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1.
Pain Med ; 20(6): 1105-1119, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30272177

RESUMO

OBJECTIVE: To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model. DESIGN: Our logic model-driven evaluation focused primarily on qualitative data sources. SETTING: This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting. METHODS: Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data. RESULTS: We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments. CONCLUSIONS: These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.


Assuntos
Dor nas Costas/terapia , Atenção à Saúde/normas , Medição da Dor/normas , Fisioterapeutas/normas , Atenção Primária à Saúde/normas , Avaliação de Processos em Cuidados de Saúde/normas , Dor nas Costas/epidemiologia , Atenção à Saúde/métodos , Humanos , Medição da Dor/métodos , Atenção Primária à Saúde/métodos , Avaliação de Processos em Cuidados de Saúde/métodos , Medição de Risco/métodos , Medição de Risco/normas , Estados Unidos/epidemiologia
2.
J Gen Intern Med ; 33(8): 1324-1336, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29790073

RESUMO

BACKGROUND: The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients' function while reducing costs in England. OBJECTIVE: This trial evaluated the effect of implementing an adaptation of this approach in a US setting. DESIGN: The Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial was a pragmatic cluster randomized trial with a pre-intervention baseline period. Six primary care clinics were pair randomized, three to training in the STarT Back strategy and three to serve as controls. PARTICIPANTS: Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months (primary endpoint) later. INTERVENTIONS: The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data (the STarT Back Tool) to categorize patients' risk of persistent disabling pain. Primary care clinicians in the intervention clinics attended six didactic sessions to improve their understanding LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record (EHR). Physical therapists received 5 days of intensive training. Control clinics received no training. MAIN MEASURES: Primary outcomes were back-related physical function and pain severity. Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics. Differences in change scores by trial arm and time period were estimated using linear mixed effect models. Secondary outcomes included healthcare utilization. KEY RESULTS: Although clinicians used the tool for about half of their patients, they did not change the treatments they recommended. The intervention had no significant effect on patient outcomes or healthcare use. CONCLUSIONS: A resource-intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use. TRIAL REGISTRATION: National Clinical Trial Number NCT02286141.


Assuntos
Dor Lombar/terapia , Manejo da Dor/métodos , Atenção Primária à Saúde/métodos , Adolescente , Adulto , Método Duplo-Cego , Feminino , Humanos , Dor Lombar/economia , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Medição de Risco/métodos , Adulto Jovem
3.
AIDS Care ; 28(9): 1154-8, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-26915281

RESUMO

Pre-exposure prophylaxis (PrEP), the antiretroviral treatment regimen for HIV-negative people at high risk of acquiring HIV, has demonstrated efficacy across clinical trials in several patient populations. The Centers for Disease Control (CDC) have released detailed guidelines to aid providers in prescribing PrEP for their high-risk patients, including men who have sex with men (MSM), high-risk heterosexuals, and injection drug users (IDUs). Given that much attention in PrEP has focused on MSM patients, the present study used an online survey to assess factors involved in HIV care providers' (n = 363) decisions about prescribing PrEP, along with their willingness to prescribe PrEP to patients from various risk populations (e.g., MSM, heterosexuals, IDUs). The efficacy of PrEP was an important factor in providers' decisions about prescribing PrEP, as were considerations about patients' adherence to the regimen, regular follow-up for care, and medication costs. This survey's findings also suggest that providers' willingness to prescribe PrEP varies by patient group, with providers most willing to initiate the regimen with MSM who have an HIV-positive partner, and least willing to prescribe to high-risk heterosexuals or IDUs. In the context of the current CDC recommendations for PrEP that include MSM, heterosexuals, and IDUs, examining providers' rationales for and barriers against supporting this HIV prevention strategy across patient groups merits further attention.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Atitude do Pessoal de Saúde , Infecções por HIV/prevenção & controle , Padrões de Prática Médica , Profilaxia Pré-Exposição , Adulto , Fármacos Anti-HIV/economia , Tomada de Decisões , Feminino , Heterossexualidade , Homossexualidade Masculina , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Assunção de Riscos , Abuso de Substâncias por Via Intravenosa/complicações , Inquéritos e Questionários
4.
Behav Sleep Med ; 14(5): 514-27, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26485203

RESUMO

This article considers methodology for developing an education-only control group and proposes a simple approach to designing rigorous and well-accepted control groups. This approach is demonstrated in a large randomized trial. The Lifestyles trial (n = 367) compared three group interventions: (a) cognitive-behavioral treatment (CBT) for osteoarthritis pain, (b) CBT for osteoarthritis pain and insomnia, and (c) education-only control (EOC). EOC emulated the interventions excluding hypothesized treatment components and controlling for nonspecific treatment effects. Results showed this approach resulted in a control group that was highly credible and acceptable to patients. This approach can be an effective and practical guide for developing high-quality control groups in trials of behavioral interventions.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Idoso , Grupos Controle , Método Duplo-Cego , Feminino , Humanos , Estudos Longitudinais , Masculino , Distúrbios do Início e da Manutenção do Sono , Resultado do Tratamento
5.
BMC Musculoskelet Disord ; 17(1): 361, 2016 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-27553626

RESUMO

BACKGROUND: Despite numerous options for treating back pain and the increasing healthcare resources devoted to this problem, the prevalence and impact of back pain-related disability has not improved. It is now recognized that psychosocial factors, as well as physical factors, are important predictors of poor outcomes for back pain. A promising new approach that matches treatments to the physical and psychosocial obstacles to recovery, the STarT Back risk stratification approach, improved patients' physical function while reducing costs of care in the United Kingdom (UK). This trial evaluates implementation of this strategy in a United States (US) healthcare setting. METHODS: Six large primary care clinics in an integrated healthcare system in Washington State were block-randomized, three to receive an intensive quality improvement intervention for back pain and three to serve as controls for secular trends. The intervention included 6 one-hour training sessions for physicians, 5 days of training for physical therapists, individualized and group coaching of clinicians, and integration of the STarT Back tool into the electronic health record. This prognostic tool uses 9 questions to categorize patients at low, medium or high risk of persistent disabling pain with recommendations about evidence-based treatment options appropriate for each subgroup. Patients at least 18 years of age, receiving primary care for non-specific low back pain, were invited to provide data 1-3 weeks after their primary care visit and follow-up data 2 months and 6 months (primary endpoint) later. The primary outcomes are back-related physical function and pain severity. Using an intention to treat approach, intervention effects on patient outcomes will be estimated by comparing mean changes at the 2 and 6 month follow-up between the pre- and post-implementation periods. The inclusion of control clinics permits adjustment for secular trends. Differences in change scores by intervention group and time period will be estimated using linear mixed models with random effects. Secondary outcomes include healthcare utilization and adherence to clinical guidelines. DISCUSSION: This trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system. TRIAL REGISTRATION: NCT02286141. Registered November 5, 2014.


Assuntos
Educação Médica/métodos , Dor Lombar/terapia , Fisioterapeutas/educação , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade , Adulto , Protocolos Clínicos , Avaliação da Deficiência , Registros Eletrônicos de Saúde , Humanos , Dor Lombar/complicações , Dor Lombar/psicologia , Medição da Dor , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos , Inquéritos e Questionários , Reino Unido , Estados Unidos
6.
JAMA ; 315(12): 1240-9, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27002445

RESUMO

IMPORTANCE: Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain. OBJECTIVE: To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care. DESIGN, SETTING, AND PARTICIPANTS: Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). INTERVENTIONS: CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received. MAIN OUTCOMES AND MEASURES: Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks. RESULTS: There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes. CONCLUSIONS AND RELEVANCE: Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01467843.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Dor Lombar/psicologia , Dor Lombar/terapia , Atenção Plena/métodos , Estresse Psicológico/terapia , Yoga , Adulto , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Tamanho da Amostra , Estresse Fisiológico , Resultado do Tratamento , Washington , Adulto Jovem
7.
Subst Abus ; 35(3): 245-53, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24625188

RESUMO

BACKGROUND: Alcohol use, and particularly unhealthy alcohol use, is associated with poor human immunodeficiency virus (HIV)-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are underdescribed in this population. The authors describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to antiretroviral therapy (ART). METHODS: Participants were recruited from acquired immunodeficiency syndrome (AIDS) service organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) alcohol screen, sociodemographic characteristics, substance use, and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into nondrinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1-3, 4-6, and 7-12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers. RESULTS: Among 447 participants, 57% reported drinking in the past year (35%, 15%, and 7% reported low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively). Any drinking was most common among men and those who were lesbian, gay, bisexual, or transgender (LGBT), married/partnered, had received past-year alcohol treatment, and never used injection drugs (P values all <.05). Differences in race, employment status, past-year alcohol treatment, and positive depression screening (P values all <.05) were observed across AUDIT-C categories, with African American race, less than full-time employment, past-year alcohol treatment, and positive depression screening being most common among those with the most severe unhealthy drinking. CONCLUSIONS: In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.


Assuntos
Consumo de Bebidas Alcoólicas/psicologia , Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Adesão à Medicação/psicologia , Transtornos Mentais/epidemiologia , Antirretrovirais/uso terapêutico , Comorbidade , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos/epidemiologia
8.
JAMA Intern Med ; 184(1): 54-62, 2024 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-38010725

RESUMO

Importance: Modifiable risk factors are hypothesized to account for 30% to 40% of dementia; yet, few trials have demonstrated that risk-reduction interventions, especially multidomain, are efficacious. Objective: To determine if a personalized, multidomain risk reduction intervention improves cognition and dementia risk profile among older adults. Design, Setting, and Participants: The Systematic Multi-Domain Alzheimer Risk Reduction Trial was a randomized clinical trial with a 2-year personalized, risk-reduction intervention. A total of 172 adults at elevated risk for dementia (age 70-89 years and with ≥2 of 8 targeted risk factors) were recruited from primary care clinics associated with Kaiser Permanente Washington. Data were collected from August 2018 to August 2022 and analyzed from October 2022 to September 2023. Intervention: Participants were randomly assigned to the intervention (personalized risk-reduction goals with health coaching and nurse visits) or to a health education control. Main Outcomes and Measures: The primary outcome was change in a composite modified Neuropsychological Test Battery; preplanned secondary outcomes were change in risk factors and quality of life (QOL). Outcomes were assessed at baseline and 6, 12, 18, and 24 months. Linear mixed models were used to compare, by intention to treat, average treatment effects (ATEs) from baseline over follow-up. The intervention and outcomes were initially in person but then, due to onset of the COVID-19 pandemic, were remote. Results: The 172 total participants had a mean (SD) age of 75.7 (4.8) years, and 108 (62.8%) were women. After 2 years, compared with the 90 participants in the control group, the 82 participants assigned to intervention demonstrated larger improvements in the composite cognitive score (ATE of SD, 0.14; 95% CI, 0.03-0.25; P = .02; a 74% improvement compared with the change in the control group), better composite risk factor score (ATE of SD, 0.11; 95% CI, 0.01-0.20; P = .03), and improved QOL (ATE, 0.81 points; 95% CI, -0.21 to 1.84; P = .12). There were no between-group differences in serious adverse events (24 in the intervention group and 23 in the control group; P = .59), but the intervention group had greater treatment-related adverse events such as musculoskeletal pain (14 in the intervention group vs 0 in the control group; P < .001). Conclusions and Relevance: In this randomized clinical trial, a 2-year, personalized, multidomain intervention led to modest improvements in cognition, dementia risk factors, and QOL. Modifiable risk-reduction strategies should be considered for older adults at risk for dementia. Trial Registration: ClinicalTrials.gov Identifier: NCT03683394.


Assuntos
Demência , Qualidade de Vida , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Masculino , Pandemias , Cognição , Comportamento de Redução do Risco , Demência/prevenção & controle , Demência/epidemiologia
9.
AIDS Care ; 25(4): 451-8, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-22894702

RESUMO

The population of persons living with HIV (PLWH) is growing older and more prone to developing other chronic health conditions. Disease progression has been shown to be related to quality of life (QoL). However, descriptions of chronic comorbid illnesses and the unique QoL challenges of older adults living with HIV are not well understood and have not been examined in multiple geographic locations. About 452 PLWH aged 50 years or older were recruited from AIDS Service Organizations in nine states. Participants completed a telephone survey that included measures of other chronic health conditions, perceived stress, depression, and health-related quality of life. As much as 94% of the sample reported a chronic health condition in addition to HIV (mode = 2). The highest reported conditions were hypertension, chronic pain, hepatitis, and arthritis. Despite relatively high rates of depression, overall QoL was moderately high for the sample. Physical functioning was most impacted by the addition of other chronic health problems. Social functioning, mental health functioning, stress, and depression were also strongly associated with chronic disease burden. Additional chronic health problems are the norm for PLWH aged 50 years and older. QoL is significantly related to the addition of chronic health problems. As increasing numbers of PLWH reach older age, this raises challenges for providing comprehensive healthcare to older PLWH with multiple chronic conditions.


Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Doença Crônica/epidemiologia , Soropositividade para HIV/epidemiologia , Qualidade de Vida , Síndrome da Imunodeficiência Adquirida/complicações , Síndrome da Imunodeficiência Adquirida/psicologia , Idoso , Envelhecimento , Artrite/epidemiologia , Comorbidade , Efeitos Psicossociais da Doença , Estudos Transversais , Depressão/epidemiologia , Progressão da Doença , Feminino , Soropositividade para HIV/complicações , Soropositividade para HIV/psicologia , Nível de Saúde , Hepatite/epidemiologia , Humanos , Hipertensão/epidemiologia , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Estados Unidos/epidemiologia
10.
J Pain ; 24(2): 282-303, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36180008

RESUMO

Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.


Assuntos
Dor Crônica , Terapia Cognitivo-Comportamental , Dor Lombar , Atenção Plena , Adulto , Humanos , Atenção Plena/métodos , Dor Lombar/terapia , Terapia Cognitivo-Comportamental/métodos , Manejo da Dor , Transtornos de Ansiedade , Estresse Psicológico/terapia , Resultado do Tratamento , Dor Crônica/terapia
11.
J Am Geriatr Soc ; 71(5): 1580-1586, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36546768

RESUMO

BACKGROUND: While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics. METHODS: An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses. RESULTS: Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively. CONCLUSION: Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.


Assuntos
Dor Crônica , Desprescrições , Humanos , Analgésicos Opioides/uso terapêutico , Dor Crônica/diagnóstico , Autoeficácia , Hipnóticos e Sedativos/uso terapêutico
12.
Trials ; 24(1): 322, 2023 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-37170329

RESUMO

BACKGROUND: Central nervous system (CNS) active medications have been consistently linked to falls in older people. However, few randomized trials have evaluated whether CNS-active medication reduction reduces falls and fall-related injuries. The objective of the Reducing CNS-active Medications to Prevent Falls and Injuries in Older Adults (STOP-FALLS) trial is to test the effectiveness of a health-system-embedded deprescribing intervention focused on CNS-active medications on the incidence of medically treated falls among community-dwelling older adults. METHODS: We will conduct a pragmatic, cluster-randomized, parallel-group, controlled clinical trial within Kaiser Permanente Washington to test the effectiveness of a 12-month deprescribing intervention consisting of (1) an educational brochure and self-care handouts mailed to older adults prescribed one or more CNS-active medications (aged 60 + : opioids, benzodiazepines and Z-drugs; aged 65 + : skeletal muscle relaxants, tricyclic antidepressants, and antihistamines) and (2) decision support for their primary health care providers. Outcomes are examined over 18-26 months post-intervention. The primary outcome is first incident (post-baseline) medically treated fall as determined from health plan data. Our sample size calculations ensure at least 80% power to detect a 20% reduction in the rate of medically treated falls for participants receiving care within the intervention (n = 9) versus usual care clinics (n = 9) assuming 18 months of follow-up. Secondary outcomes include medication discontinuation or dose reduction of any target medications. Safety outcomes include serious adverse drug withdrawal events, unintentional overdose, and death. We will also examine medication signetur fields for attempts to decrease medications. We will report factors affecting implementation of the intervention. DISCUSSION: The STOP-FALLS trial will provide new information about whether a health-system-embedded deprescribing intervention that targets older participants and their primary care providers reduces medically treated falls and CNS-active medication use. Insights into factors affecting implementation will inform future research and healthcare organizations that may be interested in replicating the intervention. TRIAL REGISTRATION: ClinicalTrial.gov NCT05689554. Registered on 18 January 2023, retrospectively registered.


Assuntos
Desprescrições , Idoso , Humanos , Analgésicos Opioides , Benzodiazepinas , Ensaios Clínicos Pragmáticos como Assunto
13.
Trials ; 24(1): 196, 2023 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-36927459

RESUMO

BACKGROUND: Cognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use. METHODS: As part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment. DISCUSSION: This large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services. TRIAL REGISTRATION: ClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.


Assuntos
Dor Crônica , Terapia Cognitivo-Comportamental , Telemedicina , Humanos , Análise Custo-Benefício , Dor Crônica/diagnóstico , Dor Crônica/terapia , Qualidade de Vida , Terapia Cognitivo-Comportamental/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto
14.
AIDS Behav ; 16(1): 108-20, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21553252

RESUMO

Greater understanding of barriers to risk reduction among incarcerated HIV+ persons reentering the community is needed to inform culturally tailored interventions. This qualitative study elicited HIV prevention-related information, motivation and behavioral skills (IMB) needs of 30 incarcerated HIV+ men and women awaiting release from state prison. Unmet information needs included risk questions about viral loads, positive sexual partners, and transmission through casual contact. Social motivational barriers to risk reduction included partner perceptions that prison release increases sexual desirability, partners' negative condom attitudes, and HIV disclosure-related fears of rejection. Personal motivational barriers included depression and strong desires for sex or substance use upon release. Behavioral skills needs included initiating safer behaviors with partners with whom condoms had not been used prior to incarceration, disclosing HIV status, and acquiring clean needles or condoms upon release. Stigma and privacy concerns were prominent prison context barriers to delivering HIV prevention services during incarceration.


Assuntos
Infecções por HIV/prevenção & controle , Comportamentos Relacionados com a Saúde , Conhecimentos, Atitudes e Prática em Saúde , Necessidades e Demandas de Serviços de Saúde , Prisioneiros/psicologia , Comportamento Sexual , Adulto , Preservativos/estatística & dados numéricos , Feminino , Infecções por HIV/transmissão , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Motivação , Prisões , Pesquisa Qualitativa , Assunção de Riscos , Parceiros Sexuais , Wisconsin , Adulto Jovem
16.
AIDS Patient Care STDS ; 32(8): 314-320, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30067406

RESUMO

Hepatitis C virus (HCV) is frequently comorbid with HIV infection and is independently associated with a significant increase in all-cause mortality among HIV-positive adults. HIV specialists' role and experiences in treating HCV has been understudied, especially among those providers who actively treat patients with HCV. We conducted a brief online survey of HIV specialists (physicians, nurse practitioners, physician assistants, and prescribing pharmacists) who treat patients with HCV to examine their experiences with treating these patients (HCV monoinfected, HIV/HCV coinfected). Survey questions assessed providers' annual caseloads, barriers, and facilitators to providing HCV care, likelihood of providing HCV treatment to patients with various risk factors, and the extent to which their HCV screening practices aligned with CDC (Centers for Disease Control) guidelines for patients from various risk groups. A total of 168 HIV care providers were included in analyses. Nearly all specialists surveyed actively treated HIV/HCV coinfected patients, while fewer treated any HCV monoinfected patients. Providers' screening practices typically aligned with guidelines across patient groups, but their likelihood of prescribing HCV treatment to patients varied across patients' risk profiles. Providers endorsed high levels of knowledge to treat HCV-infected patients, but highlighted key barriers to providing optimal care. Given that HIV specialists are an active group treating patients with HCV, they may benefit from specialized guidance on managing HCV in patients with complex histories, including comorbid HIV infection.


Assuntos
Infecções por HIV/tratamento farmacológico , Pessoal de Saúde , Hepatite C Crônica/tratamento farmacológico , Assistência ao Paciente , Adulto , Comorbidade , Feminino , Infecções por HIV/epidemiologia , Pesquisas sobre Atenção à Saúde , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Hepatite C Crônica/epidemiologia , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Fatores de Risco , Inquéritos e Questionários
17.
Health Educ Behav ; 45(5): 723-729, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29353546

RESUMO

Uptake of preexposure prophylaxis (PrEP) has been slow, but is increasing. Although PrEP is indicated for many patients, it has been concentrated among men who have sex with men (MSM). Awareness of PrEP is limited among non-MSM individuals, and among some MSM. As such, individuals at risk for HIV who are unaware of PrEP must rely on their medical providers to initiate conversations about PrEP. Members of a national professional organization of HIV specialists with prescribing privileges, including physicians, nurse practitioners, and physician assistants, participated in an online survey ( n = 342) to characterize their PrEP prescribing behaviors and the demographic membership of their PrEP patients. Results indicated that when discussing PrEP with their patients, providers who more frequently initiated these conversations had a higher percentage of non-MSM patients in their PrEP caseload (e.g., women, people who inject drugs, transgender patients). Encouraging providers to initiate discussions about PrEP with their patients and helping them locate support to offset the cost may help increase uptake, particularly among at-risk patients who are underrepresented in PrEP adoption.


Assuntos
Infecções por HIV/prevenção & controle , Médicos/estatística & dados numéricos , Padrões de Prática Médica , Profilaxia Pré-Exposição/métodos , Conscientização , Comunicação em Saúde , Humanos , Internet , Minorias Sexuais e de Gênero , Inquéritos e Questionários
18.
Spine (Phila Pa 1976) ; 42(20): 1511-1520, 2017 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-28742756

RESUMO

STUDY DESIGN: Economic evaluation alongside a randomized trial of cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) versus usual care alone (UC) for chronic low back pain (CLBP). OBJECTIVE: To determine 1-year cost-effectiveness of CBT and MBSR compared to 33 UC. SUMMARY OF BACKGROUND DATA: CLBP is expensive in terms of healthcare costs and lost productivity. Mind-body interventions have been found effective for back pain, but their cost-effectiveness is unexplored. METHODS: A total of 342 adults in an integrated healthcare system with CLBP were randomized to receive MBSR (n = 116), CBT (n = 113), or UC (n = 113). CBT and MBSR were offered in 8-weekly 2-hour group sessions. Cost-effectiveness from the societal perspective was calculated as the incremental sum of healthcare costs and productivity losses over change in quality-adjusted life-years (QALYs). The payer perspective only included healthcare costs. This economic evaluation was limited to the 301 health plan members enrolled ≥180 days in the years pre-and postrandomization. RESULTS: Compared with UC, the mean incremental cost per participant to society of CBT was $125 (95% confidence interval, CI: -4103, 4307) and of MBSR was -$724 (CI: -4386, 2778)-that is, a net saving of $724. Incremental costs per participant to the health plan were $495 for CBT over UC and -$982 for MBSR, and incremental back-related costs per participant were $984 for CBT over UC and -$127 for MBSR. These costs (and cost savings) were associated with statistically significant gains in QALYs over UC: 0.041 (0.015, 0.067) for CBT and 0.034 (0.008, 0.060) for MBSR. CONCLUSION: In this setting CBT and MBSR have high probabilities of being cost-effective, and MBSR may be cost saving, as compared with UC for adults with CLBP. These findings suggest that MBSR, and to a lesser extent CBT, may provide cost-effective treatment for CLBP for payers and society. LEVEL OF EVIDENCE: 2.


Assuntos
Dor Crônica/economia , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício/métodos , Dor Lombar/economia , Atenção Plena/economia , Estresse Psicológico/economia , Adulto , Dor Crônica/terapia , Terapia Cognitivo-Comportamental/métodos , Feminino , Custos de Cuidados de Saúde , Humanos , Dor Lombar/terapia , Masculino , Pessoa de Meia-Idade , Atenção Plena/métodos , Anos de Vida Ajustados por Qualidade de Vida , Estresse Psicológico/terapia , Resultado do Tratamento
19.
J Int Assoc Provid AIDS Care ; 15(3): 248-55, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-27071744

RESUMO

BACKGROUND: Despite the success of antiretroviral therapy (ART), HIV-infected older African Americans experience higher mortality rates compared to their white counterparts. This disparity may be partly attributable to the differences in ART adherence by different racial and gender groups. The purpose of this study was to describe demographic, psychosocial, and HIV disease-related factors that influence ART adherence and to determine whether race and gender impact ART adherence among HIV-infected adults aged 50 years and older. METHODS: This descriptive study involved a secondary analysis of baseline data from 426 participants in "PRIME," a telephone-based ART adherence and quality-of-life intervention trial. Logistic regression was used to examine the association between independent variables and ART adherence. RESULTS: Higher annual income and increased self-efficacy were associated with being ≥95% ART adherent. Race and gender were not associated with ART adherence. CONCLUSION: These findings indicated that improvements in self-efficacy for taking ART may be an effective strategy to improve adherence regardless of race or gender.


Assuntos
Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Adesão à Medicação/estatística & dados numéricos , Negro ou Afro-Americano , Idoso , Antirretrovirais/uso terapêutico , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autoeficácia , Fatores Socioeconômicos , Estados Unidos/epidemiologia
20.
Pain ; 157(11): 2434-2444, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27257859

RESUMO

Cognitive behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit patients with chronic pain by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR vs CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with chronic low back pain (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (nonreactivity, nonjudging, and acting with awareness; all P values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P values <0.05) measures. Catastrophizing decreased slightly more posttreatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the subsample of participants who attended ≥6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness and similar effects of MBSR and CBT on these measures among individuals with chronic low back pain.


Assuntos
Catastrofização , Terapia Cognitivo-Comportamental , Dor Lombar , Atenção Plena/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Autoeficácia , Estresse Psicológico/reabilitação , Adulto , Idoso , Dor Crônica/reabilitação , Feminino , Humanos , Dor Lombar/complicações , Dor Lombar/psicologia , Dor Lombar/reabilitação , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Estresse Psicológico/etiologia , Adulto Jovem
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