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Treacy J, Morrato EH, Horne R, Wolf MS, Bakhai A, Wilson MC, Lightowler M, Guerler S, Jokinen J. Behavioral Science: Enhancing Our Approach to the Development of Effective Additional Risk Minimization Strategies. Drug Saf 2024:10.1007/s40264-024-01420-w. [PMID: 38594553 DOI: 10.1007/s40264-024-01420-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Abstract
Additional risk minimization strategies may be required to assure a positive benefit-risk balance for some therapeutic products associated with serious adverse drug reactions/risks of use, without which these products may be otherwise unavailable to patients. The goals of risk minimization strategies are often fundamentally to influence the behavior of healthcare professionals (HCPs) and/or patients and can include appropriate patient selection, provision of education and counselling, appropriate medication use, adverse drug reaction monitoring, and adoption of other elements to assure safe use, such as pregnancy prevention. Current approaches to additional risk minimization strategy development rely heavily on information provision, without full consideration of the contextual factors and multi-level influences on patient and HCP behaviors that impact adoption and long-term adherence to these interventions. Application of evidence-based behavioral science methods are urgently needed to improve the quality and effectiveness of these strategies. Evidence from the fields of adherence, health promotion, and drug utilization research underscores the value and necessity for using established behavioral science frameworks and methods if we are to achieve clinical safety goals for patients. The current paper aims to enhance additional risk minimization strategy development and effectiveness by considering how a behavioral science approach can be applied, drawing from evidence in understanding of engagement with pharmaceutical medicines as well as wider public health interventions for patients and HCPs.
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Affiliation(s)
| | - Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
| | - Robert Horne
- Spoonful of Sugar Ltd, University College London Business Company, Brighton and Hove, UK
| | - Michael S Wolf
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ameet Bakhai
- The Royal Free and University College Medical School, London, UK
| | | | - Mark Lightowler
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Science, King's College London, London, UK
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Escoffery C, Petagna CN, Wangen M, Flicker KJ, Noblet SB, Sakhuja M, Thomson CA, Morrato EH, Adams S, Leeman J, Friedman DB. Mixed methods evaluation of the inaugural year of the Cancer Prevention and Control Research Network's (CPCRN) scholars program. Cancer Causes Control 2023; 34:57-73. [PMID: 37106215 PMCID: PMC10139907 DOI: 10.1007/s10552-023-01702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE A diverse workforce trained in dissemination & implementation (D&I) science is critical for improving cancer outcomes and reducing cancer-related health disparities. This study aims to describe and evaluate impact of the Cancer Prevention and Control Research Network (CPCRN) Scholars Program in preparing scholars for collaborative careers in cancer control and implementation research and practice, and offers evaluation-driven recommendations for program improvements. METHODS The CPCRN Scholars Workgroup conducted a sequential, mixed methods evaluation. We collected baseline and follow-up surveys and invited all 20 scholars and ten mentors to participate in an exit interview. We assessed the experience with the Scholar's program, ratings of D&I competences, progress on their project, feedback about the curriculum, and understanding of implementation science. RESULTS Over 86% partially or fully completed their project within 9 months; 78% of scholars engaged with a CPCRN workgroup. Scholars rated the following program components as valuable: the Putting Public Health Evidence in Action (PPHEIA) training (88.9%), D&I training modules (83.3%), and webinars (kickoff webinar-88.9% and selecting theories/models-88.9%). There was an increase in D&I competencies from baseline to posttest, with the greatest in community engagement topics. About 78% reported that they were satisfied with format of the activities and increased confidence in ability to discuss D&I concepts. From the qualitative interviews, the benefit of the program was becoming more knowledgeable about D&I research and networking. CONCLUSION The inaugural year of the program yielded positive results, particularly related to increasing knowledge about D&I science and cancer control. This program builds the capacity of students, researchers and practitioners in D&I science.
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Affiliation(s)
- Cam Escoffery
- Rollins School of Public Health, Department of Behavioral, Social, and Health Education Sciences, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, USA.
| | - Courtney N Petagna
- Rollins School of Public Health, Department of Behavioral, Social, and Health Education Sciences, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Mary Wangen
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kimberly J Flicker
- The University of South Carolina, Arnold School of Public, Health Health Promotion, Education, and Behavior, Columbia, SC, USA
| | - Samuel B Noblet
- The University of South Carolina, Arnold School of Public, Health Health Promotion, Education, and Behavior, Columbia, SC, USA
| | - Mayank Sakhuja
- The University of South Carolina, Arnold School of Public, Health Health Promotion, Education, and Behavior, Columbia, SC, USA
| | - Cynthia A Thomson
- Health Promotion Sciences Department, University of Arizona, Mel and Enid Zuckerman, Tucson, Arizona, USA
| | - Elaine H Morrato
- Loyola University Chicago, Parkinson School of Health Sciences and Public Health, Chicago, Illinois, USA
| | - Swann Adams
- The University of South Carolina, Arnold School of Public, Health Health Promotion, Education, and Behavior, Columbia, SC, USA
| | - Jennifer Leeman
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniela B Friedman
- The University of South Carolina, Arnold School of Public, Health Health Promotion, Education, and Behavior, Columbia, SC, USA
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Mora N, Arvanitakis Z, Thomas M, Kramer H, Morrato EH, Markossian TW. Applying Customer Discovery Method to a Chronic Disease Self-Management Mobile App: Qualitative Study. JMIR Form Res 2023; 7:e50334. [PMID: 37955947 PMCID: PMC10682919 DOI: 10.2196/50334] [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: 07/10/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND A significant health challenge is evident in the United States, with 6 in 10 adults having a chronic disease and 4 in 10 adults having 2 or more. Chronic disease self-management aims to prevent or delay disease progression and disability and reduce mortality risk. The evidence to support the use of information technology tools, including mobile apps, web-based portals, and web-based educational interventions, that support disease self-management and improve clinical outcomes is growing. Customer discovery and value proposition design methodology is a form of stakeholder engagement and is based on marketing and lean start-up business methods. As applied in health care, customer discovery and value proposition methodology can be used to understand the clinical problem and articulate the product's hypothesized unique value proposition relative to alternative options that are available to end users. OBJECTIVE This study aims to describe the experience and findings of academic researchers applying the customer discovery and value proposition methodology to identify stakeholders, needs, adaptability, and sustainability of a chronic disease self-management mobile app (CDapp). The motivation of the work is to make mobile health app interventions accessible and acceptable for all segments of patients' chronic diseases. METHODS Data were obtained through key informant interviews and analyzed using rapid qualitative analysis techniques. The value proposition framework was used to build the interview guide. The aim was to identify the needs, challenges (pains), and potential benefits (gains) of the CDapp for our stakeholders. RESULTS Our results showed that the primary consumers (end users) of a CDapp were the patients. The app adopters (decision makers) can be medical center leaders including population health department managers or insurance providers, while the consumer adoption influencers (influencers or saboteurs) are clinicians and patient caregivers. We developed an ecosystem map to visualize the clinical practice workflow and how an app for chronic disease management might integrate within an academic health care center or system. A value proposition for the identified customer segments was generated. Each stakeholder segment was working within a different framework to improve patient self-management. Patients needed help to adhere to self-care activities and they needed tailored health education. Health care leaders aim to improve the quality of care while reducing costs and workload. Clinicians wanted to improve patient education and care while reducing the time burden. Our results also showed that within academic medical centers, there were variations regarding patients' self-reported abilities to manage their diseases. CONCLUSIONS Customer discovery is a useful form of stakeholder engagement when designing studies that seek to implement, adapt, and sustain an intervention. The customer discovery and value proposition methodology can be used as an alternative or complementary approach to formative research to generate valuable information in a brief period.
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Affiliation(s)
- Nallely Mora
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Zoe Arvanitakis
- Rush Medical College, Rush University Medical Center, Chicago, IL, United States
| | - Merly Thomas
- Center for Health Innovation and Entrepreneurship, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Holly Kramer
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
- Department of Medicine, Loyola University of Chicago, Maywood, IL, United States
| | - Elaine H Morrato
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Talar W Markossian
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
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Toyserkani GA, Ewusie SB, Turk P, Quick J, Morrato EH. Evolution of Cross-Sectional Survey Protocol Quality Over Time: A Case Series of Index U.S. REMS Knowledge Survey Protocols (2007-2020). Drug Saf 2023; 46:1073-1087. [PMID: 37697204 DOI: 10.1007/s40264-023-01344-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Surveys are commonly used to assess effectiveness of FDA-required risk evaluation and mitigation strategies (REMS) for drugs and biologics in the United States. OBJECTIVE The aim of this study was to assess the scientific rigor of REMS knowledge survey protocols submitted to FDA and compare protocols before and after FDA's 2012 public workshop and 2019 draft guidance. METHOD A content analysis of index survey protocols submitted to FDA (2007-2020) for single-product REMS with elements to assure safe use (39 programs, 78 protocols) was conducted. Each protocol was scored against 52 core essential elements (CEE), abstracted from FDA's guidance and grouped into six domains: study objective (n = 5), study design (n = 18), survey instrument (n = 9), participant recruitment (n = 7), survey administration (n = 9), and statistical analysis plan (n = 4). Scores were collected by time periods: (A) Oct 2007 to Jul 2012; (B) Aug 2012 to Feb 2019; (C) Mar 2019 to Dec 2020; and compared using logistic generalized linear mixed models adjusting for domain, survey population, vendor, program, and protocol. RESULTS There were 30 (38.5%), 40 (51.3%), and 8 (10.3%) protocols submitted in time period A, B, and C, respectively. Adjusted marginal means of elements present (on the probability scale) by time period were 0.5816 (SE = 0.0242), 0.6429 (SE = 0.0229), and 0.7543 (SE = 0.0394). The likelihood of missing a CEE declined over time (adjusted p-value = 0.0094, time period A vs C). The statistical analysis plan domain had the most improvement; study design remained the weakest domain with the scientific justification CEE particularly underrepresented. CONCLUSION The rigor of REMS knowledge survey protocols improved over time consistent with FDA's efforts to advance regulatory science, but gaps remain.
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Affiliation(s)
- Gita A Toyserkani
- Food and Drug Administration, 10903 New Hampshire Avenue, Building 22, Room 1106, Silver Spring, MD, 20993, USA.
| | - Samuel B Ewusie
- Food and Drug Administration, 10903 New Hampshire Avenue, Building 22, Room 1106, Silver Spring, MD, 20993, USA
- Oak Ridge Institute for Science and Education (ORISE) Program, Oak Ridge, TN, USA
| | - Philip Turk
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Janifer Quick
- Food and Drug Administration, 10903 New Hampshire Avenue, Building 22, Room 1106, Silver Spring, MD, 20993, USA
- Oak Ridge Institute for Science and Education (ORISE) Program, Oak Ridge, TN, USA
| | - Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
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Morrato EH, Lennox LA, Dearing JW, Coughlan AT, Gano ES, McFadden D, Mora N, Pincus HA, Firestein GS, Toto R, Reis SE. The Evolve to Next-Gen ACT Network: An evolving open-access, real-world data resource primed for real-world evidence research across the Clinical and Translational Science Award Consortium. J Clin Transl Sci 2023; 7:e224. [PMID: 38028333 PMCID: PMC10643916 DOI: 10.1017/cts.2023.617] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 12/01/2023] Open
Abstract
The ACT Network was funded by NIH to provide investigators from across the Clinical and Translational Science Award (CTSA) Consortium the ability to directly query national federated electronic health record (EHR) data for cohort discovery and feasibility assessment of multi-site studies. NIH refunded the program for expanded research application to become "Evolve to Next-Gen ACT" (ENACT). In parallel, the US Food and Drug Administration has been evaluating the use of real-world data (RWD), including EHR data, as sources of real-world evidence (RWE) for its regulatory decisions involving drug and biological products. Using insights from implementation science, six lessons learned from ACT for developing and sustaining RWD/RWE infrastructures and networks across the CTSA Consortium are presented in order to inform ENACT's development from the outset. Lessons include intentional institutional relationship management, end-user engagement, beta-testing, and customer-driven adaptation. The ENACT team is also conducting customer discovery interviews with CTSA hub and investigators using Innovation-Corps@NCATS (I-Corps™) methodology for biomedical entrepreneurs to uncover unmet RWD needs. Possible ENACT value proposition hypotheses are presented by stage of research. Developing evidence about methods for sustaining academically derived data infrastructures and support can advance the science of translation and support our nation's RWD/RWE research capacity.
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Affiliation(s)
- Elaine H. Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
- Institute for Translational Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Lindsay A. Lennox
- Colorado Clinical and Translational Sciences Institute, CU Anschutz Medical Campus, Aurora, CO, USA
| | - James W. Dearing
- College of Communications, Arts and Sciences, Michigan State University, East Lansing, MI, USA
| | - Anne T. Coughlan
- Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | | | - Doug McFadden
- Harvard Catalyst, Harvard University, Boston, MA, USA
| | - Nallely Mora
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
- Institute for Translational Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Harold Alan Pincus
- Irving Institute for Clinical and Translational Research, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Gary S. Firestein
- Altman Clinical and Translational Research Institute at the University of California San Diego, San Diego, CA, USA
| | - Robert Toto
- Center for Translational Medicine, UT Southwestern, Dallas, TX, USA
| | - Steven E. Reis
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
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McNeal DM, Sahler OJZ, Noll RB, Fairclough DL, Voll ME, Bhat S, Morrato EH. Core functions and forms of Bright IDEAS: A multi-methods evaluation of the adoption of an evidence-based psychosocial training program through iterative adaptation. Front Health Serv 2022; 2:928580. [PMID: 36925829 PMCID: PMC10012676 DOI: 10.3389/frhs.2022.928580] [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] [Received: 05/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
Background Despite efforts to widely disseminate interventions designed to increase access to quality supportive care to pediatric cancer patients and their families, many of these interventions fail to meet expectations once deployed in real-life clinical settings. This study identifies the functions and forms of Bright IDEAS: Problem-Solving Skills Training, an evidence based psychosocial intervention for caregivers of children recently diagnosed with cancer, to identify pragmatic program adaptations in its real-world clinical implementation. We compare intervention adoption before and after adaptations to the Bright IDEAS training program as part of a national training program designed to disseminate the intervention. Methods 209 pediatric psychosocial oncology practitioners representing 134 unique institutions were trained during 10 in-person 8-hour workshops (2015-2019). Functions and forms of Bright IDEAS were identified, and adaptations made to the training agenda and curriculum based on practitioner feedback following implementation in local institutions. Mixed method evaluation included longitudinal surveys at 6- and 12-months post training; and qualitative interviews among a subgroup of practitioners (N = 47) to understand and compare perspectives on intervention adoption and barriers to implementation before and after adaptations to the Bright IDEAS training program. The RE-AIM framework was used to guide dissemination evaluation. Results A total of four adaptations were tailored to the identified forms of the intervention: case studies; pre-training reading materials; training videos; and letters of institutional support from primary supervisor. Pre- and post-training adaptations to the Bright IDEAS training program were mapped to RE-AIM constructs. Quantitative findings demonstrate that adaptations appeared to improve adoption and usage overall. Conclusion This study provides insight into how contextual factors influence psychosocial practitioners' capacity to adopt, implement, and maintain Bright IDEAS in the clinical setting. This study demonstrates the use of real-time stakeholder feedback to guide intervention translation from research to practice settings.
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Affiliation(s)
- Demetria M. McNeal
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Olle Jane Z. Sahler
- Division of Pediatric Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Golisano Children's Hospital, Rochester, NY, United States
| | - Robert B. Noll
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Diane L. Fairclough
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Megan E. Voll
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shubha Bhat
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elaine H. Morrato
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, United States
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Voll M, Fairclough DL, Morrato EH, McNeal DM, Embry L, Pelletier W, Noll RB, Sahler OJZ. Dissemination of an evidence-based behavioral intervention to alleviate distress in caregivers of children recently diagnosed with cancer: Bright IDEAS. Pediatr Blood Cancer 2022; 69:e29904. [PMID: 35929012 PMCID: PMC9420785 DOI: 10.1002/pbc.29904] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 05/11/2022] [Revised: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Four multisite randomized clinical trials of > 1400 caregivers of children newly diagnosed with cancer showed that the Bright IDEAS (BI) paradigm of problem-solving skills training is an acceptable and efficacious approach to alleviating the high levels of distress they experience. To facilitate providing evidence-based caregiver support as recommended in the pediatric oncology standards of care, the project described here was designed to disseminate BI to 200 psychosocial professionals. PROCEDURE We partnered with the Children's Oncology Group (COG), Association of Pediatric Oncology Social Workers (APOSW), Association of Pediatric Hematology/Oncology Nurses (APHON), and special interest group in pediatric hematology/oncology of the Society for Pediatric Psychology (SPP). Membership surveys revealed substantial enthusiasm for training in BI. We structured training to include review of the evidence base for BI, role plays, and strategies for implementation at individual sites. Four conference calls designed to enhance implementation were held one, two, three, and five months after training. RESULTS Ten 1.5-day workshops were held in conjunction with annual meetings of COG, APOSW, APHON, and SPP. A total of 209 psychosocial clinicians from 134 sites were trained. Evaluations were highly favorable. Trainees had provided BI to 545 individuals as of the last conference call. CONCLUSIONS Initial dissemination goals were met. BI is now available at numerous pediatric oncology centers, but it has not become part of routine care. Future work focused on implementation might consider top-down approaches that include direct communication with pediatric oncologists and hospital leaders about the benefits of incorporating this evidence-based intervention systemically.
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Affiliation(s)
- Megan Voll
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, Pennsylvania
| | - Diane L. Fairclough
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus Aurora, Aurora, Colorado
| | - Elaine H. Morrato
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois
| | - Demetria M. McNeal
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Leanne Embry
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, Texas
| | - Wendy Pelletier
- Pediatric Hematology/Oncology/Transplant Program, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | - Robert B. Noll
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, Pennsylvania
| | - Olle Jane Z. Sahler
- University of Rochester School of Medicine and Dentistry, Golisano Children’s Hospital, Division of Pediatric Hematology/Oncology, Rochester, New York
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Haddad R, Badke D'Andrea C, Ricchio A, Evanoff B, Morrato EH, Parks J, Newcomer JW, Nicol GE. Using Innovation-Corps (I-Corps™) Methods to Adapt a Mobile Health (mHealth) Obesity Treatment for Community Mental Health Settings. Front Digit Health 2022; 4:835002. [PMID: 35721796 PMCID: PMC9197731 DOI: 10.3389/fdgth.2022.835002] [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] [Received: 12/14/2021] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background We employed Innovation Corps (I-Corps™) methods to adaptation of a mobile health (mHealth) short-message-system (SMS) -based interactive obesity treatment approach (iOTA) for adults with severe mentall illness receiving care in community settings. Methods We hypothesized "jobs to be done" in three broad stakeholder groups: "decision makers" (DM = state and community clinic administrators), "clinician consumers" (CC = case managers, peer supports, nurses, prescribers) and "service consumers" (SC = patients, peers and family members). Semistructured interviews (N = 29) were recorded and transcribed ver batim and coded based on pragmatic-variant grounded theory methods. Results Four themes emerged across groups: education, inertia, resources and ownership. Sub-themes in education and ownership differed between DM and CC groups on implementation ownership, intersecting with professional development, suggesting the importance of training and supervision in scalability. Sub-themes in resources and intertia differed between CC and SC groups, suggesting illness severity and access to healthy food as major barriers to engagement, whereas the SC group identified the need for enhanced emotional support, in addition to pragmatic skills like menu planning and cooking, to promote health behavior change. Although SMS was percieved as a viable education and support tool, CC and DM groups had limited familiarity with use in clinical care delivery. Conclusions Based on customer discovery, the characteristics of a minimum viable iOTA for implementation, scalability and sustainability include population- and context-specific adaptations to treatment content, interventionist training and delivery mechanism. Successful implementation of an SMS-based intervention will likely require micro-adaptations to fit specific clinical settings.
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Affiliation(s)
- Rita Haddad
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Carolina Badke D'Andrea
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Amanda Ricchio
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Bradley Evanoff
- Center for Healthy Work, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Elaine H. Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Chicago, IL, United States
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Joseph Parks
- National Council for Mental Wellbeing, Washington, DC, United States
| | - John W. Newcomer
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
- Thriving Mind South Florida, Miami, FL, United States
| | - Ginger E. Nicol
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
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Butler H, Rice JD, Carlson NE, Morrato EH. A flexible mixed data model applied to claims data for post‐market surveillance of prescription drug safety behavior. Pharm Stat 2022; 21:1022-1036. [PMID: 35373459 PMCID: PMC9546139 DOI: 10.1002/pst.2213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 01/10/2022] [Accepted: 03/20/2022] [Indexed: 12/03/2022]
Abstract
We develop a new modeling framework for jointly modeling first prescription times and the presence of risk‐mitigating behavior for prescription drugs using real‐world data. We are interested in active surveillance of clinical quality improvement programs, especially for drugs which enter the market under an FDA‐mandated Risk Evaluation and Mitigation Strategy (REMS). Our modeling framework attempts to jointly model two important aspects of prescribing, the time between a drug's initial marketing and a patient's first prescription of that drug, and the presence of risk‐mitigating behavior at the first prescription. First prescription times can be flexibly modeled as a mixture of component distributions to accommodate different subpopulations and allow the proportion of prescriptions that exhibit risk‐mitigating behavior to change for each component. Risk‐mitigating behavior is defined in the context of each drug. We develop a joint model using a mixture of positive unimodal distributions to model first prescription times, and a logistic regression model conditioned on component membership to model the presence of risk‐mitigating behavior. We apply our model to two recently approved extended release/long‐acting (ER/LA) opioids, which have an FDA‐approved blueprint for best prescribing practices to inform our definition of risk‐mitigating behavior. We also apply our methods to simulated data to evaluate their performance under various conditions such as clustering.
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Affiliation(s)
- Harris Butler
- Biostatistics and Informatics, Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - John D. Rice
- Biostatistics and Informatics, Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - Nichole E. Carlson
- Biostatistics and Informatics, Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora Colorado USA
| | - Elaine H. Morrato
- Parkinson School of Health Sciences and Public Health Loyola University Chicago Chicago Illinois USA
- Health Systems, Management, and Policy, Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora Colorado USA
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Abstract
Designing for dissemination and sustainability (D4DS) refers to principles and methods for enhancing the fit between a health program, policy, or practice and the context in which it is intended to be adopted. In this article we first summarize the historical context of D4DS and justify the need to shift traditional health research and dissemination practices. We present a diverse literature according to a D4DS organizing schema and describe a variety of dissemination products, design processes and outcomes, and approaches to messaging, packaging, and distribution. D4DS design processes include stakeholder engagement, participatory codesign, and context and situation analysis, and leverage methods and frameworks from dissemination and implementation science, marketing and business, communications and visual arts, and systems science. Finally, we present eight recommendations to adopt a D4DS paradigm, reflecting shifts in ways of thinking, skills and approaches, and infrastructure and systems for training and evaluation. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Bethany M. Kwan
- Department of Family Medicine and Adult & Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ross C. Brownson
- Prevention Research Center, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine St. Louis, Missouri, USA
| | - Russell E. Glasgow
- Department of Family Medicine and Adult & Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elaine H. Morrato
- Parkinson School of Health Sciences and Public Health and Institute for Translational Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Douglas A. Luke
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
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11
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Schuster ALR, Perraillon MC, Paul JJ, Leiferman JA, Battaglia C, Morrato EH. The Effect of the Affordable Care Act on Women's Postpartum Insurance and Depression in 5 States That Did Not Expand Medicaid, 2012-2015. Med Care 2022; 60:22-28. [PMID: 34670222 PMCID: PMC8811754 DOI: 10.1097/mlr.0000000000001652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/03/2023]
Abstract
BACKGROUND Before the Affordable Care Act (ACA), most women who gained pregnancy-related Medicaid were not eligible for Medicaid as parents postpartum. The ACA aimed to expand health insurance coverage, in part, by expanding Medicaid; introducing mandates; reforming regulations; and establishing exchanges with federal subsidies. Federal subsidies offer a means to coverage for individuals with income at 100%-400% of the federal poverty level who do not qualify for Medicaid. OBJECTIVE The objective of this study was to identify the effects of the ACA's non-Medicaid provisions on women's postpartum insurance coverage and depressive symptoms in nonexpansion states with low parental Medicaid thresholds. PARTICIPANTS Women with incomes at 100%-400% of the federal poverty level who had prenatal insurance and completed the Pregnancy Risk Assessment Monitoring System (2012-2015). SETTING Five non-Medicaid expansion states with Medicaid parental eligibility thresholds below the federal poverty level. DESIGN Interrupted time-series analyses were conducted to examine changes between pre-ACA (January 2012-November 2013) and post-ACA (December 2013-December 2015) trends for self-reported loss of postpartum insurance and symptoms of postpartum depression. RESULTS The sample included 9,472 women. Results showed significant post-ACA improvements where the: (1) trend for loss of postpartum insurance reversed (change of -0.26 percentage points per month, P=0.047) and (2) level of postpartum depressive symptoms decreased (change of -3.5 percentage points, P=0.042). CONCLUSIONS In these 5 states, the ACA's non-Medicaid provisions were associated with large increases in retention of postpartum insurance and reductions in postpartum depressive symptoms, although depressive symptoms findings are sensitive to model specification.
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Affiliation(s)
| | | | | | - Jenn A Leiferman
- Community & Behavioral Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Elaine H Morrato
- Departments of Health Systems, Management, and Policy
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL
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12
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Fort MP, Reid M, Russell J, Santos CJ, Running Bear U, Begay RL, Smith SL, Morrato EH, Manson SM. Diabetes Prevention and Care Capacity at Urban Indian Health Organizations. Front Public Health 2021; 9:740946. [PMID: 34900897 PMCID: PMC8661087 DOI: 10.3389/fpubh.2021.740946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.
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Affiliation(s)
- Meredith P Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Margaret Reid
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jenn Russell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Cornelia J Santos
- Environmental Studies-Indigenous Sustainability Studies Program, Bemidji State University, Bemidji, MN, United States
| | - Ursula Running Bear
- Department of Population Health, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rene L Begay
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Savannah L Smith
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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13
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Huynh L, Toyserkani GA, Morrato EH. Pragmatic applications of implementation science frameworks to regulatory science: an assessment of FDA Risk Evaluation and Mitigation Strategies (REMS) (2014-2018). BMC Health Serv Res 2021; 21:779. [PMID: 34362367 PMCID: PMC8348874 DOI: 10.1186/s12913-021-06808-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background A Risk Evaluation and Mitigation Strategy (REMS) is a drug safety program for certain medications with serious safety concerns required by the U.S. Food and Drug Administration (FDA) of manufacturers to implement to help ensure the benefits of the medication outweigh its risks. FDA is encouraging “the research community to develop novel methods for assessing REMS,” conveying the unmet need for a standardized evaluation method of these regulatory-mandated healthcare programs. The objective of this research is to evaluate FDA REMS assessment plans using established implementation science frameworks and identify opportunities for strengthening REMS evaluation. Methods A content analysis was conducted of publicly available assessment plans for all REMS programs (N = 23) approved 1/1/2014–12/31/2018 for new drug applications (NDAs) and biologics license applications (BLAs) requiring FDA-mandated Elements to Assure Safe Use (ETASU). Blinded reviewers critically appraised REMS assessment measures (n = 674) using three established implementation science frameworks: RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance); PRECEDE-PROCEED (Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation – Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development); and CFIR (Consolidated Framework for Implementation Research). Framework constructs were mapped to REMS Assessment categories as defined by FDA Guidance for Industry to evaluate congruence. Results REMS assessment measures demonstrated strong congruence (> 90% mapping rate) with the evaluative constructs of RE-AIM, PRECEDE-PROCEED, and CFIR. Application of the frameworks revealed that REMS assessment measures heavily emphasize implementation and operations, focus less on health outcomes, and do not evaluate program context and design assumptions. Conclusions Implementation science frameworks have utility for evaluating FDA-mandated drug safety programs including the selection of primary measures to determine whether REMS goals are being met and of secondary measures to evaluate contextual factors affecting REMS effectiveness in varying organizational settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06808-3.
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Affiliation(s)
- Linda Huynh
- Food and Drug Administration, Silver Spring, MD, USA.,Oak Ridge Institute for Science and Education (ORISE) Program, Oak Ridge, TN, USA
| | | | - Elaine H Morrato
- Food and Drug Administration, Silver Spring, MD, USA.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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14
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Risendal BC, Hébert JR, Morrato EH, Thomson CA, Escoffery CN, Friedman DB, Dwyer AJ, Overholser LS, Wheeler SB. Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network. Am J Prev Med 2021; 60:877-882. [PMID: 33785276 PMCID: PMC7900782 DOI: 10.1016/j.amepre.2021.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Betsy C Risendal
- Community & Behavioral Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado
| | - James R Hébert
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; The Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois
| | - Cynthia A Thomson
- Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona; Population Sciences, University of Arizona Cancer Center, Tucson, Arizona.
| | - Cam N Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Daniela B Friedman
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | | | - Linda S Overholser
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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15
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Morrato EH. Interpreting evidence on long-acting injectable antipsychotics. Lancet Psychiatry 2021; 8:349-351. [PMID: 33862019 DOI: 10.1016/s2215-0366(21)00072-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL 60153, USA.
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16
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Kepper MM, Walsh-Bailey C, Brownson RC, Kwan BM, Morrato EH, Garbutt J, de las Fuentes L, Glasgow RE, Lopetegui MA, Foraker R. Development of a Health Information Technology Tool for Behavior Change to Address Obesity and Prevent Chronic Disease Among Adolescents: Designing for Dissemination and Sustainment Using the ORBIT Model. Front Digit Health 2021; 3:648777. [PMID: 34713122 PMCID: PMC8521811 DOI: 10.3389/fdgth.2021.648777] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
Health information technology (HIT) has not been broadly adopted for use in outpatient healthcare settings to effectively address obesity in youth, especially among disadvantaged populations that face greater barriers to good health. A well-designed HIT tool can deliver behavior change recommendations and provide community resources to address this gap, and the Obesity-Related Behavioral Intervention Trials (ORBIT) model can guide its development and refinement. This article reports the application of the ORBIT model to (1) describe the characteristics and design of a novel HIT tool (the PREVENT tool) using behavioral theory, (2) illustrate the use of stakeholder-centered "designing for dissemination and sustainability" principles, and (3) discuss the practical implications and directions for future research. Two types of stakeholder engagement (customer discovery and user testing) were conducted with end users (outpatient healthcare teams). Customer discovery interviews (n = 20) informed PREVENT tool components and intervention targets by identifying (1) what healthcare teams (e.g., physicians, dietitians) identified as their most important "jobs to be done" in helping adolescents who are overweight/obese adopt healthy behaviors, (2) their most critical "pains" and "gains" related to overweight/obesity treatment, and (3) how they define success compared to competing alternatives. Interviews revealed the need for a tool to help healthcare teams efficiently deliver tailored, evidence-based behavior change recommendations, motivate patients, and follow-up with patients within the constraints of clinic schedules and workflows. The PREVENT tool was developed to meet these needs. It facilitates prevention discussions, delivers tailored, evidence-based recommendations for physical activity and food intake, includes an interactive map of community resources to support behavior change, and automates patient follow-up. Based on Self-Determination Theory, the PREVENT tool engages the patient to encourage competence and autonomy to motivate behavior change. The use of this intentional, user-centered design process should increase the likelihood of the intended outcomes (e.g., behavior change, weight stabilization/loss) and ultimately increase uptake, implementation success, and long-term results. After initial tool development, user-testing interviews (n = 13) were conducted using a think-aloud protocol that provided insight into users' (i.e., healthcare teams) cognitive processes, attitudes, and challenges when using the tool. Overall, the PREVENT tool was perceived to be useful, well-organized, and visually appealing.
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Affiliation(s)
- Maura M. Kepper
- Prevention Research Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States,Institute for Public Health, Washington University in St. Louis, St. Louis, MO, United States,*Correspondence: Maura M. Kepper
| | - Callie Walsh-Bailey
- Prevention Research Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Ross C. Brownson
- Prevention Research Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States,Institute for Public Health, Washington University in St. Louis, St. Louis, MO, United States,Division of Public Health Sciences, Department of Surgery, Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Bethany M. Kwan
- Department of Family Medicine, Adult & Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Camps, Aurora, CO, United States
| | - Elaine H. Morrato
- Department of Family Medicine, Adult & Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Camps, Aurora, CO, United States,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, United States
| | - Jane Garbutt
- Institute for Public Health, Washington University in St. Louis, St. Louis, MO, United States,Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Lisa de las Fuentes
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Russell E. Glasgow
- Department of Family Medicine, Adult & Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Camps, Aurora, CO, United States
| | - Marcelo A. Lopetegui
- Centro de Informática Biomédica, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Randi Foraker
- Institute for Public Health, Washington University in St. Louis, St. Louis, MO, United States,Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States,Center for Population Health Informatics, Institute for Informatics, Washington University in St. Louis, St. Louis, MO, United States
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17
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Toyserkani GA, Huynh L, Morrato EH. Adaptation for Regulatory Application: A Content Analysis of FDA Risk Evaluation and Mitigation Strategies Assessment Plans (2014-2018) Using RE-AIM. Front Public Health 2020; 8:43. [PMID: 32158741 PMCID: PMC7052173 DOI: 10.3389/fpubh.2020.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Risk Evaluation and Mitigation Strategies (REMS) are safety programs that U.S. Food and Drug Administration can require to ensure a drug's benefits outweigh its risks and can be considered public health interventions. FDA's 2019 draft Guidance for Industry on REMS Assessments encourages the development of “novel methods for assessing REMS [to] help advance the science of post-market assessment of effectiveness of risk mitigation strategies.” Objective: To characterize REMS assessment plans using RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identify areas for advancing methods for evaluating REMS programs. RE-AIM was selected for its wide application evaluating the translation of scientific advances into practice for public health impact. Methods: A content analysis of REMS assessment plans (N = 18) and measures(n = 540) was conducted for REMS programs approved by FDA between 1/1/2014–12/31/2018. Eligibility criteria were: a new drug application or biologic license application, included FDA-mandated mitigation strategies called elements to assure safe use (ETASU), and represented a single product REMS program. Assessment plans were collected from publicly available regulatory approval letters from REMS@FDA website. Blinded reviewers categorized each REMS assessment measure to a RE-AIM dimension, adjudicated their application (average IRR 75%), and refined the adapted dimensions' definitions. Dimensions were also mapped to REMS Assessment guidance categories. Results: The median number of assessment measures per REMS assessment plan was 31 (IQR: 21–36). Frequency of measures per RE-AIM criteria per REMS program was: Reach (median = 2; IQR: 2–4); Effectiveness (median = 2.5; IQR:1–4); Adoption (median = 3.5; IQR: 2–5); Implementation (median = 18; IQR: 15–24); Maintenance (median = 0; IQR: 0–1). Adoption (among prescriber, health system agents of implementation) was more commonly assessed than Reach (population-attributable number of patients affected). Assessment of heterogeneity of Adoption and Reach was generally absent. Implementation assessment measures were most common among drugs requiring evidence of safe-use conditions before dispensing or administering the drug. Patient-level Effectiveness and Maintenance assessments were most common among drugs requiring patient monitoring. Discussion: Implementation science frameworks, such as RE-AIM, can be applied to characterize REMS assessment measures and identify opportunities for standardizing and strengthening their evaluation. Methods to measure Maintenance are needed to provide real-world evidence of REMS integration into the healthcare system.
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Affiliation(s)
| | - Linda Huynh
- Food and Drug Administration, Silver Spring, MD, United States.,Oak Ridge Institute for Science and Education (ORISE) Program, Silver Spring, MD, United States
| | - Elaine H Morrato
- Food and Drug Administration, Silver Spring, MD, United States.,Colorado School of Public Health, University of Colorado Anschutz Medical, Aurora, CO, United States
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18
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McManus BM, Murphy N, Richardson Z, Khetani MA, Schenkman M, Morrato EH. Family-centred care in early intervention: Examining caregiver perceptions of family-centred care and early intervention service use intensity. Child Care Health Dev 2020; 46:1-8. [PMID: 31782824 PMCID: PMC6949406 DOI: 10.1111/cch.12724] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/15/2019] [Accepted: 11/23/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Family-centred care (FCC) is an approach to paediatric rehabilitation service delivery endorsing shared decision making and effective communication with families. There is great need to understand how early intervention (EI) programmes implement these processes, how EI caregivers perceive them, and how they relate to EI service use. Therefore, the purpose of this study is to examine (a) parent and provider perceptions about EI FCC processes and (b) the association between FCC perceptions and EI service intensity. METHODS In this cross-sectional study, parent perceptions of EI FCC were measured using the electronically administered Measures of Processes of Care (MPOC-56 and MPOC-SP; using 7-point scales). Participants included EI parents (n = 29) and providers (n = 9) from one urban EI programme (1/1/18-6/1/18). We linked survey responses with child characteristics and service use ascertained through EI records. We estimated parent-provider MPOC score correlations and the association between EI service intensity (hr/month) and parent MPOC scores using adjusted linear regression accounting for child characteristics. RESULTS Parents (M = 4.2, SD = 1.1) and providers (M = 5.8, SD = 1.3) reported low involvement related to general information exchange. Parent and provider subscale scores were not correlated except that parent-reported receipt of specific information was inversely associated with provider-reported provision of general information (r = -0.4, P < .05). In adjusted models, parent perceptions related to respectful and supportive (b = 1.57, SE = 0.56) and enabling (b = 1.42, SE = 0.67) care were positively associated with EI intensity, whereas specific information exchange and general information exchange were not associated with intensity. CONCLUSION We found that EI parents and providers reported high levels of investment in the family centredness of their EI care, with the exception of information sharing. Greater EI service intensity was associated with higher perception of involvement with some metrics of family centredness.
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Affiliation(s)
- Beth M. McManus
- Department of Health Systems, Management and Policy, Colorado School of Public Health
| | - Natalie Murphy
- Physical Therapy Program, University of Colorado School of Medicine
| | - Zachary Richardson
- Data Science to Patient Value (D2V), University of Colorado Anschutz Medical Campus
| | - Mary A. Khetani
- Department of Occupational Therapy, University of Illinois at Chicago
| | | | - Elaine H. Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health
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19
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Morrato EH, Hamer MK, Sills M, Kwan B, Schilling LM. Applying a Commercialization-Readiness Framework to Optimize Value for Achieving Sustainability of an Electronic Health Data Research Network and Its Data Capabilities: The SAFTINet Experience. EGEMS (Wash DC) 2019; 7:48. [PMID: 31523697 PMCID: PMC6715936 DOI: 10.5334/egems.295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 06/21/2019] [Indexed: 12/29/2022]
Abstract
CONTEXT Sustaining electronic health data networks and maximizing return on federal investment in their development is essential for achieving national data insight goals for transforming health care. However, crossing the business model chasm from grant funding to self-sustaining viability is challenging. CASE DESCRIPTION This paper presents lessons learned in seeking the sustainability of the Scalable Architecture for Federated Translational Inquiries Network (SAFTINet), and electronic health data network involving over 50 primary care practices in three states. SAFTINet was developed with funding from the Agency for Healthcare Research and Quality to create a multi-state network for comparative effectiveness research (CER) involving safety-net patients. METHODS Three analyses were performed: (1) a product gap analysis of alternative data sources; (2) a Strengths-Weaknesses-Opportunities-Threat (SWOT) analysis of SAFTINet in the context of competing alternatives; and (3) a customer discovery process involving approximately 150 SAFTINet stakeholders to identify SAFTINet's sustaining value proposition for health services researchers, clinical data partners, and policy makers. FINDINGS The results of this business model analysis informed SAFTINet's sustainability strategy. The fundamental high-level product needs were similar between the three primary customer segments: credible data, efficient and easy to use, and relevance to their daily work or 'jobs to be done'. However, how these benefits needed to be minimally demonstrated varied by customer such that different supporting evidence was required. MAJOR THEMES The SAFTINet experience illustrates that commercialization-readiness and business model methods can be used to identify multi-sided value propositions for sustaining electronic health data networks and their data capabilities as drivers of health care transformation.
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Affiliation(s)
- Elaine H. Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, US
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, US
| | - Mika K. Hamer
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, US
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, US
| | - Marion Sills
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, US
- Departments of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, US
| | - Bethany Kwan
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, US
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, US
| | - Lisa M. Schilling
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, US
- Division of Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, US
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20
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McManus BM, Richardson Z, Schenkman M, Murphy N, Morrato EH. Timing and Intensity of Early Intervention Service Use and Outcomes Among a Safety-Net Population of Children. JAMA Netw Open 2019; 2:e187529. [PMID: 30681716 PMCID: PMC6484581 DOI: 10.1001/jamanetworkopen.2018.7529] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Federal per-child early intervention (EI) appropriations have declined, while accountability for improving children's development and function has increased. It is critical to understand high-value EI services and systems. OBJECTIVE To examine EI service timeliness and intensity, and the association between service intensity and outcomes. DESIGN, SETTING, AND PARTICIPANTS This secondary data analysis cohort study linked pediatric primary care electronic health records and EI program records from October 1, 2014, to September 30, 2016. Sample children from a large, urban safety-net health system and EI program who were younger than 35 months with a developmental disability or delay were examined. Data analysis was conducted from December 15, 2017, to May 15, 2018. EXPOSURES The study included measures of condition type and severity, race and ethnicity, family income, insurance type, sex, birth weight, and language. MAIN OUTCOMES AND MEASURES The timeliness of EI (days from referral to EI care plan), service intensity (hours per month) overall and for core EI services (physical, occupational, speech therapy, and developmental intervention), and change in function (measured on a 13-point scale). Adjusted quantile median regression estimated timeliness and intensity. Adjusted linear regression estimated change in function. RESULTS Of the 722 children who received an EI care plan (median [interquartile range] time to receive EI care plan, 56.0 [1.0-111.0] days) 457 (63.3%) were male, 447 (62.0%) were younger than 12 months, 207 (28.7%) were 12 to 24 months, and 68 (9.3%) were 25 to 35 months. A total of 663 children (91.8%) had a household income of less than $20 000 annually; 305 (43%) of the sample children received an EI care plan within the 45-day deadline. Median (interquartile range) for EI intensity was 2.7 (2.3-3.6) hours per month. Children living above the federal poverty threshold received greater occupational therapy intensity (b, 1.9; 95% CI, 0.9-3.0). Greater clinical severity was associated with more timely receipt of an EI care plan. Compared with infants, 2-year-old children received a care plan almost 2 months sooner (b, -52.0; 95% CI, -79.7 to -24.3). An additional hour per month of EI service was associated with a 3-point functional gain (b, 3.0; 95% CI, 1.5-5.9) among children with complete outcomes information (n = 448). CONCLUSIONS AND RELEVANCE In this study, greater EI service intensity was associated with better functional gains, yet most children in the study received delayed care and/or low service intensity. Clinical and EI record linkages could serve as a framework for improving EI processes.
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Affiliation(s)
- Beth M. McManus
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora
| | - Zachary Richardson
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora
| | - Margaret Schenkman
- Physical Therapy Program, University of Colorado School of Medicine, Aurora
| | - Natalie Murphy
- Physical Therapy Program, University of Colorado School of Medicine, Aurora
| | - Elaine H. Morrato
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora
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Abstract
Implementation is the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns. In their article, "Implementation-the missing link in the research translation pipeline," Lynch et al1 report that only a small fraction of published stroke rehabilitation research in leading clinical journals evaluates the implementation of evidence-based interventions into health care practice. Their findings are a wake-up call. If we are to achieve the end goals of our research investment and improve population health, then we need to also ensure that the evidence we generate is translated into real-world use.
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Affiliation(s)
- Elaine H Morrato
- 1 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Visweswaran S, Becich MJ, D'Itri VS, Sendro ER, MacFadden D, Anderson NR, Allen KA, Ranganathan D, Murphy SN, Morrato EH, Pincus HA, Toto R, Firestein GS, Nadler LM, Reis SE. Accrual to Clinical Trials (ACT): A Clinical and Translational Science Award Consortium Network. JAMIA Open 2018; 1:147-152. [PMID: 30474072 PMCID: PMC6241502 DOI: 10.1093/jamiaopen/ooy033] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/15/2018] [Accepted: 07/13/2018] [Indexed: 11/13/2022] Open
Abstract
The Accrual to Clinical Trials (ACT) network is a federated network of sites from the National Clinical and Translational Science Award (CTSA) Consortium that has been created to significantly increase participant accrual to multi-site clinical trials. The ACT network represents an unprecedented collaboration among diverse CTSA sites. The network has created governance and regulatory frameworks and a common data model to harmonize electronic health record (EHR) data, and deployed a set of Informatics for Integrating Biology and the Bedside (i2b2) data repositories that are linked by the Shared Health Research Information Network (SHRINE) platform. It provides investigators the ability to query the network in real time and to obtain aggregate counts of patients who meet clinical trial inclusion and exclusion criteria from sites across the United States. The ACT network infrastructure provides a basis for cohort discovery and for developing new informatics tools to identify and recruit participants for multi-site clinical trials.
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Affiliation(s)
- Shyam Visweswaran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Becich
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Douglas MacFadden
- The Harvard Clinical and Translational Science Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas R Anderson
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Karen A Allen
- Office of Research, University of California, Irvine, California, USA
| | - Dipti Ranganathan
- Academic Information Systems, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shawn N Murphy
- Research Computing, Partners HealthCare, Charlestown, Massachusetts, USA
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Harold A Pincus
- Department of Psychiatry, Columbia University, New York, New York, USA
| | - Robert Toto
- The Center for Translational Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gary S Firestein
- Altman Clinical and Translational Research Institute, University of California, San Diego, California, USA
| | - Lee M Nadler
- The Harvard Clinical and Translational Science Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven E Reis
- The Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Holtrop JS, Ruland S, Diaz S, Morrato EH, Jones E. Using Social Network Analysis to Examine the Effect of Care Management Structure on Chronic Disease Management Communication Within Primary Care. J Gen Intern Med 2018; 33:612-620. [PMID: 29313225 PMCID: PMC5910335 DOI: 10.1007/s11606-017-4247-z] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/19/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Care management and care managers are becoming increasingly prevalent in primary care medical practice as a means of improving population health and reducing unnecessary care. Care managers are often involved in chronic disease management and associated transitional care. In this study, we examined the communication regarding chronic disease care within 24 primary care practices in Michigan and Colorado. We sought to answer the following questions: Do care managers play a key role in chronic disease management in the practice? Does the prominence of the care manager's connectivity within the practice's communication network vary by the type of care management structure implemented? METHODS Individual written surveys were given to all practice members in the participating practices. Survey questions assessed demographics as well as practice culture, quality improvement, care management activities, and communication regarding chronic disease care. Using social network analysis and other statistical methods, we analyzed the communication dynamics related to chronic disease care for each practice. RESULTS The structure of chronic disease communication varies greatly from practice to practice. Care managers who were embedded in the practice or co-located were more likely to be in the core of the communication network than were off-site care managers. These care managers also had higher in-degree centrality, indicating that they acted as a hub for communication with team members in many other roles. DISCUSSION Social network analysis provided a useful means of examining chronic disease communication in practice, and highlighted the central role of care managers in this communication when their role structure supported such communication. Structuring care managers as embedded team members within the practice has important implications for their role in chronic disease communication within primary care.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA.
| | - Sandra Ruland
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA
| | - Stephanie Diaz
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Eric Jones
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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Dew K, Gardner J, Morrato EH, Norris P, Chamberlain K, Hodgetts D, Gabe J. Public engagement and the role of the media in post-marketing drug safety: the case of Eltroxin® (levothyroxine) in New Zealand. Critical Public Health 2017. [DOI: 10.1080/09581596.2017.1329520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kevin Dew
- School of Social and Cultural Studies, Victoria University of Wellington , Wellington, New Zealand
| | - John Gardner
- School of Social Sciences, Monash University , Clayton, Australia
| | - Elaine H. Morrato
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus , Aurora, CO, USA
| | - Pauline Norris
- School of Pharmacy, University of Otago , Dunedin, New Zealand
| | | | - Darrin Hodgetts
- School of Psychology, Massey University , Auckland, New Zealand
| | - Jonathan Gabe
- Criminology and Sociology, School of Law, Royal Holloway, University of London , Egham, UK
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Affiliation(s)
- James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, Aurora2Division of General Pediatrics, University of Colorado Anschutz Medical Campus, Aurora
| | - Elaine H Morrato
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, Aurora3Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Chris Feudtner
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania5Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Morrato EH, Brewer SE, Campagna EJ, Dickinson LM, Thomas DSK, Druss BG, Miller BF, Newcomer JW, Lindrooth RC. Glucose Testing for Adults Receiving Medicaid and Antipsychotics: A Population-Based Prescriber Survey on Behaviors, Attitudes, and Barriers. Psychiatr Serv 2016; 67:798-802. [PMID: 27032657 PMCID: PMC4939591 DOI: 10.1176/appi.ps.201500181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to assess provider attitudes about glucose testing for adults prescribed second-generation antipsychotic medication. METHODS Missouri Medicaid prescribers of antipsychotics in 2011 were surveyed (N=924, 25% response rate). Pearson's chi square test was used to compare responses between prescriber specialty setting. Multivariable log-binomial regression evaluated the association of factors hypothesized as barriers to screening. RESULTS Prescribers in community mental health centers were more likely than primary care providers to report that they would definitely order baseline testing (57% versus 39%, p<.001) and were greater promoters of screening to colleagues (76% versus 49%, p<.001). The strongest predictor of screening intent was disagreeing strongly that "metabolic screening is not a priority for me or my organization" (94% more likely to screen at drug initiation and 74% more likely at annual evaluation, both p<.001). CONCLUSIONS Establishing organizational priority across all treatment settings is important for achieving population-based diabetes screening goals for all Medicaid patients receiving antipsychotics.
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Affiliation(s)
- Elaine H Morrato
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Sarah E Brewer
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Elizabeth J Campagna
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - L Miriam Dickinson
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Deborah S K Thomas
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Benjamin G Druss
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Benjamin F Miller
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - John W Newcomer
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Richard C Lindrooth
- Dr. Morrato and Dr. Lindrooth are with the Colorado School of Public Health and Dr. Dickinson and Dr. Miller are with the Department of Family Medicine, all at the University of Colorado Anschutz Medical Campus, Aurora (e-mail: ). Dr. Morrato and Dr. Dickinson are also with the Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, where Ms. Brewer and Ms. Campagna are affiliated. Dr. Thomas is with the Department of Geography and Environmental Sciences, University of Colorado Denver, Denver. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
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Morrato EH, Campagna EJ, Brewer SE, Dickinson LM, Thomas DSK, Miller BF, Dearing J, Druss BG, Lindrooth RC. Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals. JAMA Psychiatry 2016; 73:721-30. [PMID: 27167755 DOI: 10.1001/jamapsychiatry.2016.0538] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 11/14/2022]
Abstract
IMPORTANCE Medicaid quality indicators track diabetes mellitus and cardiovascular disease screening in adults receiving antipsychotics and/or those with serious mental illness. OBJECTIVE To inform performance improvement interventions by evaluating the relative importance of patient, prescriber, and practice factors affecting metabolic testing. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using Missouri Medicaid administrative claims data (January 1, 2010, to December 31, 2012) linked with prescriber market data. The analysis included 9316 adults (age, 18-64 years) who were starting antipsychotic medication. Secondary analysis included the subset of adults (n = 1813) for whom prescriber knowledge, attitudes, and behavior survey data were available. Generalized estimating equations were performed to identify factors associated with failure to receive annual testing during antipsychotic treatment (adjusted odds ratio [OR], <1 favor testing). Data analysis was performed from October 1, 2014, to February 18, 2016. EXPOSURE Oral second-generation antipsychotics. MAIN OUTCOMES AND MEASURES A medical claim for glucose or lipid testing occurring within 180 days before and after the antipsychotic prescription claim. RESULTS The 9317 patients (mean [SD] age, 37.6 [12.0] years) initiated antipsychotic medication in a variety of prescriber specialty-settings: 24.3%, community mental health center (CMHC); 27.6%, non-CMHC behavioral health; 24.3%, primary care practitioners; and 23.8%, other/unknown. Annual testing rates were 79.6% for glucose and 41.2% for lipids. Failure to test glucose and lipids was most strongly associated with patient factors and health care utilization. To illustrate by using findings from glucose modeling (reported as adjusted OR [95% CI]), lower failure to receive testing was associated with older age (40-49 vs 18-29 years; 0.64 [0.55-0.74]), diagnosis of schizophrenia or bipolar disorder (0.55 [0.44-0.67]), cardiometabolic comorbidity (dyslipidemia, 0.28 [0.22-0.37]), hypertension (0.59 [0.50-0.69]), and greater outpatient utilization (>6 encounters vs none; 0.33 [0.28-0.39]). Analysis incorporating prescriber practice information found lower failure to receive glucose testing if the patient received care at a CMHC (0.74 [0.64-0.85]) or if the initiating prescriber was a primary care practitioner (0.81 [0.66-1.00]). However, the initiating prescriber specialty-setting was not associated with lipid testing. CONCLUSIONS AND RELEVANCE Compared with prior reports, progress has been made to improve diabetes screening, but lipid screening remains particularly underutilized. Medicaid performance improvement initiatives should target all prescriber settings and not just behavioral health.
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Affiliation(s)
- Elaine H Morrato
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora2Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, Univ
| | - Elizabeth J Campagna
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Sarah E Brewer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - L Miriam Dickinson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora3Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical C
| | - Deborah S K Thomas
- Department of Geography and Environmental Sciences, College of Liberal Arts and Sciences, University of Colorado, Denver
| | - Benjamin F Miller
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - James Dearing
- Department of Communication, College of Communication Arts and Sciences, Michigan State University, East Lansing
| | - Benjamin G Druss
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Richard C Lindrooth
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
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Nicol GE, Campagna EJ, Garfield LD, Newcomer JW, Parks JJ, Morrato EH. The Role of Clinical Setting and Management Approach in Metabolic Testing Among Youths and Adults Treated With Antipsychotics. Psychiatr Serv 2016; 67:128-32. [PMID: 26325456 PMCID: PMC4701636 DOI: 10.1176/appi.ps.201400428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/30/2022]
Abstract
OBJECTIVE This study compared metabolic screening among patients who received antipsychotic treatment at community mental health centers (CMHCs), with or without case management, and patients treated elsewhere. METHODS Rates of glucose and lipid testing among youths and adults in Missouri Medicaid (N=9,473) who received antipsychotic treatment at CMHCs, with and without case management, were evaluated. Multivariable logistic regressions determined which characteristics were independently associated with metabolic testing. RESULTS A total of 37.0% and 17.3% of youths and 68.7% and 34.9% of adults had glucose and lipid testing, respectively. Compared with treatment elsewhere, treatment at CMHCs, with or without case management, respectively, was associated with higher odds of glucose testing (youths, adjusted odds ratio [AOR]=1.68 and 1.89; adults, AOR=1.43 and 1.44) and lipid testing (youths, AOR=2.40 and 2.35; adults, AOR=1.97 and 1.48). CONCLUSIONS CMHCs had higher rates of metabolic testing, possibly reflecting Missouri's efforts to promote testing in these settings.
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Affiliation(s)
- Ginger E Nicol
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
| | - Elizabeth J Campagna
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
| | - Lauren D Garfield
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
| | - John W Newcomer
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
| | - Joseph J Parks
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
| | - Elaine H Morrato
- Dr. Nicol is with the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (e-mail: ). Ms. Campagna and Dr. Morrato are with the Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Denver. Dr. Garfield is with Mercy Virtual Care Center, St. Louis. Dr. Newcomer is with the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton. Dr. Parks is with MO HealthNet, Missouri Department of Social Services, Jefferson City, and with the Missouri Institute of Mental Health, University of Missouri-St. Louis
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Merchant AT, Nahhas GJ, Wadwa RP, Zhang J, Tang Y, Johnson LR, Maahs DM, Bishop F, Teles R, Morrato EH. Periodontal Microorganisms and Cardiovascular Risk Markers in Youth With Type 1 Diabetes and Without Diabetes. J Periodontol 2015; 87:376-84. [PMID: 26616842 DOI: 10.1902/jop.2015.150531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 01/28/2023]
Abstract
BACKGROUND A subset of periodontal microorganisms has been associated with cardiovascular disease (CVD), which is the leading complication of type 1 diabetes (t1DM). The authors therefore evaluated the association between periodontal microorganism groups and early markers of CVD in youth with t1DM. METHODS A cross-sectional analysis was conducted among youth aged 12 to 19 years at enrollment; 105 had t1DM for ≥5 years and were seeking care at the Barbara Davis Center, University of Colorado, from 2009 to 2011, and 71 did not have diabetes. Subgingival plaque samples were assessed for counts of 41 periodontal microorganisms using DNA-DNA hybridization. Microorganisms were classified using cluster analysis into four groups named red-orange, orange-green, blue/other, and yellow/other, modified from Socransky's color scheme for periodontal microorganisms. Subsamples (54 with t1DM and 48 without diabetes) also received a periodontal examination at the University of Colorado School of Dental Medicine. RESULTS Participants were ≈15 years old on average, and 74% were white. Mean periodontal probing depth was 2 mm (SE 0.02), and 17% had bleeding on probing. In multivariable analyses, glycated hemoglobin (HbA1c) was inversely associated with the yellow/other cluster (microorganisms that are not associated with periodontal disease) among youth with t1DM. Blood pressure, triglycerides, low-density lipoprotein, high-density lipoprotein, and total cholesterol were not associated with microorganism clusters in this group. HbA1c was not associated with periodontal microorganism clusters among youth without diabetes. CONCLUSION Among youth with t1DM who had good oral health, periodontal microorganisms were not associated with CVD risk factors.
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Affiliation(s)
- Anwar T Merchant
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC
| | - Georges J Nahhas
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC
| | - R Paul Wadwa
- University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Jiajia Zhang
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC
| | - Yifan Tang
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC
| | | | - David M Maahs
- University of Colorado, Anschutz Medical Campus, Aurora, CO
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Morrato EH, Rabin B, Proctor J, Cicutto LC, Battaglia CT, Lambert-Kerzner A, Leeman-Castillo B, Prahl-Wretling M, Nuechterlein B, Glasgow RE, Kempe A. Bringing it home: expanding the local reach of dissemination and implementation training via a university-based workshop. Implement Sci 2015; 10:94. [PMID: 26141909 PMCID: PMC4490605 DOI: 10.1186/s13012-015-0281-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [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: 10/19/2014] [Accepted: 06/15/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Currently, national training programs do not have the capacity to meet the growing demand for dissemination and implementation (D&I) workforce education and development. The Colorado Research in Implementation Science Program (CRISP) developed and delivered an introductory D&I workshop adapted from national programs to extend training reach and foster a local learning community for D&I. METHODS To gauge interest and assess learning needs, a pre-registration survey was administered. Based on feedback, a 1.5-day workshop was designed. Day 1 introduced D&I frameworks, strategies, and evaluation principles. Local and national D&I experts provided ignite-style talks on key lessons followed by panel discussion. Breakout sessions discussed community engagement and applying for D&I grants. A workbook was developed to enhance the training and provided exercises for application to an individual's projects. Day 2 offered expert-led mentoring sessions with selected participants who desired advanced instruction. Two follow-up surveys (immediate post-workshop, 6 months) assessed knowledge gained from participation and utilization of workshop content. RESULTS Ninety-three workshop registrants completed an assessment survey to inform workshop objectives and curriculum design; 43 % were new and 54 % reported a basic understanding of the D&I field. Pre-registrants intended to use the training to "apply for a D&I grant" (73 %); "incorporate D&I into existing projects" (76 %), and for quality improvement (51 %). Sixty-eight individuals attended Day 1; 11 also attended Day 2 mentoring sessions. In the 1-week post-workshop survey (n = 34), 100 % strongly agreed they were satisfied with the training; 97 % strongly agreed the workshop workbook was a valuable resource. All Day 2 participants strongly agreed that working closely with faculty and experts increased their overall confidence. In the 6-month follow-up evaluation (n = 23), evidence of new D&I-related manuscripts and grant proposals was found. Training materials were published online ( www.ucdenver.edu/implementation/workshops ) and disseminated via the National Institutes of Health (NIH) Clinical and Translational Science Awards Consortium. To sustain reach, CRISP adapted the materials into an interactive e-book ( www.CRISPebooks.org ) and launched a new graduate course. CONCLUSIONS Local D&I training workshops can extend the reach of national training programs.
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Affiliation(s)
- Elaine H Morrato
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA.
- Colorado Research in Implementation Science Program, Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Borsika Rabin
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
- Colorado Research in Implementation Science Program, Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Health Care System, Denver, CO, USA
- Denver Seattle Center for Veteran-centric Value-based Research (DiSCoVVR), Denver, CO, USA
| | - Jeff Proctor
- The Evaluation Center, School of Education and Human Development, University of Colorado Denver, Denver, CO, USA
| | - Lisa C Cicutto
- Clinical Science Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- National Jewish Health, Denver, CO, USA
| | - Catherine T Battaglia
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
- VA Eastern Colorado Health Care System, Denver, CO, USA
- Denver Seattle Center for Veteran-centric Value-based Research (DiSCoVVR), Denver, CO, USA
- Clinical Science Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anne Lambert-Kerzner
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
- VA Eastern Colorado Health Care System, Denver, CO, USA
- Denver Seattle Center for Veteran-centric Value-based Research (DiSCoVVR), Denver, CO, USA
| | | | - Michelle Prahl-Wretling
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
| | - Bridget Nuechterlein
- The Evaluation Center, School of Education and Human Development, University of Colorado Denver, Denver, CO, USA
| | - Russell E Glasgow
- Colorado Research in Implementation Science Program, Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Allison Kempe
- Colorado Research in Implementation Science Program, Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Morrato EH, Parks J, Campagna EJ, Muser E, Thomas DSK, Fang H, Doshi D. Comparative effectiveness of injectable paliperidone palmitate versus oral atypical antipsychotics: early postmarketing evidence. J Comp Eff Res 2015; 4:89-99. [DOI: 10.2217/cer.14.50] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To provide comparative effectiveness evidence for long-acting injectable paliperidone palmitate versus oral atypical antipsychotics. Patients & methods: We performed a retrospective, observational cohort study using patient claims data from Missouri Medicaid to compare the likelihood of emergency department (ED) visits and hospitalizations in the year following drug initiation using multivariable logistic regression. Results: Adjusted odds ratios (AOR) for ED visits (AOR: 0.63; 95% CI: 0.47–0.85) and hospitalizations (AOR: 0.85; 95% CI: 0.64–1.13) were lower in paliperidone palmitate patients, although hospitalizations did not achieve statistical significance. Sensitivity analyses examining mental health-related outcomes and using different analytic strategies for patient selection bias showed directionally similar beneficial effects but were not statistically significant. Conclusion: Early evidence for paliperidone palmitate under real-world conditions is encouraging. However, caution should be taken until additional research substantiates the findings with greater certainty.
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Affiliation(s)
- Elaine H Morrato
- Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
- Colorado Health Outcomes Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Joe Parks
- Missouri Institute of Mental Health, University of Missouri St. Louis, St. Louis, MO, USA
| | - Elizabeth J Campagna
- Colorado Health Outcomes Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Erik Muser
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | - Hai Fang
- Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Dilesh Doshi
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Morrato EH, Smith MY. Integrating risk minimization planning throughout the clinical development and commercialization lifecycle: an opinion on how drug development could be improved. Ther Clin Risk Manag 2015; 11:339-48. [PMID: 25750537 PMCID: PMC4348129 DOI: 10.2147/tcrm.s78202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pharmaceutical risk minimization programs are now an established requirement in the regulatory landscape. However, pharmaceutical companies have been slow to recognize and embrace the significant potential these programs offer in terms of enhancing trust with health care professionals and patients, and for providing a mechanism for bringing products to the market that might not otherwise have been approved. Pitfalls of the current drug development process include risk minimization programs that are not data driven; missed opportunities to incorporate pragmatic methods and market-based insights, outmoded tools and data sources, lack of rapid evaluative learning to support timely adaption, lack of systematic approaches for patient engagement, and questions on staffing and organizational infrastructure. We propose better integration of risk minimization with clinical drug development and commercialization work streams throughout the product lifecycle. We articulate a vision and propose broad adoption of organizational models for incorporating risk minimization expertise into the drug development process. Three organizational models are discussed and compared: outsource/external vendor, embedded risk management specialist model, and Center of Excellence.
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Affiliation(s)
- Elaine H Morrato
- Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Root ED, Thomas DSK, Campagna EJ, Morrato EH. Adjusting for geographic variation in observational comparative effectiveness studies: a case study of antipsychotics using state Medicaid data. BMC Health Serv Res 2014; 14:355. [PMID: 25164423 PMCID: PMC4161848 DOI: 10.1186/1472-6963-14-355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 11/20/2013] [Accepted: 07/29/2014] [Indexed: 11/24/2022] Open
Abstract
Background Area-level variation in treatment and outcomes may be a potential source of confounding bias in observational comparative effectiveness studies. This paper demonstrates how to use exploratory spatial data analysis (ESDA) and spatial statistical methods to investigate and control for these potential biases. The case presented compares the effectiveness of two antipsychotic treatment strategies: oral second-generation antipsychotics (SGAs) vs. long-acting paliperiodone palmitate (PP). Methods A new-start cohort study was conducted analyzing patient-level administrative claims data (8/1/2008–4/30/2011) from Missouri Medicaid. ESDA techniques were used to examine spatial patterns of antipsychotic prescriptions and outcomes (hospitalization and emergency department (ED) visits). Likelihood of mental health-related outcomes were compared between patients starting PP (N = 295) and oral SGAs (N = 8,626) using multilevel logistic regression models adjusting for patient composition (demographic and clinical factors) and geographic region. Results ESDA indicated significant spatial variation in antipsychotic prescription patterns and moderate variation in hospitalization and ED visits thereby indicating possible confounding by geography. In the multilevel models for this antipsychotic case example, patient composition represented a stronger source of confounding than geographic context. Conclusion Because geographic variation in health care delivery is ubiquitous, it could be a comparative effectiveness research (CER) best practice to test for possible geographic confounding in observational data. Though the magnitude of the area-level geography effects were small in this case, they were still statistically significant and should therefore be examined as part of this observational CER study. More research is needed to better estimate the range of confounding due to geography across different types of observational comparative effectiveness studies and healthcare utilization outcomes. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-355) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elisabeth Dowling Root
- Department of Geography and Institute for Behavioral Science, University of Colorado at Boulder, Boulder, CO 80309, USA.
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Campagna EJ, Muser E, Parks J, Morrato EH. Methodological considerations in estimating adherence and persistence for a long-acting injectable medication. J Manag Care Spec Pharm 2014; 20:756-66. [PMID: 24967528 PMCID: PMC10437404 DOI: 10.18553/jmcp.2014.20.7.756] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Measures of medication adherence and persistence are important for researchers and policymakers to assess quality of care. Lack of adherence has been associated with adverse outcomes and higher costs of care. Long-acting medication formulations, including injectable forms, have been proposed as interventions to increase adherence and in turn improve health outcomes and costs. Standard measures of adherence/persistence were developed for orally administered medications. Methods for assessing adherence/persistence of long-acting injectable dose forms are understudied. OBJECTIVE To compare the consistency between standard measures of adherence/persistence versus proposed variations that consider the data quality and injectable administration method for a long-acting injectable second-generation antipsychotic (SGA) using an orally administered SGA as the reference. METHODS Standard adherence/persistence measures were designed for oral tablet formulations, in particular accounting for accumulation of pills caused by early refills. To address this limitation and the accuracy of the days supply field for long-acting injectable SGAs in pharmacy claims, 2 alternatives are proposed. The first approach calculates days supply using the labeled dosing schedule for the given injectable. The second approach builds on the first and sets days supply to the minimum of the time between injections and the time frame according to the labeled dosing schedule. Administrative health care claims data from the Missouri Medicaid system were analyzed to compare adherence/persistence measures between formulations. Common adherence/persistence measures, including medication possession ratio (MPR) and proportion of days covered (PDC), were evaluated in this study. The analysis cohorts comprised 195 adult patients with schizophrenia who initiated a long-acting injectable SGA (LA-SGA) and 369 patients initiating an oral SGA (O-SGA) from August 1, 2009, through April 30, 2010. Chi-squared tests, the Kruskal-Wallis test, and Kaplan-Meier curves were used to compare adherence/persistence measures between cohorts. RESULTS Days supply was most frequently recorded as 30 days for O-SGA and 28 days for LA-SGA. Time between claim fills was most commonly 28 days for both cohorts. Using the LA-SGA pharmacy claims data, MPR was 0.91 and did not vary significantly from MPR of O-SGA (0.90; test statistic = 0.29, P = 0.590). When applying the labeled dosing schedule to compute days supply, the LA-SGA MPR rose to 0.97 and varied significantly from MPR of O-SGA (test statistic = 9.60, P = 0.002). Additionally controlling for the inability for excess medication accumulation, MPR for LA-SGA dropped to 0.86, which varied significantly from MPR of O-SGA (test statistic = 4.01, P = 0.045). PDC varied from 0.55 to 0.61 for LA-SGA but was consistently significantly different from the 0.37 PDC value of O-SGA (P less than 0.05 for each comparison). CONCLUSIONS Standard medication adherence/persistence measures yielded different conclusions when comparing a LA-SGA and an O-SGA, depending on the measure and underlying assumption for days supply. Adherence/persistence measures that address pharmacological differences in terms of formulation and duration of therapeutic drug levels between medications may be necessary and are particularly important as more injectable antipsychotic medications are approved in the United States. Therefore, payers and investigators should consider sensitivity analysis using different adherence/persistence definitions when making product comparisons to ensure confidence in conclusions.
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Affiliation(s)
- Elizabeth J. Campagna
- University of Colorado Anschutz Medical Campus, 13199 E. Montview Blvd., Ste. 300, MS F443, Aurora, CO 80045.
| | - Erik Muser
- University of Colorado Anschutz Medical Campus, 13199 E. Montview Blvd., Ste. 300, MS F443, Aurora, CO 80045.
| | - Joseph Parks
- University of Colorado Anschutz Medical Campus, 13199 E. Montview Blvd., Ste. 300, MS F443, Aurora, CO 80045.
| | - Elaine H. Morrato
- University of Colorado Anschutz Medical Campus, 13199 E. Montview Blvd., Ste. 300, MS F443, Aurora, CO 80045.
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Morrato EH, Concannon TW, Meissner P, Shah ND, Turner BJ. Dissemination and implementation of comparative effectiveness evidence: key informant interviews with Clinical and Translational Science Award institutions. J Comp Eff Res 2014; 2:185-94. [PMID: 24236560 DOI: 10.2217/cer.13.10] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To identify ongoing practices and opportunities for improving national comparative effectiveness research (CER) translation through dissemination and implementation (D&I) via NIH-funded Clinical and Translational Science Award (CTSA) institutions. MATERIALS & METHODS Key informant interviews were conducted with 18 CTSA grantees sampled to represent a range of D&I efforts. RESULTS & CONCLUSIONS The institutional representatives endorsed fostering CER translation nationally via the CTSA Consortium. However, five themes emerged from the interviews as barriers to CER D&I: lack of institutional awareness, insufficient capacity, lack of established D&I methods, confusion among stakeholders about what CER actually is and limited funding opportunities. Interviewees offered two key recommendations to improve CER translation: development of a centralized clearing house to facilitate the diffusion of CER D&I resources and methods across CTSA institutions; and formalization of the national CTSA network to leverage existing community engagement relationships and resources for the purpose of adapting and disseminating robust CER evidence locally with providers, patients and healthcare systems.
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Affiliation(s)
- Elaine H Morrato
- Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, CO, USA.
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Barnard JG, Albright K, Morrato EH, Nowels CT, Benefield EM, Hadley-Miller NA, Kempe A, Erickson MA. Paediatric spinal fusion surgery and the transition to home-based care: provider expectations and carer experiences. Health Soc Care Community 2013; 21:634-643. [PMID: 23647700 DOI: 10.1111/hsc.12049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/05/2013] [Indexed: 06/02/2023]
Abstract
There are more than 12 million children with special healthcare needs (CSHCNs) in the United States, many of whom require specialised health-care to treat chronic physical and developmental conditions. This study is a qualitative investigation of programme, surgical and at-home recovery experiences among CSHCNs and their family carers who participated in a spine surgical care programme at a paediatric hospital in the Western United States. The programme is designed to manage increased surgical risk and the transition of care from hospital to home for children with severe scoliosis undergoing spinal fusion surgery. We conducted 30 semi-structured in-depth interviews with 14 surgical team members and 16 family carers of children who had programme evaluations and spinal surgeries in 2006. Data were collected in 2008 and 2009 in hospital or at home locations to gather programme participation feedback from families and inform the adequacy of programme support to families during at-home recovery. Data were analysed by reflexive team and content analysis methodologies. Results showed the programme was effective at improving preoperative surgical evaluation and helping families to anticipate some aspects of the surgical experience and hospital discharge. However, the impact of spinal fusion surgery and the subsequent transition to home-based care was profoundly emotional for patients and their carers. Our data indicate that programme providers underestimated the extent of emotional trauma experienced by patients and families, particularly during the at-home recovery process. The data also suggest meaningful differences in providers' and carers' expectations for surgery. Carers' disappointment with their recovery experiences and the perceived lack of post-discharge support impacted their interpretations of and perspectives on their surgical experience. Implications of this research for surgical care programmes include the need for assessment and provision of support for physical, social, and emotional burdens experienced by patients and carers at pre-surgical, surgical and at-home recovery phases.
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Affiliation(s)
- Juliana G Barnard
- Children's Outcomes Research Program, Children's Hospital Colorado, Aurora, CO, USA
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Victoroff MS, Drury BM, Campagna EJ, Morrato EH. Impact of electronic health records on malpractice claims in a sample of physician offices in Colorado: a retrospective cohort study. J Gen Intern Med 2013; 28:637-44. [PMID: 23192449 PMCID: PMC3631062 DOI: 10.1007/s11606-012-2283-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 08/15/2012] [Accepted: 10/29/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Electronic health records (EHRs) might reduce medical liability claims and potentially justify premium credits from liability insurers, but the evidence is limited. OBJECTIVES To evaluate the association between EHR use and medical liability claims in a population of office-based physicians, including claims that could potentially be directly prevented by features available in EHRs ("EHR-sensitive" claims). DESIGN Retrospective cohort study of medical liability claims and analysis of claim abstracts. PARTICIPANTS The 26 % of Colorado office-based physicians insured through COPIC Insurance Company who responded to a survey on EHR use (894 respondents out of 3,502 invitees). MAIN MEASURES Claims incidence rate ratio (IRR); prevalence of "EHR-sensitive" claims. KEY RESULTS 473 physicians (53 % of respondents) used an office-based EHR. After adjustment for sex, birth cohort, specialty, practice setting and use of an EHR in settings other than an office, IRR for all claims was not significantly different between EHR users and non-users (0.88, 95 % CI 0.52-1.46; p = 0.61), or for users after EHR implementation as compared to before (0.73, 95 % CI 0.41-1.29; p = 0.28). Of 1,569 claim abstracts reviewed, 3 % were judged "Plausibly EHR-sensitive," 82 % "Unlikely EHR-sensitive," and 15 % "Unable to determine." EHR-sensitive claims occurred in six out of 633 non-users and two out of 251 EHR users. Incidence rate ratios were 0.01 for both groups. CONCLUSIONS Colorado physicians using office-based EHRs did not have significantly different rates of liability claims than non-EHR users; nor were rates different for EHR users before and after EHR implementation. The lack of significant effect may be due to a low prevalence of EHR-sensitive claims. Further research on EHR use and medical liability across a larger population of physicians is warranted.
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Affiliation(s)
- Michael S Victoroff
- Department of Family Medicine, University of Colorado School of Medicine, 5195 E. Weaver Dr., Centennial, CO 80121-3500, USA.
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Affiliation(s)
- Elaine H. Morrato
- Department of Health Systems, Management, and Policy, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - David B. Allison
- Office of Energetics, Nutrition & Obesity Research Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Sømme S, Bronsert M, Kempe A, Morrato EH, Ziegler M. Alignment of training curriculum and surgical practice: implications for competency, manpower, and practice modeling. Eur J Pediatr Surg 2012; 22:74-9. [PMID: 22434230 DOI: 10.1055/s-0032-1306262] [Citation(s) in RCA: 17] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The attractiveness of pediatric surgery (PS) as a specialty includes its primary role in the care of multisystemic disease. We were interested in identifying changes in operative case quality and quantity when comparing PS residents to PS practitioners. METHODS The 2006 Accreditation Council for Graduate Medical Education PS resident current procedural terminology (CPT) code database (26,077 resident cases) was merged with the 2006 Kids' Inpatient Database of International Classification of Diseases (ICD)-9 procedure codes (230,504 practitioner cases) and categorized by case type and volumes according to a resident CPT reference file. Cases were categorized into 84 procedure types. A recent estimate of 691 practicing pediatric surgeons was used as denominator to calculate case volume per surgeon. Our analysis focused on the PS index cases and we compared PS residents to subspecialty board certified general pediatric surgeons in practice. We excluded cases that may be performed by general surgeons without PS training. RESULTS Our data indicate that, on average, 501 cases are performed annually by each PS resident. We identified significant differences in case volume per surgeon between training and practice for most PS index cases.CONCLUSIONS The PS index case quantity declined significantly from training to practice. If a volume to outcome relationship applies to these complex and infrequent PS cases, then to sustain and improve clinical quality post-training will require a new paradigm of continued learning. Additionally, a relook at the optimal manpower and more focused regionalization is warranted.
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Affiliation(s)
- S Sømme
- Department of Pediatric Surgery, The Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado 80045, USA.
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Gohlke JM, Dhurandhar EJ, Correll CU, Morrato EH, Newcomer JW, Remington G, Nasrallah HA, Crystal S, Nicol G, Allison DB. Recent advances in understanding and mitigating adipogenic and metabolic effects of antipsychotic drugs. Front Psychiatry 2012; 3:62. [PMID: 22754543 PMCID: PMC3385013 DOI: 10.3389/fpsyt.2012.00062] [Citation(s) in RCA: 22] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 06/06/2012] [Indexed: 12/19/2022] Open
Abstract
Although offering many benefits for several psychiatric disorders, antipsychotic drugs (APDs) as a class have a major liability in their tendency to promote adiposity, obesity, and metabolic dysregulation in an already metabolically vulnerable population. The past decade has witnessed substantial research aimed at investigating the mechanisms of these adverse effects and mitigating them. On July 11 and 12, 2011, with support from 2 NIH institutes, leading experts convened to discuss current research findings and to consider future research strategies. Five areas where significant advances are being made emerged from the conference: (1) methodological issues in the study of APD effects; (2) unique characteristics and needs of pediatric patients; (3) genetic components underlying susceptibility to APD-induced metabolic effects; (4) APD effects on weight gain and adiposity in relation to their acute effects on glucose regulation and diabetes risk; and (5) the utility of behavioral, dietary, and pharmacological interventions in mitigating APD-induced metabolic side effects. This paper summarizes the major conclusions and important supporting data from the meeting.
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Affiliation(s)
- Julia M Gohlke
- Department of Environmental Health Sciences, School of Public Health, University of Alabama at Birmingham Birmingham, AL, USA
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Merchant AT, Oranbandid S, Jethwani M, Choi YH, Morrato EH, Pitiphat W, Mayer-Davis EJ. Oral care practices and A1c among youth with type 1 and type 2 diabetes. J Periodontol 2011; 83:856-63. [PMID: 22141359 DOI: 10.1902/jop.2011.110416] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Periodontal treatment is associated with lower hemoglobin A1c in individuals with diabetes, but the relationship between oral hygiene practices and A1c among youth with diabetes is understudied. METHODS This study evaluates the cross-sectional relationships among oral health habits, reported oral conditions, and A1c and control of diabetes among a subset of youth with diabetes enrolled in the SEARCH for Diabetes in Youth study in South Carolina. Oral hygiene practices were determined by questionnaire, and periodontal bone loss was defined as alveolar bone loss ≥3 mm on ≥1 permanent tooth site on preexisting bitewing radiographs. A1c was considered controlled if individuals were aged ≤6 years with A1c <8.5%; aged 7 to 11 years with A1c <8.0%; aged 12 to 18 years with A1c <7.5%; and aged ≥19 years with A1c <7.0%. RESULTS Among 155 participants, 68% brushed their teeth no less than once daily, 84% flossed, and 70% rinsed, respectively, less than once a week. Diabetes control was associated with toothbrushing (≥1 time daily [odds ratio (OR) = 3.10; 95% confidence interval (CI) = 1.26 to 7.62] and using mouthrinse at least once weekly (OR = 3.33; 95% CI = 1.30 to 8.54) after multivariate adjustment. Periodontal bone loss was three times more common among those with dry mouth (OR = 3.05; 95% CI = 1.07 to 8.70). CONCLUSIONS Clinicians should be aware that children with diabetes tend to have poor oral hygiene practices. Dry mouth may indicate periodontal bone loss in children with diabetes.
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Affiliation(s)
- Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health and Center for Research in Nutrition and Health Disparities, University of South Carolina, Columbia, South Carolina 29208, USA.
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Merchant AT, Jethwani M, Choi YH, Morrato EH, Liese AD, Mayer-Davis E. Associations between periodontal disease and selected risk factors of early complications among youth with type 1 and type 2 diabetes: a pilot study. Pediatr Diabetes 2011; 12:529-35. [PMID: 21392193 DOI: 10.1111/j.1399-5448.2010.00736.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [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: 11/26/2022] Open
Abstract
BACKGROUND Most studies evaluating the relation between periodontal disease and diabetes in children have not considered diabetes type. OBJECTIVE To evaluate the relationship between periodontal damage and risk factors of diabetes complications among youth by diabetes type in a pilot study. SUBJECTS 155 participants (126 with type 1 diabetes; 29 with type 2 diabetes) from the SEARCH for Diabetes in Youth study in South Carolina who were <20 yr of age at diagnosis. METHODS Cross-sectional analysis of periodontal damage (bone loss ≥3 mm on ≥1 permanent tooth site on pre-existing bitewing radiographs) and diabetes type assigned by the provider at diagnosis. RESULTS Periodontal damage was observed in 52 individuals (34%) overall, but was more common in type 2 (16/29, 55%) vs. type 1 diabetes (37/126, 29%). Among youth with type 2 diabetes, those with periodontal damage had lower fasting c-peptide (2.3 vs. 3.4 ng/mL, p-value=0.01), and higher triglyceride levels (171.8 vs. 87.2, p-value=0.01) than those without periodontal damage after adjustment for age, sex, race, education level, family income, duration of diabetes, diabetes control, time between study visit and date of radiograph, tooth brushing, and visits to the dentist. Blood pressure, waist circumference, LDL cholesterol and A1c were not associated with periodontal damage. CONCLUSIONS The associations between periodontal disease and risk factors for diabetes complications differ by diabetes type. Periodontal damage is associated with impaired beta cell function and metabolic syndrome components in type 2 but not type 1 diabetes. These findings need to be confirmed in larger, prospective studies.
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Affiliation(s)
- Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health and Center for Research in Nutrition and Health Disparities, University of South Carolina, Columbia, SC 29208, USA.
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Nicol GE, Morrato EH, Johnson MC, Campagna E, Yingling MD, Pham V, Newcomer JW. Best practices: implementation of a glucose screening program based on diffusion of innovation theory methods. Psychiatr Serv 2011; 62:12-4. [PMID: 21209293 DOI: 10.1176/ps.62.1.pss6201_0012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [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: 11/30/2022]
Abstract
There is public health interest in the identification and treatment of modifiable cardiometabolic risk factors among patients treated with antipsychotic medications. However, best-practice screening recommendations endorsed by multiple medical organizations have not translated into real-world clinical practice. Quality improvement strategies may help to address the gap between policy and implementation. This column describes the successful implementation of a best-practice glucose screening program in a large network of community mental health centers that was based on Six Sigma and diffusion of innovation theory.
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Affiliation(s)
- Ginger E Nicol
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8134, St. Louis, MO 63110, USA.
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Morrato EH, Druss BG, Hartung DM, Valuck RJ, Thomas D, Allen R, Campagna E, Newcomer JW. Small area variation and geographic and patient-specific determinants of metabolic testing in antipsychotic users. Pharmacoepidemiol Drug Saf 2010; 20:66-75. [PMID: 21182154 DOI: 10.1002/pds.2062] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 08/13/2010] [Accepted: 09/07/2010] [Indexed: 11/07/2022]
Abstract
PURPOSE The American Diabetes Association and American Psychiatric Association recommend metabolic monitoring for all patients using second-generation antipsychotic (SGA) drugs. We estimated glucose and lipid testing rates among SGA-users from three state Medicaid programs and investigated small area variation and patient and geographic determinants of testing. METHODS A retrospective new-user cohort study using Medicaid claims data from California, Missouri, and Oregon was conducted among 30,563 patients in 207 counties starting SGA medication September 2004-December 2005. Adjusted odds ratios for state, county, and patient factors associated with testing were calculated from multivariable hierarchical logistic regression models. RESULTS Mean 6-month testing rates were 51.6% (glucose) and 26.2% (lipids). Screening rates were positively associated with the number of Type 2 diabetes risk factors (RF) present: glucose -39% (0 RF) to 82% (5 RF); lipids -13% (0 RF) to 66% (5 RF). A four-fold difference in glucose testing rates (21-85%) and a greater than six-fold difference in lipid testing rates (0-62%) were observed between counties. In the adjusted regression models, age, cardiometabolic co-morbidity (diabetes, dyslipidemia), serious mental illness, persistent use of SGAs, and frequency of non-psychiatric medical office visits were significant determinants of glucose and lipid testing. Lipid testing was more likely for children and adults in California, as was glucose testing for children. CONCLUSIONS Glucose and lipid testing among SGA-users varied significantly between states, counties, and by patient characteristics. More effort is needed to understand provider and system reasons for testing disparities in order to inform risk management quality improvement interventions.
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Affiliation(s)
- Elaine H Morrato
- Department of Health Systems, Colorado School of Public Health, University of Colorado Denver, Aurora, CO 80045, USA.
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Morrato EH, Nicol GE, Maahs D, Druss BG, Hartung DM, Valuck RJ, Campagna E, Newcomer JW. Metabolic screening in children receiving antipsychotic drug treatment. ACTA ACUST UNITED AC 2010; 164:344-51. [PMID: 20368487 DOI: 10.1001/archpediatrics.2010.48] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To estimate metabolic screening rates, predictors of screening, and incidence of metabolic disturbances in children initiating second-generation antipsychotic (SGA) drug treatment. DESIGN A retrospective, new-user cohort study (between July 1, 2004, and June 30, 2006) using Medicaid claims data. SETTINGS California, Missouri, and Oregon. PATIENTS A total of 5370 children (aged 6-17 years) without diabetes mellitus taking SGA drugs and 15,000 children without diabetes taking albuterol (control individuals) [corrected] but no SGA drugs. INTERVENTION Findings 1 year after recommendations from the American Diabetes Association and American Psychiatric Association called for metabolic screening of patients receiving SGA drugs. OUTCOME MEASURES Serum glucose and lipid testing, 6-month incidence of diabetes, and dyslipidemia disturbances. RESULTS Glucose screening was performed in 1699 (31.6% [95% confidence interval (CI), 30.4%-32.9%]) SGA-treated children vs 1891 (12.6% [12.1%-13.2%]) control individuals. Lipid testing was performed in 720 (13.4% [95% CI, 12.5%-14.4%]) SGA-treated children vs 458 (3.1% [2.8%-3.3%]) controls. In multivariate logistic regression analysis, children with serious and/or multiple psychiatric diagnoses and those who used health care services more intensively were more likely to receive metabolic screening. The case incidence of glucose and lipid disorders was higher in SGA-treated vs albuterol-treated children (8.9 per 1000 children [95% CI, 6.6%-11.8%] vs 4.9 per 1000 children [3.9%-6.2%]; and 9.7 per 1000 children [95% CI, 7.2%-12.7%] vs 4.6 per 1000 children [95% CI, 3.6%-5.8%], respectively). CONCLUSION Most children starting treatment with SGA medications in this public sector sample did not receive recommended glucose and lipid screening.
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Affiliation(s)
- Elaine H Morrato
- Department of Health Systems, Management,and Policy, Colorado School of Public Health, University of Colorado at Denver, Aurora, Colorado 80045, USA.
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Morrato EH, Druss B, Hartung DM, Valuck RJ, Allen R, Campagna E, Newcomer JW. Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Arch Gen Psychiatry 2010; 67:17-24. [PMID: 20048219 DOI: 10.1001/archgenpsychiatry.2009.179] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT In 2003, the Food and Drug Administration (FDA) required a warning on diabetes risk for second-generation antipsychotic (SGA) drugs. The American Diabetes Association (ADA) and American Psychiatric Association (APA) recommended glucose and lipid testing for all patients starting to receive SGA drugs. OBJECTIVE To characterize associations between the combined warnings and recommendations and baseline metabolic testing and SGA drug selection. DESIGN Interrupted time-series analysis. SETTING California, Missouri, and Oregon. Patients A total of 109 451 individuals receiving Medicaid who began taking SGA medication and a control cohort of 203 527 patients who began taking albuterol but did not receive antipsychotic medication. INTERVENTIONS Prewarning and postwarning trends in metabolic testing were compared using laboratory claims for the cohort collected January 1, 2002, through December 31, 2005. Changes in SGA prescribing practices were similarly evaluated. MAIN OUTCOME MEASURES Monthly rates of baseline serum glucose and lipid testing for SGA-treated and propensity-matched albuterol-treated patients and monthly share of new prescriptions for each SGA drug. RESULTS Initial testing rates for SGA-treated patients were low (glucose, 27%; lipids, 10%). The warning was not associated with an increase in glucose testing among SGA-treated patients and was associated with only a marginal increase in lipid testing rates (1.7%; P = .02). Testing rates and trends in SGA-treated patients were not different from background rates observed in the albuterol control group. New prescriptions of olanzapine (higher metabolic risk) declined during the warning period (annual share decline, 19.9%; P < .001). New prescriptions of aripiprazole (lower metabolic risk) increased during the warning period (share increase, 12.1%; P < .001) but may be attributable to the elimination of prior authorization in California during the same time frame. Quetiapine, risperidone, and ziprasidone use were not associated with the warning. CONCLUSIONS In a Medicaid-receiving population, baseline glucose and lipid testing for SGA-treated patients was infrequent and showed little change following the diabetes warning and monitoring recommendations. A change in SGA drug selection consistent with intentions to reduce metabolic risk was observed.
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Affiliation(s)
- Elaine H Morrato
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
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Banta JE, Morrato EH, Lee SW, Haviland MG. Retrospective analysis of diabetes care in California Medicaid patients with mental illness. J Gen Intern Med 2009; 24:802-8. [PMID: 19415391 PMCID: PMC2695534 DOI: 10.1007/s11606-009-0994-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [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: 07/17/2008] [Revised: 12/23/2008] [Accepted: 04/09/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Serious mental illness often is associated with an increased risk of diabetes and sub-optimal diabetes care. OBJECTIVE To examine diabetes prevalence and care among Medicaid patients from one county mental health system. DESIGN Retrospective cohort study combining county records and 12 months of state Medicaid claims. SUBJECTS Patients ages 18 to 59 receiving mental health services between November 1 and 14, 2004. MEASUREMENTS Dependent variables were glycolated hemoglobin A1C (HbA1c) testing, lipid testing, and eye examinations. Psychiatric status was assessed by second generation antipsychotic prescription (SGA) and low Global Assessment of Functioning (GAF) score. RESULTS Among psychiatric patients, 482 (11.8%) had diabetes. Among those with diabetes, 47.3% received annual HbA1c testing, 56.0% lipid testing, and 31.7% eye examinations. Low GAF scores were associated with lower likelihood of lipid testing (OR 0.43). SGA prescription reduced the likelihood of HbA1c testing (OR 0.58) but increased the likelihood of eye examinations (OR 2.02). Primary care visits were positively associated with HbA1c and lipid testing (ORs 5.01 and 2.21, respectively). Patients seen by a fee-for-service psychiatrist were more likely to have lipid testing (OR 2.35) and eye examinations (OR 2.03). CONCLUSION Among Medicaid psychiatric patients, worse diabetes care was associated with SGA prescription, more serious psychiatric symptoms, and receiving psychiatric care only in public mental health clinics. Diabetes care improved when patients were seen by fee-for-service psychiatrists or primary care physicians. Further study is needed to identify methods for improving diabetes care of public mental health patients.
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Affiliation(s)
- Jim E Banta
- Department of Health Policy and Management, School of Public Health, Loma Linda University, 24951 North Circle Drive, Loma Linda, CA 92350, USA.
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Morrato EH, Newcomer JW, Kamat S, Baser O, Harnett J, Cuffel B. Metabolic screening after the American Diabetes Association's consensus statement on antipsychotic drugs and diabetes. Diabetes Care 2009; 32:1037-42. [PMID: 19244091 PMCID: PMC2681020 DOI: 10.2337/dc08-1720] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Several second-generation antipsychotic (SGA) drugs have been associated with weight gain, hyperglycemia, and dyslipidemia. We evaluated whether glucose and lipid testing increased after the American Diabetes Association (ADA) consensus statement recommending metabolic monitoring for SGA-treated patients. RESEARCH DESIGN AND METHODS Laboratory claims for serum glucose and lipid testing were identified for an incident cohort of 18,876 adults initiating SGA drugs in a U.S. commercial health plan (2001-2006) and a control group of 56,522 adults with diabetes not receiving antipsychotics. Interrupted time-series models were used to estimate the effect of ADA recommendations on baseline and annual testing trends after adjusting for differences in age, sex, mental health diagnoses, and cardiovascular risk using propensity score matching. RESULTS Mean baseline testing rates for SGA-treated patients during the study period were 23% (glucose) and 8% (lipids). Among persistent users of SGA medication, annual testing rates were 38% (glucose) and 23% (lipid). Before the ADA statement, screening rates for SGA-treated patients were increasing (glucose: baseline 3.6% per year, annual 7.2% per year; lipid: baseline 1.2% per year, annual 4.8% per year; P < 0.001 for each trend). Increases were similar to background testing trends in control subjects. The ADA statement was not associated with an increase in screening rates. CONCLUSIONS In a commercially insured population, glucose and lipid testing for SGA-treated adults was infrequent. A gradual increase in screening rates occurred over the 6-year period, but the changes were not temporally associated with the ADA statement. More effort is needed to improve diabetes and dyslipidemia screening in these at-risk patients.
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Affiliation(s)
- Elaine H Morrato
- Departments of Pediatrics, Health Services Management and Policy, and Clinical Pharmacy, University of Colorado Denver, Aurora, Colorado, USA.
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Morrato EH, Newcomer JW, Allen RR, Valuck RJ. Prevalence of baseline serum glucose and lipid testing in users of second-generation antipsychotic drugs: a retrospective, population-based study of Medicaid claims data. J Clin Psychiatry 2008; 69:316-22. [PMID: 18251625 DOI: 10.4088/jcp.v69n0219] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [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: 10/20/2022]
Abstract
OBJECTIVE Increased risk of diabetes and dyslipidemia is associated with major mental illness and antipsychotic drug use. This study aimed to determine the prevalence of serum glucose and lipid monitoring in public mental health clients initiating second-generation antipsychotic (SGA) drugs. METHOD This retrospective cohort study using Medicaid claims data from California, Oregon, Tennessee, and Utah evaluated 55,436 enrollees with a prescription claim for an SGA drug between January 1, 1998, and December 31, 2003. Serum glucose and lipid testing were identified using Current Procedural Terminology (CPT) procedure codes. Baseline was defined as 14 days before through 28 days after the date of the first SGA prescription. Multivariate logistic regression identified patient characteristics associated with testing. Generalized estimating equations evaluated changes associated with SGA drug initiation compared to background rates of testing. RESULTS On average, < 20% of individuals initiating SGA drug therapy received baseline glucose testing, and < 10% received baseline lipid testing. Baseline glucose and lipid testing increased modestly with SGA initiation (glucose: 7%-11% increase; lipids: 2%-3% increase; p < .001). Preexisting diabetes and dyslipidemia were associated with a 2- to 3-fold greater likelihood of baseline glucose and lipid testing. The likelihood of glucose testing increased 2-fold between 1998 and 2003 and was 46% more likely in patients with schizophrenia. Enrollees from Oregon, Tennessee, and Utah were 50% to 90% less likely to receive baseline glucose or lipid testing than enrollees from California. CONCLUSIONS Glucose and lipid screening is underutilized in patients initiating SGA drug therapy. Psychiatrists can play an important role to ensure metabolic risk is adequately assessed.
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Affiliation(s)
- Elaine H Morrato
- Department of Pediatrics, School of Medicine, University of Colorado at Denver, Aurora, CO 80045-0508, USA.
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Partrick DA, Morrato EH, Roach JP, Ziegler MM. QS351. The National Frequency of Gastrointestinal Pediatric Surgery in Hospitalized Neonates. J Surg Res 2008. [DOI: 10.1016/j.jss.2007.12.604] [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: 10/22/2022]
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