Nina Aileen Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.,Department of Psychiatry, University of Minnesota Medical School, F282/2A West Building, 2450 Riverside Avenue S, Minneapolis, MN, 55454, USA
| | - Shannon Marie Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.,National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
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16
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Gustavson AM, Wisdom JP, Kenny ME, Salameh HA, Ackland PE, Clothier B, Noorbaloochi S, Gordon AJ, Hagedorn HJ. Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration. Implement Sci Commun 2021; 2:20. [PMID: 33588952 PMCID: PMC7885503 DOI: 10.1186/s43058-021-00119-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/28/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. METHODS Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. RESULTS Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. CONCLUSIONS Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.
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Affiliation(s)
- Allison M Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA.
| | | | - Marie E Kenny
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Hope A Salameh
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Princess E Ackland
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Barbara Clothier
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Siamak Noorbaloochi
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Hildi J Hagedorn
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA
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Japuntich SJ, Hammett PJ, Rogers ES, Fu S, Burgess DJ, El Shahawy O, Melzer AC, Noorbaloochi S, Krebs P, Sherman SE. Effectiveness of Proactive Tobacco Cessation Treatment Outreach Among Smokers With Serious Mental Illness. Nicotine Tob Res 2021; 22:1433-1438. [PMID: 31957794 DOI: 10.1093/ntr/ntaa013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION People with serious mental illness (SMI) have a high smoking prevalence and low quit rates. Few cessation treatments are tested in smokers with SMI. Mental health (MH) providers are reluctant to address smoking. Proactive tobacco cessation treatment strategies reach out directly to smokers to offer counseling and medication and improve treatment utilization and quit rates. The current study is a secondary analysis of a randomized controlled trial of proactive outreach for tobacco cessation treatment in VA MH patients. AIMS AND METHODS Participants (N = 1938, 83% male, mean age 55.7) across four recruitment sites, who were current smokers and had a MH visit in the past 12 months, were identified using the electronic medical record. Participants were randomized to Intervention (telephone outreach call plus invitation to engage in MH tailored telephone counseling and assistance obtaining nicotine replacement therapy) or Control (usual care). The current study assessed outcomes in participants with SMI (N = 982). RESULTS Compared to the Control group, participants assigned to the Intervention group were more likely to engage in telephone counseling (22% vs. 3%) and use nicotine replacement therapy (51% vs. 41%). Participants in the Intervention group were more likely to be abstinent (7-day point prevalence; 18%) at 12 months than participants in the Control group (11%) but equally likely to make quit attempts. CONCLUSIONS Proactive tobacco cessation treatment is an effective strategy for tobacco users with SMI. Proactive outreach had a particularly strong effect on counseling utilization. Future randomized clinical trials examining proactive tobacco treatment approaches in SMI treatment settings are needed. IMPLICATIONS Few effective treatment models exist for smokers with SMI. Proactive tobacco cessation outreach with connections to MH tailored telephone counseling and medication promotes tobacco abstinence among smokers with SMI and is an effective treatment strategy for this underserved population.
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Affiliation(s)
- Sandra J Japuntich
- Department of Clinical Pharmacology and Toxicology, Hennepin Healthcare, Minneapolis, MN
| | - Patrick J Hammett
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Erin S Rogers
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY.,Department of Population Health, New York University School of Medicine, New York, NY
| | - Steven Fu
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Omar El Shahawy
- Department of Population Health, New York University School of Medicine, New York, NY
| | - Anne C Melzer
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Siamak Noorbaloochi
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Paul Krebs
- Department of Mental Health, VA San Diego Healthcare System, San Diego, CA
| | - Scott E Sherman
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY.,Department of Population Health, New York University School of Medicine, New York, NY
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Goldsmith ES, MacLehose RF, Jensen AC, Clothier B, Noorbaloochi S, Martinson BC, Donaldson MT, Krebs EE. Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids. Med Care 2020; 58 Suppl 2 9S:S116-S124. [PMID: 32826781 PMCID: PMC7444474 DOI: 10.1097/mlr.0000000000001333] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics. OBJECTIVE The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain. RESEARCH DESIGN National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis. SUBJECTS US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics. MEASURES Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function. RESULTS In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual). CONCLUSIONS Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.
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Affiliation(s)
- Elizabeth S. Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, MN
| | - Richard F. MacLehose
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, MN
| | - Agnes C. Jensen
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
| | - Barbara Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Brian C Martinson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
| | - Melvin T. Donaldson
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Erin E. Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
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19
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Hammett PJ, Japuntich SJ, Sherman SE, Rogers ES, Danan ER, Noorbaloochi S, El-Shahawy O, Burgess DJ, Fu SS. Proactive tobacco treatment for veterans with posttraumatic stress disorder. Psychol Trauma 2020; 13:114-122. [PMID: 32614201 DOI: 10.1037/tra0000613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD. METHOD This is a secondary analysis of a randomized controlled trial conducted from 2013 to 2017 that demonstrated the effectiveness of proactive outreach among veterans using Veterans Affairs mental health care services. Electronic medical record data were used to identify participants with (n = 355) and without (n = 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively. RESULTS Compared to usual care, proactive outreach increased combined counseling and NRT utilization among participants with PTSD (odds ratio [OR] = 26.25, 95% confidence interval [3.43, 201.17]) and without PTSD (OR = 10.20, [5.21, 19.98]). Proactive outreach also increased 7-day point prevalence abstinence at 12 months among participants with PTSD (OR = 2.62, [1.16, 5.91]) and without PTSD (OR = 1.61, [1.11, 2.34]). CONCLUSIONS Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Steven S Fu
- VA HSR&D Center for Care Delivery and Outcomes Research
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20
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Krebs EE, Clothier B, Nugent S, Jensen AC, Martinson BC, Goldsmith ES, Donaldson MT, Frank JW, Rutks I, Noorbaloochi S. The evaluating prescription opioid changes in veterans (EPOCH) study: Design, survey response, and baseline characteristics. PLoS One 2020; 15:e0230751. [PMID: 32320421 PMCID: PMC7176145 DOI: 10.1371/journal.pone.0230751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/07/2020] [Indexed: 11/28/2022] Open
Abstract
In the United States (US), long-term opioid therapy has been commonly prescribed for chronic pain. Since recognition of the opioid overdose epidemic, clinical practice guidelines have recommended tapering long-term opioids to reduced doses or discontinuation. The Effects of Prescription Opioid Changes for veterans (EPOCH) study is a national population-based prospective observational study of US Veterans Health Administration primary care patients designed to assess effects of evolving opioid prescribing practice on patients treated with long-term opioids for chronic pain. A stratified random sampling design was used to identify a survey sample from the target population of patients treated with opioid analgesics for ≥ 6 months. Demographic, diagnostic, visit, and pharmacy dispensing data were extracted from existing datasets. A 2016 mixed-mode mail and telephone survey collected patient-reported data, including the main patient-reported outcomes of pain-related function (Brief Pain Inventory interference; BPI-I scores 0–10, higher scores = worse) and health-related quality of life. Data on survey participants and non-participants were analyzed to assess potential nonresponse bias. Weights were used to account for design. Linear regression models were used to assess cross-sectional associations of opioid treatment with patient-reported measures. Of 14,160 patients contacted, 9253 (65.4%) completed the survey. Participants were older than non-participants (63.9 ± 10.6 vs. 59.6 ± 13.0 years). The mean number of bothersome pain locations was 6.8 (SE 0.04). Effectiveness of pain treatment and quality of pain care were rated fair or poor by 56.1% and 45.3%, respectively. The opioid daily dosage range was 1.6 to 1038.2 mg, with mean = 50.6 mg (SE 1.1) and median = 30.9 mg (IQR 40.7). Among the 73.2% of patients who did not receive long-acting opioids, the mean daily dosage was 30.4 mg (SE 0.6) and mean BPI-I was 6.4 (SE 00.4). Among patients who received long-acting opioids, the mean daily dosage was 106.2 mg (SE 2.8) and mean BPI-I was 6.8 (SE 0.07). Higher daily dosage was associated with worse pain-related function and quality of life among patients without long-acting opioids, but not among patients with long-acting opioids. Future analyses will use follow-up data to examine effects of opioid dose reduction and discontinuation on patient outcomes.
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Affiliation(s)
- Erin E. Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Barbara Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Sean Nugent
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Agnes C. Jensen
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Brian C. Martinson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Elizabeth S. Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, United States of America
| | - Melvin T. Donaldson
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, United States of America
- Medical Scientist Training Program, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Joseph W. Frank
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, United States of America
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Indulis Rutks
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States of America
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
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21
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Murdoch M, Kehle-Forbes S, Spoont M, Sayer NA, Noorbaloochi S, Arbisi P. Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study. Mil Med 2019; 184:715-722. [PMID: 30938816 DOI: 10.1093/milmed/usz052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/07/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration's work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans' disability benefits has not been described. MATERIALS AND METHODS The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits. Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution's Internal Review Board reviewed and approved the study. RESULTS Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings. For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts. CONCLUSIONS Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.
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Affiliation(s)
- Maureen Murdoch
- Section of General Internal Medicine, Minneapolis VA Health Care System, One Veterans Drive (111-0), Minneapolis, MN 55417.,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455
| | - Shannon Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455.,National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130
| | - Michele Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455.,National Centers for PTSD, Pacific Islands Division, Department of Veterans Affairs 3375 Koapaka Street, Suite I-560; Honolulu, HI 96819.,Department of Psychiatry, University of Minnesota Medical School, F282/2 A West Building, 2450 Riverside Avenue S, Minneapolis, MN 55454
| | - Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455.,Department of Psychiatry, University of Minnesota Medical School, F282/2 A West Building, 2450 Riverside Avenue S, Minneapolis, MN 55454
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417.,Department of Internal Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN 55455
| | - Paul Arbisi
- Department of Psychiatry, University of Minnesota Medical School, F282/2 A West Building, 2450 Riverside Avenue S, Minneapolis, MN 55454.,Department of Psychology, College of Liberal Arts, University of Minnesota, 75 E River Rd, Minneapolis, MN 55455.,Psychology Service, Minneapolis VA Health Care System, One Veterans Drive (116-B), Minneapolis, MN 55417
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22
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Rosen CS, Bernardy NC, Chard KM, Clothier B, Cook JM, Crowley J, Eftekhari A, Kehle-Forbes SM, Mohr DC, Noorbaloochi S, Orazem RJ, Ruzek JI, Schnurr PP, Smith BN, Sayer NA. Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics? J Anxiety Disord 2019; 62:53-60. [PMID: 30550959 DOI: 10.1016/j.janxdis.2018.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/13/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.
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Affiliation(s)
- Craig S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Nancy C Bernardy
- Executive Division, National Center for PTSD, 215N Main St. White River Junction, VT 05009, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
| | - Kathleen M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, 3200 Vine St, Cincinnati, OH 45220, USA; University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Joan M Cook
- Evaluation Division, National Center for PTSD, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT 06516, USA; Yale School of Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT, USA.
| | - Jill Crowley
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Afsoon Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Shannon M Kehle-Forbes
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA.
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130, USA; Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA.
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Robert J Orazem
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Josef I Ruzek
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA; Palo Alto University, 1791 Arastradero Rd, Palo Alto, CA 94304, USA.
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, 215N Main St. White River Junction, VT 05009, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
| | - Brandy N Smith
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Nina A Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA; Department of Psychiatry, University of Minnesota, 2450 Riverside Ave, Minneapolis, MN 55454, USA; Department of Psychology, University of Minnesota, 75 E River Rd, Minneapolis, MN 55455, USA.
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Meis LA, Noorbaloochi S, Campbell EMH, Erbes CR, Polusny MA, Velasquez TL, Bangerter A, Cutting A, Eftekhari A, Rosen C, Tuerk PW, Burmeister LB, Spoont MR. Sticking it out in trauma-focused treatment for PTSD: It takes a village. J Consult Clin Psychol 2019; 87:246-256. [PMID: 30777776 PMCID: PMC6548182 DOI: 10.1037/ccp0000386] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE One in 3 veterans will dropout from trauma-focused treatments for posttraumatic stress disorder (PTSD). Social environments may be particularly important to influencing treatment retention. We examined the role of 2 support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage veterans to participate in treatment and face distress) and symptom accommodation (changes in loved ones' behavior to reduce veterans' PTSD-related distress). METHOD Veterans and a loved one were surveyed across 4 VA hospitals. All veterans were initiating prolonged exposure therapy or cognitive processing therapy (n = 272 dyads). Dropout was coded through review of VA hospital records. RESULTS Regression analyses controlled for traditional, individual-focused factors likely to influence treatment dropout. We found that, even after accounting for these factors, veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than veterans who denied such encouragement. CONCLUSIONS Clinicians initiating trauma-focused treatments with veterans should routinely assess how open veterans' support systems are to encouraging veterans to face their distress. Outreach to support networks is warranted to ensure loved ones back the underlying philosophy of trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Laura A. Meis
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
| | - Siamak Noorbaloochi
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
| | - Emily M. Hagel Campbell
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Christopher R. Erbes
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Psychiatry
| | - Melissa A. Polusny
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Psychiatry
| | - Tina L. Velasquez
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Ann Bangerter
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Andrea Cutting
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Afsoon Eftekhari
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Craig Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Peter W. Tuerk
- University of Virginia, Sheila C Johnson Center for Human Services
| | | | - Michele R. Spoont
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
- University of Minnesota, Medical School, Department of Psychiatry
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Hagedorn H, Kenny M, Gordon AJ, Ackland PE, Noorbaloochi S, Yu W, Harris AHS. Advancing pharmacological treatments for opioid use disorder (ADaPT-OUD): protocol for testing a novel strategy to improve implementation of medication-assisted treatment for veterans with opioid use disorders in low-performing facilities. Addict Sci Clin Pract 2018; 13:25. [PMID: 30545409 PMCID: PMC6293521 DOI: 10.1186/s13722-018-0127-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the US, emergency room visits and overdoses related to prescription opioids have soared and the rates of illicit opioid use, including heroin and fentanyl, are increasing. Opioid use disorder (OUD) is associated with higher morbidity and mortality, higher HIV and HCV infection rates, and criminal behavior. Opioid agonist therapy (OAT; methadone and buprenorphine) is proven to be effective in treating OUD and decreasing its negative consequences. While the efficacy of OAT has been established, too few providers prescribe OAT to patients with OUD due to patient, provider, or system factors. While the Veterans Health Administration (VHA) has made great strides in OAT implementation, national treatment rates remain low (35% of patients with OUD) and several facilities continue to have much lower prescribing rates. METHODS Eight VA sites with low baseline prescribing rates (lowest quartile, < 21%) were randomly selected from the 35 low prescribing sites to receive an intensive external facilitation implementation intervention to increase OAT prescribing rates. The intervention includes a site-specific developmental evaluation, a kick-off site visit, and 12 months of ongoing facilitation. The developmental evaluation includes qualitative interviews with patients, substance use disorders clinic staff, and primary care and general mental health leadership to assess site-level barriers. The site visit includes: (1) a review of site-specific barriers and potential implementation strategies; (2) instruction on using available dashboards to track prescribing rates and identify actionable patients; and (3) education on OAT, including, if requested, buprenorphine certification training for prescribers. On-going facilitation consists of monthly conference calls with individual site teams and expert clinical consultation. The primary outcomes is the proportion of Veterans with OUD initiating and sustaining OAT, with intervention sites expected to have larger increases in prescribing compared to control sites. Final qualitative interviews and a cost assessment will inform future implementation efforts. DISCUSSION This project will examine and respond to barriers encountered in low prescribing VHA clinics allowing refinement of an intervention to enhance access to medication treatment for OUD in additional facilities.
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Affiliation(s)
- Hildi Hagedorn
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, USA
| | - Marie Kenny
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148 USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132 USA
| | - Princess E. Ackland
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, South. Bldg. 9 Rm#316, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Siamak Noorbaloochi
- Department of Medicine, University of Minnesota, Minneapolis, USA
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, South. Bldg. 9 Rm#219, Mail Code#152, Minneapolis, MN 55417 USA
| | - Wei Yu
- Health Economics Research Center, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA 94025 USA
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, USA
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Palo Alto Health Care System, 795 Willow Rd, MC152, Palo Alto, CA 94304 USA
- Department of Surgery, Stanford University, Stanford, USA
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25
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Danan ER, Fu SS, Clothier BA, Noorbaloochi S, Hammett PJ, Widome R, Burgess DJ. The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial. Am J Prev Med 2018; 55:506-516. [PMID: 30139707 DOI: 10.1016/j.amepre.2018.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/14/2018] [Accepted: 05/16/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention. METHODS This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up. RESULTS Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0). CONCLUSIONS In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT00608426.
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Affiliation(s)
- Elisheva R Danan
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.
| | - Steven S Fu
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Barbara A Clothier
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Siamak Noorbaloochi
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Patrick J Hammett
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Rachel Widome
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Diana J Burgess
- Veterans Affairs Health Services Research & Development Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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Affiliation(s)
- Erin E Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
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27
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Mohr DC, Rosen CS, Schnurr PP, Orazem RJ, Noorbaloochi S, Clothier BA, Eftekhari A, Bernardy NC, Chard KM, Crowley JJ, Cook JM, Kehle-Forbes SM, Ruzek JI, Sayer NA. The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies. Psychiatr Serv 2018; 69:879-886. [PMID: 29793398 DOI: 10.1176/appi.ps.201700432] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE It has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability. METHODS This observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability. RESULTS Sustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability. CONCLUSIONS There was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.
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Affiliation(s)
- David C Mohr
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Craig S Rosen
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Paula P Schnurr
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Robert J Orazem
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Siamak Noorbaloochi
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Barbara A Clothier
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Afsoon Eftekhari
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Nancy C Bernardy
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Kathleen M Chard
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Jill J Crowley
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Joan M Cook
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Shannon M Kehle-Forbes
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Josef I Ruzek
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
| | - Nina A Sayer
- Dr. Mohr is with the Center for Healthcare Organization and Implementation Research and Dr. Kehle-Forbes is with the National Center for PTSD Women's Health Sciences Division, U.S. Department of Veterans Affairs (VA) Boston Healthcare System, Boston. Dr. Mohr is also with the School of Public Health, Boston University, Boston. Dr. Kehle-Forbes is also with the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, where Mr. Orazem, Dr. Noorbaloochi, Ms. Clothier, and Dr. Sayer are affiliated. Dr. Noorbaloochi and Dr. Sayer are also with the Department of Medicine, University of Minnesota, Minneapolis. Dr. Rosen, Dr. Eftekhari, Dr. Crowley, and Dr. Ruzek are with the Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California. Dr. Rosen and Dr. Ruzek are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California. Dr. Schnurr and Dr. Bernardy are with the Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, and also with the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Chard is with the PTSD Division, Cincinnati VA Medical Center, Cincinnati. Dr. Cook is with the Evaluation Division, National Center for PTSD, and with the Yale University School of Medicine, both in New Haven, Connecticut
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Melzer AC, Pinsker EA, Clothier B, Noorbaloochi S, Burgess DJ, Danan ER, Fu SS. Validating the use of veterans affairs tobacco health factors for assessing change in smoking status: accuracy, availability, and approach. BMC Med Res Methodol 2018; 18:39. [PMID: 29751746 PMCID: PMC5948734 DOI: 10.1186/s12874-018-0501-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/30/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Accurate smoking status is key for research purposes, but can be costly and difficult to measure. Within the Veteran's Health Administration (VA), smoking status is recorded as part of routine care as "health factors" (HF)-fields that researchers can query through the electronic health record (EHR). Many researchers are interested in using these fields to track changes in smoking status over time, however the validity of this measure for assessing change is unknown. The primary goal of this project was to examine whether HFs can be used to accurately measure change in tobacco status over time, with secondary goals of assessing the optimum timeframe for assessment and variation in accuracy by site. METHODS Secondary analysis of the Veterans VICTORY study, a pragmatic smoking cessation randomized controlled trial conducted from 2009 to 2011. Eligible subjects were identified via the EHR using a past 90-day HF indicating current tobacco use (for example: "CURRENT SMOKER", "CURRENTLY USES TOBACCO"). Participants were surveyed at 1 year to determine prolonged smoking abstinence. We identified HFs for tobacco status within +/- 120 days of the follow-up survey mailing date and recorded the temporally closest HF. Among subjects with both measures, we compared the two for agreement using kappa statistics and concordance. RESULTS 1713 subjects (33%) had both follow-up survey and HF data, 1594 (31%) had only a survey response, 790 (15%) had only HF and 1026 (20%) had neither. For subjects with both measures, there was 90% concordance and moderate agreement (Kappa 0.48, 95%CI 0.41-0.55, Sensitivity 54.4, 95%CI 41.1-67.7, Specificity 94.3, 95%CI 87.5-100.0). CONCLUSIONS We found high concordance but only moderate agreement by kappa statistics between HFs and survey data. The difference is likely accounted for by the natural history of quit attempts, in which patients cycle in and out of quit attempts. HFs appear to provide an accurate measure of population level quit behavior utilizing data collected in the course of clinical care.
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Affiliation(s)
- Anne C. Melzer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55417 USA
- Pulmonary and Critical Care Medicine, Minneapolis VA Health Care System, Minneapolis, MN USA
| | - Erika A. Pinsker
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55417 USA
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
| | - Diana J. Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55417 USA
| | - Elisheva R. Danan
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55417 USA
| | - Steven S. Fu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Veterans Drive, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55417 USA
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Rogers ES, Fu SS, Krebs P, Noorbaloochi S, Nugent SM, Gravely A, Sherman SE. Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics. Am J Prev Med 2018; 54:620-629. [PMID: 29551324 DOI: 10.1016/j.amepre.2018.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/06/2018] [Accepted: 02/06/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients. STUDY DESIGN RCT. SETTING/PARTICIPANTS The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months. INTERVENTION Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy. MAIN OUTCOME MEASURES Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up. RESULTS At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05). CONCLUSIONS Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01737281.
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Affiliation(s)
- Erin S Rogers
- VA New York Harbor Healthcare System, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York.
| | - Steven S Fu
- VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Paul Krebs
- VA New York Harbor Healthcare System, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York
| | - Siamak Noorbaloochi
- VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Sean M Nugent
- VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Amy Gravely
- VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York
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Talaie R, Richards M, Krug H, Dorman C, Noorbaloochi S, Golzarian J. 4:12 PM Abstract No. 209 Neovascularization in knee osteoarthritis: a new mouse model using micro computed tomography to delineate pathological vascular remodeling. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 2018; 319:872-882. [PMID: 29509867 PMCID: PMC5885909 DOI: 10.1001/jama.2018.0899] [Citation(s) in RCA: 575] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/01/2018] [Indexed: 01/20/2023]
Abstract
Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain. Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects. Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized. Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19). Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, -0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]). Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. Trial Registration clinicaltrials.gov Identifier: NCT01583985.
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MESH Headings
- Acetaminophen/therapeutic use
- Adult
- Aged
- Aged, 80 and over
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Back Pain/drug therapy
- Chronic Pain/drug therapy
- Chronic Pain/etiology
- Drug Therapy, Combination
- Female
- Humans
- Intention to Treat Analysis
- Male
- Middle Aged
- Osteoarthritis, Hip/complications
- Osteoarthritis, Hip/drug therapy
- Osteoarthritis, Knee/complications
- Osteoarthritis, Knee/drug therapy
- Pain Measurement
- Young Adult
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Affiliation(s)
- Erin E. Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Agnes C. Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Elizabeth S. Goldsmith
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minneapolis, Minnesota
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Matthew J. Bair
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
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Japuntich SJ, Sherman SE, Joseph AM, Clothier B, Noorbaloochi S, Danan E, Burgess D, Rogers E, Fu SS. Proactive tobacco treatment for individuals with and without a mental health diagnosis: Secondary analysis of a pragmatic randomized controlled trial. Addict Behav 2018; 76:15-19. [PMID: 28735036 DOI: 10.1016/j.addbeh.2017.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Individuals with (vs. without) mental illness use tobacco at higher rates and have more difficulty quitting. Treatment models for smokers with mental illness are needed. METHODS This secondary analysis of the Victory Over Tobacco study [a pragmatic randomized clinical trial (N=5123) conducted in 2009-2011 of Proactive Care (proactive outreach plus connection to smoking cessation services) vs. Usual Care] tests the effectiveness of treatment assignment in participants with and without a mental health diagnosis on population-level, 6month prolonged abstinence at one year follow-up. RESULTS Analyses conducted in 2015-6 found that there was no interaction between treatment group and mental health group on abstinence (F(1,3300=1.12, p=0.29)). Analyses stratified by mental health group showed that those without mental illness, assigned to Proactive Care, had a significantly higher population-level abstinence rate than those assigned to Usual Care (OR=1.40, 95% CI=1.17-1.67); in those with mental illness, assignment to Proactive Care produced a non-significant increase in abstinence compared to Usual Care (OR=1.18, 95% CI=0.98-1.41). Those with mental illness reported more medical visits, cessation advice and treatment (p<0.001), similar levels of abstinence motivation (p>0.05), but lower abstinence self-efficacy (p<0.001). CONCLUSIONS Those with a mental health diagnosis benefitted less from proactive outreach regarding tobacco use. VA primary care patients with mental illness may not need additional outreach because they are connected to cessation resources during medical appointments. This group may also require more intensive cessation interventions targeting self-efficacy to improve cessation rates. Clinicaltrials.gov registration # NCT00608426.
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Affiliation(s)
- Sandra J Japuntich
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, United States; Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Providence, RI, United States.
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York City, NY, United States; New York University School of Medicine, Department of Population Health, New York City, NY, United States
| | - Anne M Joseph
- University of Minnesota Medical School, Department of Medicine, Minneapolis, MN, United States
| | - Barbara Clothier
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Siamak Noorbaloochi
- University of Minnesota Medical School, Department of Medicine, Minneapolis, MN, United States; VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Elisheva Danan
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Diana Burgess
- University of Minnesota Medical School, Department of Medicine, Minneapolis, MN, United States; VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Erin Rogers
- VA New York Harbor Healthcare System, New York City, NY, United States; New York University School of Medicine, Department of Population Health, New York City, NY, United States
| | - Steven S Fu
- University of Minnesota Medical School, Department of Medicine, Minneapolis, MN, United States; VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
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Krebs EE, Jensen AC, Nugent S, DeRonne B, Rutks I, Leverty D, Gravely A, Noorbaloochi S, Bair MJ, Kroenke K. Design, recruitment outcomes, and sample characteristics of the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. Contemp Clin Trials 2017; 62:130-139. [PMID: 28893675 DOI: 10.1016/j.cct.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/29/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
This manuscript describes the study protocol, recruitment outcomes, and baseline participant characteristics for the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. SPACE is a pragmatic randomized comparative effectiveness trial conducted in multiple VA primary care clinics within one VA health care system. The objective was to compare benefits and harms of opioid therapy versus non-opioid medication therapy over 12months among patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain despite analgesic therapy; patients already receiving regular opioid therapy were excluded. Key design features include comparing two clinically-relevant medication interventions, pragmatic eligibility criteria, and flexible treat-to-target interventions. Screening, recruitment and study enrollment were conducted over 31months. A total of 4491 patients were contacted for eligibility screening; 53.1% were ineligible, 41.0% refused, and 5.9% enrolled. The most common reasons for ineligibility were not meeting pain location and severity criteria. The most common study-specific reasons for refusal were preference for no opioid use and preference for no pain medications. Of 265 enrolled patients, 25 withdrew before randomization. Of 240 randomized patients, 87.9% were male, 84.1% were white, and age range was 21-80years. Past-year mental health diagnoses were 28.3% depression, 17% anxiety, 9.4% PTSD, 7.9% alcohol use disorder, and 2.6% drug use disorder. In conclusion, although recruitment for this trial was challenging, characteristics of enrolled participants suggest we were successful in recruiting patients similar to those prescribed opioid therapy in usual care.
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Affiliation(s)
- Erin E Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA.
| | - Agnes C Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Indulis Rutks
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - David Leverty
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA
| | - Matthew J Bair
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
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Hagedorn HJ, Noorbaloochi S, Bangerter A, Stitzer ML, Kivlahan D. Health care cost trajectories in the year prior to and following intake into Veterans Health Administration outpatient substance use disorders treatment. J Subst Abuse Treat 2017; 79:46-52. [DOI: 10.1016/j.jsat.2017.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
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Singh JA, Noorbaloochi S, Knutson KL. Cytokine and neuropeptide levels are associated with pain relief in patients with chronically painful total knee arthroplasty: a pilot study. BMC Musculoskelet Disord 2017; 18:17. [PMID: 28088207 PMCID: PMC5237514 DOI: 10.1186/s12891-016-1375-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/21/2016] [Indexed: 12/04/2022] Open
Abstract
Background There are few studies with an assessment of the levels of cytokines or neuropeptides as correlates of pain and pain relief in patients with painful joint diseases. Our objective was to assess whether improvements from baseline to 2-months in serum cytokine, chemokine and substance P levels were associated with clinically meaningful pain relief at 2-months post-injection in patients with painful total knee arthroplasty (TKA). Methods Using data from randomized trial of 60 TKAs, we assessed the association of change in cytokine/chemokine/Substance P levels with primary study outcome, clinically important improvement in Western Ontario McMaster Osteoarthritis Index (WOMAC) pain subscale at 2-months post-injection using Student’s t-tests and Spearman’s correlation coefficient (non-parametric). Patients were categorized as pain responders (20-point reduction or more on 0-100 WOMAC pain) vs. pain non-responders. Sensitivity analysis used 0–10 daytime pain numeric rating scale (NRS) instead of WOMAC pain subscale. Results In a pilot study, compared to non-responders (n = 23) on WOMAC pain scale at 2-months, pain responders (n = 12) had significantly greater increase in serum levels of IL-7, IL-10, IL-12, eotaxin, interferon gamma and TNF-α from baseline to 2-months post-injection (p < 0.05 for all). Change in several cytokine/chemokine and substance P levels from pre-injection to 2-month follow-up correlated significantly with change in WOMAC pain with correlation coefficients ranging −0.37 to −0.51: IL-2, IL-7, IL-8, IL-9, IL-16, IL-12p, GCSF, IFN gamma, IP-10, MCP, MIP1b, TNF-α and VEGF (n = 35). Sensitivity analysis showed that substance P decreased significantly more from baseline to 2-months in the pain responders (0.54 ± 0.53; n = 10) than in the pain non-responders (0.48 ± 1.18; n = 9; p = 0.023) and that this change in serum substance P correlated significantly with change in daytime NRS pain, correlation coefficient was 0.53 (p = 0.021; n = 19). Findings should be interpreted with caution, since cytokine analyses were performed for a sub-group of the entire trial population. Conclusion Serum cytokine, chemokine and Substance P levels correlated with pain response in patients with painful TKA after an intra-articular injection in a randomized trial.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, University of Alabama at Birmingham Faculty Office Tower, 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Siamak Noorbaloochi
- Center for chronic disease Outcomes Research, Minneapolis Veterans Affairs Health are System Center, Minneapolis, MN, 55121, USA.,Department of Medicine, University of Minnesota, 401 East River Parkway, Minneapolis, MN, 55455, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
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Sayer NA, Orazem RJ, Noorbaloochi S, Gravely A, Frazier P, Carlson KF, Schnurr PP, Oleson H. Iraq and Afghanistan War Veterans with Reintegration Problems: Differences by Veterans Affairs Healthcare User Status. Adm Policy Ment Health 2016; 42:493-503. [PMID: 24913102 PMCID: PMC4452614 DOI: 10.1007/s10488-014-0564-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We studied 1,292 Iraq and Afghanistan War veterans who participated in a clinical trial of expressive writing to estimate the prevalence of perceived reintegration difficulty and compare Veterans Affairs (VA) healthcare users to nonusers in terms of demographic and clinical characteristics. About half of participants perceived reintegration difficulty. VA users and nonusers differed in age and military background. Levels of mental and physical problems were higher in VA users. In multivariate analysis, military service variables and probable traumatic brain injury independently predicted VA use. Findings demonstrate the importance of research comparing VA users to nonusers to understand veteran healthcare needs.
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Affiliation(s)
- Nina A Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,
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Hilton ME, Gioe T, Noorbaloochi S, Singh JA. Increasing comorbidity is associated with worsening physical function and pain after primary total knee arthroplasty. BMC Musculoskelet Disord 2016; 17:421. [PMID: 27717340 PMCID: PMC5055707 DOI: 10.1186/s12891-016-1261-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/23/2016] [Indexed: 02/07/2023] Open
Abstract
Background Previous studies suggested that pre-operative comorbidity was a risk factor for worse outcomes after TKA. To our knowledge, studies have not examined whether postoperative changes in comorbidity impact pain and function outcomes longitudinally. Our objective was to examine if increasing comorbidity postoperatively is associated with worsening physical function and pain after primary total knee arthroplasty (TKA). Methods We performed a retrospective chart review of veterans who had completed Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF36) surveys at regular intervals after primary TKA. Comorbidity was assessed using a variety of scales: validated Charlson comorbidity index score, and a novel Arthroplasty Comorbidity Severity Index score (Including medical index, local musculoskeletal index [including lower extremity and spine] and TKA-related index subscales; higher scores are worse ), at multiple time-points post-TKA. We used mixed model linear regression to examine the association of worsening comorbidity post-TKA with change in WOMAC and SF-36 scores in the subsequent follow-up periods, controlling for age, length of follow-up, and repeated observations. Results The study cohort consisted of 124 patients with a mean age of 71.7 years (range 58.6–89.2, standard deviation (SD) 6.9) followed for a mean of 4.9 years post-operatively (range 1.3–11.4; SD 2.8). We found that post-operative worsening of the Charlson Index score was significantly associated with worsening SF-36 Physical Function (PF) (beta coefficient (ß) = -0.07; p < 0.0001), SF-36 Bodily Pain (BP) (ß = -0.06; p = 0.002), and WOMAC PF subscale (ß = 0.08; p < 0.001; higher scores are worse) scores, in the subsequent periods. Worsening novel medical index subscale scores were significantly associated with worsening SF-36 PF scores (ß = -0.03; p = 0.002), SF-36 BP (ß = -0.04; p < 0.001) and showed a non-significant trend for worse WOMAC PF scores (ß = 0.02; p = 0.11) subsequently. Local musculoskeletal index subscale scores were significantly associated with worsening SF-36 PF (ß = -0.05; p = 0.001), SF-36 BP (ß = -0.04; p = 0.03) and WOMAC PF (ß = 0.06; p = 0.01) subsequently. None of the novel index subscale scores were significantly associated with WOMAC pain scores. TKA complications, as assessed by TKA-related index subscale, were not significantly associated with SF-36 or WOMAC domain scores. Conclusions Increasing Charlson index as well as novel medical and local musculoskeletal index subscale scores (from novel Arthroplasty Comorbidity Severity Index) post-TKA correlated with subsequent worsening of physical function and pain outcomes post-TKA. Further studies should examine which comorbidity management could have the greatest impact on these outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1261-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maren E Hilton
- Rheumatology Section, Medicine Service and Division of Rheumatology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Present address: Arthritis and Rheumatology Consultants, 7250 France Ave #215, Edina, 55435, MN, USA
| | - Terence Gioe
- Department of Orthopedic Surgery, VA Medical Center, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Division of General Internal Medicine, VA Medical Center, Minneapolis, MN, USA
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, USA. .,Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Payabvash S, Noorbaloochi S, Qureshi AI. Topographic Assessment of Acute Ischemic Changes for Prognostication of Anterior Circulation Stroke. J Neuroimaging 2016; 27:227-231. [PMID: 27593522 DOI: 10.1111/jon.12383] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/06/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The location of acute ischemic infarct can affect the clinical outcome of stroke patients. We aimed to develop a prognostic tool based on the topographic distribution of early ischemic changes on admission computed tomography (CT) scans. METHODS Using the albumin in acute stroke (ALIAS) trials dataset, patients with anterior circulation stroke were included for analysis. A 3-month modified Rankin scale (mRs) score > 2 defined disability/death; and ≤2 defined favorable outcome. A penalized logistic regression determined independent predictors of disability/death among components of admission CT scan Alberta Stroke Program Early CT score (ASPECTS). Follow-up 24-hour CT/MRI scans were reviewed for intracranial hemorrhage (ICH). RESULTS A simplified ASPECTS (sASPECTS) was developed including the caudate, lentiform nucleus, insula, and M5 components of ASPECTS-which were independent predictors of disability/death on multivariate analysis. There was no significant difference between ASPECTS and sASPECTS in prediction of disability/death (P = .738). Among patients with sASPECTS ≥ 1, the rate of favorable outcome was higher in those with intravenous (IV) thrombolytic therapy (501/837, 59.9%) versus those without treatment (91/183, 49.7%, P = .013); whereas among patients with sASPECTS of 0, IV thrombolysis was not associated with improved outcome. Also, patients with sASPECTS of 0 were more likely to develop symptomatic ICH (odds ratio = 2.62, 95% confidence interval: 1.49-4.62), compared to those with sASPECTS ≥ 1 (P = .004). CONCLUSIONS Topographic assessment of acute ischemic changes using the sASPECTS (including caudate, lentiform nucleus, insula, and M5) can predict disability/death in anterior circulation stroke as accurately as the ASPECTS; and may help predict response to treatment and risk of developing symptomatic ICH.
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Affiliation(s)
- Seyedmehdi Payabvash
- Zeenat Qureshi Stroke Institute, St. Cloud, MN.,Neuroradiology Section, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN
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40
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Lederle F, Noorbaloochi S, Nugent S. Multicenter Study of Abdominal Aortic Aneurysm Measurement and Enlargement. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.07.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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41
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Nelson D, Noorbaloochi S. Splice plots for generalized linear models. COMMUN STAT-THEOR M 2016. [DOI: 10.1080/03610926.2014.895842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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42
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Jalaeian H, Talaie R, D'Souza D, Taleb S, Noorbaloochi S, Flanagan S, Hunter D, Golzarian J. Minilaparotomy-Assisted Transmesenteric-Transjugular Intrahepatic Portosystemic Shunt: Comparison with Conventional Transjugular Approach. Cardiovasc Intervent Radiol 2016; 39:1413-9. [PMID: 27272888 DOI: 10.1007/s00270-016-1385-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE This study was performed to compare the intrahepatic shunt function outcome and procedural complications of minilaparotomy-assisted transmesenteric (MAT)-transjugular intrahepatic portosystemic shunt (TIPS) placement with the conventional transjugular method. METHODS This is a retrospective review of all patients who had a MAT or conventional TIPS procedure over a 6-year period at our institute. The primary patency rate, fluoroscopy time, technical success, major procedure-related complications, and mortality data were compared between two treatment groups. RESULTS We included 49 patients with MAT-TIPS, and 63 with conventional TIPS, with an average follow-up of 21.43 months. The primary patency rates at 6 and 12 months were 82.9 and 66.7 % in the conventional TIPS group, and 81.0 and 76.5 % in the MAT-TIPS group (p = 1.000, and 0.529), respectively. There was no significant difference in technical success rate, post-procedure portosystemic pressure gradient, fluoroscopy time, and peri-procedural mortality rate between treatment groups. Major procedural-related complications were seen more frequently among MAT-TIPS patients (p = 0.012). In the MAT-TIPS group, 5 (10.2 %) patients developed post-procedure minilaparotomy, wound-related complications, and 5 (10.2 %) developed bacterial peritonitis; whereas, none of patients with conventional TIPS had either of these complications (p = 0.014). CONCLUSION While both MAT-TIPS and conventional TIPS had similar shunt primary patency rate and technical success rate, the MAT approach was associated with a significantly higher rate of minilaparotomy-related wound complications or infectious complications. These complications maybe prevented by a change in post-procedure monitoring and therapy.
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Affiliation(s)
- Hamed Jalaeian
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Reza Talaie
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Donna D'Souza
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Shayandokht Taleb
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | | | - Siobhan Flanagan
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - David Hunter
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Jafar Golzarian
- Division of Interventional Radiology, Department of Radiology, University of Minnesota, Mayo B228, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
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Pourahmadi M, Noorbaloochi S. Multivariate time series analysis of neuroscience data: some challenges and opportunities. Curr Opin Neurobiol 2016; 37:12-15. [PMID: 26752736 DOI: 10.1016/j.conb.2015.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/07/2015] [Accepted: 12/17/2015] [Indexed: 11/25/2022]
Abstract
Neuroimaging data may be viewed as high-dimensional multivariate time series, and analyzed using techniques from regression analysis, time series analysis and spatiotemporal analysis. We discuss issues related to data quality, model specification, estimation, interpretation, dimensionality and causality. Some recent research areas addressing aspects of some recurring challenges are introduced.
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Affiliation(s)
- Mohsen Pourahmadi
- Department of Statistics, Texas A&M University, College Station, TX 77843-3143, United States.
| | - Siamak Noorbaloochi
- VA HSR&D Center for Chronic Diseases Outcome Research and Department of Medicine, University of Minnesota, Minneapolis, MN 55455-0460, United States
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44
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Voller E, Polusny MA, Noorbaloochi S, Street A, Grill J, Murdoch M. Self-efficacy, male rape myth acceptance, and devaluation of emotions in sexual trauma sequelae: Findings from a sample of male veterans. Psychol Serv 2015; 12:420-7. [PMID: 26524284 DOI: 10.1037/ser0000046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sexual trauma is an understudied but regrettably significant problem among male Veterans. As in women, sexual trauma often results in serious mental health consequences for men. Therefore, to guide potential future interventions in this important group, we investigated associations among self-efficacy, male rape myth acceptance, devaluation of emotions, and psychiatric symptom severity after male sexual victimization. We collected data from 1,872 Gulf War era Veterans who applied for posttraumatic stress disorder (PTSD) disability benefits using standard mailed survey methods. The survey asked about history of childhood sexual abuse, sexual assault during the time of Gulf War I, and past-year sexual assault as well as Veterans' perceived self-efficacy, male rape myth acceptance, devaluation of emotions, PTSD, and depression symptoms. Structural equation modeling revealed that self-efficacy partially mediated the association between participants' sexual trauma history and psychiatric symptoms. Greater male rape myth acceptance and greater devaluation of emotions were directly associated with lower self-efficacy, but these beliefs did not moderate associations between sexual trauma and self-efficacy. In this population, sexual trauma, male rape myth acceptance, and devaluation of emotions were associated with lowered self-efficacy, which in turn was associated with more severe psychiatric symptoms. Implications for specific, trauma-focused treatment are discussed.
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45
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Sayer NA, Noorbaloochi S, Frazier PA, Pennebaker JW, Orazem RJ, Schnurr PP, Murdoch M, Carlson KF, Gravely A, Litz BT. Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans. J Trauma Stress 2015; 28:381-90. [PMID: 26467326 DOI: 10.1002/jts.22047] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We examined the efficacy of a brief, accessible, nonstigmatizing online intervention-writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self-reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6-months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes.
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Affiliation(s)
- Nina A Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Departments of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patricia A Frazier
- Department of Psychology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Robert J Orazem
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Paula P Schnurr
- National Center for PTSD, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Maureen Murdoch
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Section of General Internal Medicine, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Kathleen F Carlson
- Center to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, USA.,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Brett T Litz
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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46
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Lederle FA, Noorbaloochi S, Nugent S, Taylor BC, Grill JP, Kohler TR, Cole L. Multicentre study of abdominal aortic aneurysm measurement and enlargement. Br J Surg 2015; 102:1480-7. [DOI: 10.1002/bjs.9895] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/23/2015] [Accepted: 06/10/2015] [Indexed: 11/11/2022]
Abstract
Abstract
Background
No effective treatment is currently available to prevent progression of small and medium-sized abdominal aortic aneurysms (AAAs). Identification of drugs with sufficient promise to justify large expensive randomized trials remains challenging. One potentially useful strategy is to look for associations between commonly used drugs and AAA enlargement in appropriately adjusted observational studies.
Methods
Potential AAA measurements were identified from abdominal imaging reports in the electronic data files of three medical centres from 1995 to 2010. AAA measurements were extracted manually and patients with an aneurysm of 3 cm or larger, who had at least two measurements over an interval of at least 6 months, were identified. Other data were obtained from the electronic data files (demographics, co-morbidities, smoking status, drug use) to conduct a propensity analysis of the associations of drugs and other factors with AAA enlargement.
Results
From 52 962 abdominal imaging studies, 5362 patients with an AAA of 3 cm or more were identified, of whom 2428 had at least two measurements over at least 6 months. Mean AAA follow-up was 3·4 years and the mean AAA enlargement rate was 2·0 mm per year. Propensity analysis demonstrated no significant association of AAA enlargement with statins, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Diabetes was associated with a reduction in AAA enlargement of 1·2 mm per year (P = 0·008), and chronic obstructive pulmonary disease was associated with increased enlargement (0·5 mm per year; P = 0·050). Moderate AAA measurement variation and substantial terminal digit preference were also observed, but the digit preference became less pronounced after 2000.
Conclusion
This study confirms the negative association of diabetes with AAA progression. There was no evidence that commonly used cardiovascular drugs affect AAA enlargement.
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Affiliation(s)
- F A Lederle
- Center for Chronic Disease Outcomes Research, Veterans Affairs (VA) Health Care System, Minneapolis, Minnesota, USA
| | - S Noorbaloochi
- Center for Chronic Disease Outcomes Research, Veterans Affairs (VA) Health Care System, Minneapolis, Minnesota, USA
| | - S Nugent
- Center for Chronic Disease Outcomes Research, Veterans Affairs (VA) Health Care System, Minneapolis, Minnesota, USA
| | - B C Taylor
- Center for Chronic Disease Outcomes Research, Veterans Affairs (VA) Health Care System, Minneapolis, Minnesota, USA
| | - J P Grill
- Center for Chronic Disease Outcomes Research, Veterans Affairs (VA) Health Care System, Minneapolis, Minnesota, USA
| | - T R Kohler
- VA Medical Center, Seattle, Washington, USA
| | - L Cole
- VA Medical Center, West Los Angeles, California, USA
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Powell AA, Saini SD, Breitenstein MK, Noorbaloochi S, Cutting A, Fisher DA, Bloomfield HE, Halek K, Partin MR. Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration. J Gen Intern Med 2015; 30:732-41. [PMID: 25605531 PMCID: PMC4441657 DOI: 10.1007/s11606-014-3163-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/01/2014] [Accepted: 12/12/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inappropriate use of colorectal cancer (CRC) screening procedures can inflate healthcare costs and increase medical risk. Little is known about the prevalence or causes of inappropriate CRC screening. OBJECTIVE Our aim was to estimate the prevalence of potentially inappropriate CRC screening, and its association with patient and facility characteristics in the Veterans Health Administration (VHA) . DESIGN AND PARTICIPANTS We conducted a cross-sectional study of all VHA patients aged 50 years and older who completed a fecal occult blood test (FOBT) or a screening colonoscopy between 1 October 2009 and 31 December 2011 (n = 1,083,965). MAIN MEASURES Measures included: proportion of patients whose test was classified as potentially inappropriate; associations between potentially inappropriate screening and patient demographic and health characteristics, facility complexity, CRC screening rates, dependence on FOBT, and CRC clinical reminder attributes. KEY RESULTS Of 901,292 FOBT cases, 26.1 % were potentially inappropriate (13.9 % not due, 7.8 % limited life expectancy, 11.0 % receiving FOBT when colonoscopy was indicated). Of 134,335 screening colonoscopies, 14.2 % were potentially inappropriate (10.4 % not due, 4.4 % limited life expectancy). Each additional 10 years of patient age was associated with an increased likelihood of undergoing potentially inappropriate screening (ORs = 1.60 to 1.83 depending on screening mode). Compared to facilities scoring in the bottom third on a measure of reliance on FOBT (versus screening colonoscopy), facilities scoring in the top third were less likely to conduct potentially inappropriate FOBTs (OR = 0.,78) but more likely to conduct potentially inappropriate colonoscopies (OR = 2.20). Potentially inappropriate colonoscopies were less likely to be conducted at facilities where primary care providers were assigned partial responsibility (OR = 0.74) or full responsibility (OR = 0.73) for completing the CRC clinical reminder. CONCLUSIONS A substantial number of VHA CRC screening tests are potentially inappropriate. Establishing processes that enforce appropriate screening intervals, triage patients with limited life expectancies, and discourage the use of FOBTs when a colonoscopy is indicated may reduce inappropriate testing.
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Affiliation(s)
- Adam A Powell
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN, USA,
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Murdoch M, Polusny MA, Street A, Noorbaloochi S, Simon AB, Bangerter A, Grill J, Voller E. Sexual assault during the time of Gulf War I: a cross-sectional survey of U.S. service men who later applied for Department of Veterans Affairs PTSD disability benefits. Mil Med 2015; 179:285-93. [PMID: 24594463 DOI: 10.7205/milmed-d-12-00513] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To estimate the cumulative incidence of sexual assault during the time of Gulf War I among male Gulf War I Veterans who later applied for Department of Veterans Affairs (VA) post-traumatic stress disorder disability benefits and to identify potential risk and protective factors for sexual assault within the population. METHOD Mailed, national, cross-sectional survey supplemented with VA administrative and clinical data. RESULTS Of 2,415 Veterans sampled, 1,700 (70%) responded. After adjusting for nonignorable missing data, the cumulative incidence of sexual assault during Gulf War I in this population ranged from 18% [95% confidence intervals (CI): 5.0%-51.9%] to 21% (95% CI: 20.0-22.0). Deployment was not associated with sexual assault [Odds Ratio (OR), 0.96; 95% CI: 0.75-1.23], but combat exposure was (OR, 1.80; 95% CI: 1.52-2.10). Other correlates of sexual assault within the population included working in a unit with greater tolerance of sexual harassment (OR, 1.80; 95% CI: 1.52-2.10) and being exposed to more sexual identity challenges (OR, 1.76; 95% CI: 1.55-2.00). CONCLUSIONS The 9-month cumulative incidence of sexual assault in this particular population exceeded the lifetime cumulative incidence of sexual assault in U.S. civilian women. Although Persian Gulf deployment was not associated with sexual assault in this population, combat exposure was.
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Affiliation(s)
- Maureen Murdoch
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Melissa A Polusny
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Amy Street
- National Center for PTSD, VA Boston Healthcare System, 150 Huntington Avenue, Boston, MA 02130
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Alisha B Simon
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Ann Bangerter
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Joseph Grill
- Center for Chronic Disease Outcomes Research, VA Health Services Research and Development (HSR&D) Service Center of Excellence, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
| | - Emily Voller
- Departments of Psychiatry and Psychology, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417
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Jalaeian H, Talaie R, D’Souza D, Noorbaloochi S, Kowalik K, Hunter D, Golzarian J. Intrahepatic portosystemic shunting: is minilaparotomy-assisted transmesenteric-transjugular approach still relevant? J Vasc Interv Radiol 2015. [DOI: 10.1016/j.jvir.2014.12.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Rogers ES, Fu SS, Krebs P, Noorbaloochi S, Nugent SM, Rao R, Schlede C, Sherman SE. Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial. BMC Public Health 2014; 14:1294. [PMID: 25518878 PMCID: PMC4301886 DOI: 10.1186/1471-2458-14-1294] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/01/2014] [Indexed: 12/03/2022] Open
Abstract
Background Persons with a mental health diagnosis have high rates of tobacco use and face numerous barriers to cessation including high levels of nicotine dependence, low rates of tobacco treatment referrals from mental health providers, and limited availability of tobacco treatment targeted to their needs. This manuscript describes the rationale and methods of a clinical trial with the following aims: 1) Compare the reach and efficacy of a proactive telephone-based tobacco cessation program for Veterans Health Administration (VHA) mental health clinic patients to VHA usual care and 2) Model longitudinal associations between baseline patient characteristics and long-term abstinence. Methods/design We will use the electronic medical record to identify patients across four VHA healthcare facilities who have a clinical reminder code indicating current tobacco use in the past six months and who have had a mental health clinic visit in the past 12 months. We will send each patient an introductory letter and baseline survey. Survey respondents (N = 3840) will be randomized in a 1:1 fashion to intervention or control. Control participants will receive VHA usual care. Intervention participants will receive proactive motivational telephone outreach to offer tobacco treatment. Intervention participants interested in treatment will receive eight weeks of nicotine replacement therapy plus eight sessions of specialized telephone counseling over two months, followed by monthly maintenance counseling for four months. We will conduct telephone surveys with participants at six and 12 months to assess study outcomes. We will collect a mailed saliva sample from patients reporting 7-day abstinence on the telephone surveys. The primary outcome will be cotinine-validated abstinence at 12-month follow-up. Discussion Mental health patients are a high-risk smoking population with significant barriers to cessation. This study will evaluate the efficacy of a program that proactively reaches out to smokers with a mental health treatment history to engage them into telephone cessation counseling targeted to the needs of mental health patients. Trial registration Clinicaltrials.gov: NCT01737281 (registered November 5, 2012).
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Affiliation(s)
- Erin S Rogers
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA.
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