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Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886.
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Dor Musculoesquelética , Doenças da Coluna Vertebral , Feminino , Humanos , Pessoa de Meia-Idade , Terapia Combinada , Gastos em Saúde , Dor Musculoesquelética/economia , Dor Musculoesquelética/psicologia , Dor Musculoesquelética/terapia , Autogestão , Coluna Vertebral , Doenças da Coluna Vertebral/economia , Doenças da Coluna Vertebral/psicologia , Doenças da Coluna Vertebral/terapia , Masculino , Modalidades de Fisioterapia , Aconselhamento , Manejo da Dor/economia , Manejo da Dor/métodos , Encaminhamento e ConsultaRESUMO
Self-report of health conditions and behaviors is one potential strategy to increase the pace of enrollment into pragmatic clinical trials. In this study, we assessed the accuracy of self-reported poorly controlled hypertension among adults in the community who were screened for participation in the MedISAFE-BP trial. Of individuals who self-reported poorly controlled hypertension using the online trial enrollment platform, 64% had a systolic blood pressure less than 140 mm Hg when measured at home. Although we identified several characteristics associated with accurate self-report including older age (odds ratio [OR] 1.02 per year, 95% CI 1.01-1.03), diabetes (OR 1.59, 95% CI 1.17-2.14), and low health activation (OR 1.56 95% CI 1.17-2.07), we were unable to identify patients for whom self-reported hypertension would be a reliable method for their inclusion in a pragmatic trial.
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Pressão Sanguínea , Confiabilidade dos Dados , Hipertensão/diagnóstico , Aplicativos Móveis , Autorrelato/normas , Fatores Etários , Determinação da Pressão Arterial , Exercício Físico , Feminino , Humanos , Modelos Logísticos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Seleção de Pacientes , Autorrelato/estatística & dados numéricos , Smartphone , Inquéritos e Questionários/estatística & dados numéricosRESUMO
BACKGROUND: Hypertension is a major contributor to the health and economic burden imposed by stroke, heart disease, and renal insufficiency. Antihypertensives can prevent many of the harmful effects of elevated blood pressure, but medication nonadherence is a known barrier to the effectiveness of these treatments. Smartphone-based applications that remind patients to take their medications, provide education, and allow for social interactions between individuals with similar health concerns have been widely advocated as a strategy to improve adherence but have not been subject to rigorous testing. METHODS/DESIGN: The MedISAFE-BP study is a prospective, randomized control trial designed to evaluate the impact on blood pressure and medication adherence of an mhealth application (Medisafe). Four hundred thirteen patients with uncontrolled hypertension have been enrolled and randomized in a 1:1 fashion to usual care or to the use of the Medisafe mhealth platform. Patients will be followed up for 12 weeks and the trial's co-primary outcomes will be change in systolic blood pressure and self-reported medication adherence. DISCUSSION: The MedISAFE-BP trial is the first study to rigorously evaluate an mhealth application's effect on blood pressure and medication adherence. The results will inform the potential effectiveness of this simple system in improving cardiovascular disease risk factors and clinical outcomes.
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Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adesão à Medicação , Aplicativos Móveis , Telemedicina , Adolescente , Adulto , Idoso , Humanos , Análise de Intenção de Tratamento , Pessoa de Meia-Idade , Estudos Prospectivos , Smartphone , Adulto JovemRESUMO
BACKGROUND: To address both the growing burden of joint disease and the gaps in medical access in developing nations, medical relief organizations have begun to launch programs to perform total joint replacement (TJR) on resident populations in developing countries. One outcome of TJR of particular interest is physical activity (PA) since it is strongly linked to general health. This study evaluates the amount of postoperative participation in PA in low-income patients who received total joint replacement in the Dominican Republic and identifies preoperative predictors of postoperative PA level. METHODS: We used the Yale Physical Activity Survey (YPAS) to assess participation in postoperative PA 1-4 years following total knee or hip replacement. We compared the amount of aerobic PA reported by postoperative TJR patients with the levels of PA recommended by the CDC and WHO. We also analyzed preoperative determinants of postoperative participation in aerobic PA in bivariate and multivariate analyses. RESULTS: 64 patients out of 170 eligible subjects (52/128 TKR and 14/42 THR) who received TJR between 2009-2012 returned for an annual follow-up visit in 2013, with a mean treatment-to-follow-up time of 2.1 years. 43.3% of respondents met CDC/WHO criteria for sufficient participation in aerobic PA. Multivariate analyses including data from 56 individuals identified that patients who were both younger than 65 and at least two years postoperative had an adjusted mean activity dimensions summary index (ADSI) 22.9 points higher than patients who were 65 or older and one year postoperative. Patients who lived with friends or family had adjusted mean ADSI 17.2 points higher than patients living alone. Patients who had the most optimistic preoperative expectations of outcome had adjusted mean ADSI scores that were 19.8 points higher than those who were less optimistic. CONCLUSION: The TJR patients in the Dominican cohort participate in less PA than recommended by the CDC/WHO. Additionally, several associations were identified that potentially affect PA in this population; specifically, participants who are older than 65, recently postoperative, less optimistic about postoperative outcomes and who live alone participate in less PA.
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Artroplastia de Quadril/reabilitação , Artroplastia do Joelho/reabilitação , Atividade Motora , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antecipação Psicológica , Artroplastia de Quadril/psicologia , Artroplastia do Joelho/psicologia , Avaliação da Deficiência , República Dominicana , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Pobreza , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: In developed countries, the functional status scores of patients with poor preoperative scores undergoing total joint replacement (TJR) improve more following TJR than those for patients with better preoperative scores. However, those with better preoperative scores achieve the best postoperative functional outcomes. We determined whether similar associations exist in a developing country. METHODS: Dominican patients undergoing total hip or knee replacement completed WOMAC and SF-36 surveys preoperatively and at 12-month follow-up. Patients were stratified into low-, medium- and high-scoring preoperative groups based on their preoperative WOMAC function scores. We examined the associations between the baseline functional status of these groups and two outcomes-improvement in functional status over 12 months and functional status at 12 months-using analysis of variance with multivariable linear regression. RESULTS: Patients who scored the lowest preoperatively made the greatest gains in function and pain relief following their TJRs. However, there were no significant differences in pain or function at 12-month follow-up between patients who scored low and those who scored high on preoperative WOMAC and SF-36 surveys. CONCLUSION: Patients with poor preoperative functional status had greater improvement but similar 12-month functional outcomes compared with patients who had a higher level of function before surgery. These results suggest that a policy of focusing scarce resources on patients with worse functional status in developing countries may optimize improvement following TJR without threatening functional outcome. Additional research is needed to confirm these findings in other developing countries and to understand why these associations vary between patients in the Dominican Republic and patients from developed countries.
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Artroplastia de Quadril/reabilitação , Artroplastia do Joelho/reabilitação , Países em Desenvolvimento , Recuperação de Função Fisiológica , Idoso , República Dominicana , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Período Pré-Operatório , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Several organizations seek to address the growing burden of arthritis in developing countries by providing total joint replacements (TJR) to patients with advanced arthritis who otherwise would not have access to these procedures. Because these mission trips operate in resource poor environments, some of the features typically associated with high quality care may be difficult to implement. In the U.S., many hospitals that perform TJRs use the Blue Cross/Shield's Blue Distinction criteria as benchmarks of high quality care. Although these criteria were designed for use in the U.S., we applied them to Operation Walk (Op-Walk) Boston's medical mission trip to the Dominican Republic. Evaluating the program using these criteria illustrated that the program provides high quality care and, more importantly, helped the program to find areas of improvement. METHODS: We used the Blue Distinction criteria to determine if Op-Walk Boston achieves Blue Distinction. Each criterion was grouped according to the four categories included in the Blue Distinction criteria--"general and administrative", "structure", "process", or "outcomes and volume". Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. Of the non-replicated criteria, Op-Walk Boston's clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion. RESULTS: Out of 100 possible points, the program received 71, exceeding the 60-point threshold needed to qualify as a Blue Distinction center. The program met five out of eight "required" criteria and 11 out of 19 "informational" criteria. It scored 14/27 in the "general" category, 30/36 in the "structure" category, 17/20 in the "process" category, and 10/17 in the "outcomes and volume" category. CONCLUSION: Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries.
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Artrite/cirurgia , Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Planos de Seguro Blue Cross Blue Shield/normas , Países em Desenvolvimento , Missões Médicas/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Artrite/diagnóstico , Benchmarking/normas , Boston , República Dominicana , Acessibilidade aos Serviços de Saúde/normas , Humanos , Avaliação de Programas e Projetos de Saúde , Resultado do TratamentoRESUMO
BACKGROUND: Utilization of total knee arthroplasty is increasing rapidly. A substantial number of total knee arthroplasty recipients have persistent pain after surgery. Our objective was to design a randomized controlled trial to establish the efficacy of a motivational-interviewing-based telephone intervention aimed at improving patient outcomes and satisfaction following total knee arthroplasty. METHODS/DESIGN: The study was conducted at Brigham and Women's Hospital in Boston, Massachusetts. The study focused on individuals 40 years or older with a primary diagnosis of osteoarthritis who were scheduled for total knee arthroplasty. The study compared two management strategies over the first six months postoperatively: 1) enhanced postoperative care with frequent follow-up by a care navigator; 2) usual postoperative care. Those who were randomized into the enhanced postoperative care arm received ten calls from a trained non-clinician care navigator over the first six postoperative months. The navigator used motivational interviewing techniques to engage patients in discussions related to their rehabilitation goals, including patient's plans for and confidence in achieving those goals. Patients in the usual care arm received standard postoperative management and received no navigator phone calls. Patients in both arms were assessed at baseline, three months, and six months postoperatively. DISCUSSION: The primary outcome of the study was improvement in function as measured by the difference in Western Ontario and McMaster Universities Osteoarthritis Index function score between preoperative (baseline) status and six months postoperatively. Data were collected to identify factors that may be related to total knee arthroplasty outcomes, including preoperative pain, pain catastrophizing, self-efficacy, and depression. A formal economic analysis is also planned to determine the cost-effectiveness of the care navigator as a component of total knee arthroplasty care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01540851.
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Artroplastia do Joelho/reabilitação , Entrevista Motivacional , Osteoartrite do Joelho/cirurgia , Dor Pós-Operatória/prevenção & controle , Navegação de Pacientes , Cuidados Pós-Operatórios/métodos , Projetos de Pesquisa , Adulto , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Boston , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Entrevista Motivacional/economia , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/economia , Osteoartrite do Joelho/fisiopatologia , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Navegação de Pacientes/economia , Satisfação do Paciente , Cuidados Pós-Operatórios/economia , Recuperação de Função Fisiológica , Inquéritos e Questionários , Telefone , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: There is little prior research on the burden of arthritis in the developing world. We sought to document how patients with advanced arthritis living in the Dominican Republic are affected by and cope with their disease. METHODS: We conducted semi-structured, one-to-one interviews with economically disadvantaged Dominican patients with advanced knee and/or hip arthritis in the Dominican Republic. The interviews, conducted in Spanish, followed a moderator's guide that included topics such as the patients' understanding of disease etiology, their support networks, and their coping mechanisms. The interviews were audiotaped, transcribed verbatim in Spanish, and systematically analyzed using content analysis. We assessed agreement in coding between two investigators. RESULTS: 18 patients were interviewed (mean age 60 years, median age 62 years, 72% women, 100% response rate). Patients invoked religious and environmental theories of disease etiology, stating that their illness had been caused by God's will or through contact with water. While all patients experienced pain and functional limitation, the social effects of arthritis were gender-specific: women noted interference with homemaking and churchgoing activities, while men experienced disruption with occupational roles. The coping strategies used by patients appeared to reflect their beliefs about disease causation and included prayer and avoidance of water. CONCLUSIONS: Patients' explanatory models of arthritis influenced the psychosocial effects of the disease and coping mechanisms used. Given the increasing reach of global health programs, understanding these culturally influenced perceptions of disease will be crucial in successfully treating chronic diseases in the developing world.
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Adaptação Psicológica , Artrite/psicologia , Atitude Frente a Saúde , Conhecimentos, Atitudes e Prática em Saúde , Percepção , Adulto , Idoso , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Países em Desenvolvimento , Feminino , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Adulto JovemRESUMO
Health care professionals often participate in short-term surgical missions in underserved areas of the world. Surgical missions often rely on the use of medications to provide health care to these underserved areas in patients with multiple comorbid conditions. The direct role a pharmacist may have in surgical missions is not well described in the literature; however, numerous opportunities exist for pharmacist involvement to improve patient care and operational processes throughout medication planning and delivery of surgical missions. Pharmacists have specialized knowledge in medication acquisition, preparation, and distribution that result in a unique position to contribute positively to the mission's clinical and operational dynamics. Pharmacists may assist in various activities such as medication ordering, accrual, purchasing and preparing during the surgical mission. Pharmacists may also provide clinical support and offer alternative medications in the setting of drug intolerance or allergies. In 2008, Operation Walk Boston, a short-term surgical mission was established to provide hip and knee joint replacements to patients in the Dominican Republic. Pharmacists and pharmacy residents play a crucial role as members of this surgical mission. Based on our experience, this article aims to describe the evolving role of pharmacists as a member of a surgical mission.
Assuntos
Missões Médicas , Assistência Farmacêutica , Farmácia , Humanos , Farmacêuticos , Papel Profissional , VoluntáriosRESUMO
BACKGROUND: Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes. METHODS: The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study was conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021. DISCUSSION: The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care. TRIAL REGISTRATION NUMBER: NCT03083886.
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Dor Crônica , Gastos em Saúde , Dor Crônica/terapia , Humanos , Resultado do TratamentoRESUMO
Importance: Numerous factors are associated with the ability of patients with type 2 diabetes to achieve optimal glycemic control. However, many of these factors are not modifiable by quality improvement interventions. In contrast, the structure of how diabetes care is delivered, such as whether patients visit an endocrinologist or how prescriptions are filled, is potentially modifiable, yet its associations with glycemic control have not been rigorously evaluated. Objective: To investigate the association of diabetes care delivery with glycemic control in patients with type 2 diabetes using insulin. Design, Setting, and Participants: This retrospective cohort study used baseline claims and laboratory insurer data within a large pragmatic trial to identify individuals with type 2 diabetes using insulin with data for at least 1 hemoglobin A1c (HbA1c) test result from before trial randomization (July 1, 2014, to October 5, 2016) and for key nonmodifiable patient factors as well as diabetes care delivery and behavioral factors measured before the HbA1c test. Analyses were conducted from February 4, 2017, to November 13, 2018. Main Outcomes and Measures: Multivariable modified Poisson regression was used to evaluate the independent associations of nonmodifiable patient factors and potentially modifiable diabetes care delivery and patient behavioral factors with achieving adequate diabetes control (ie, HbA1c level <8%). The extent of measured variation explained in glycemic control by these factors was also explored using pseudo R2 and C statistics. Results: Of 1423 patients included, 565 (39.7%) were women, and the mean (SD) age was 56.4 (9.0) years. In total, 690 (48.5%) had HbA1c levels less than 8%. Age (relative risk [RR] per 1-unit increase, 1.01; 95% CI, 1.00-1.02), persistent use of basal insulin (RR, 1.20; 95% CI, 1.00-1.43), more frequent filling of glucose self-testing supplies (RR, 1.01; 95% CI, 1.01-1.02), visiting an endocrinologist (RR, 1.41; 95% CI, 1.19-1.67), and receipt of insulin prescriptions by mail order (RR, 1.23; 95% CI, 1.03-1.48) were all independently associated with adequate control. Measured potentially modifiable diabetes care factors explained more variation in adequate glycemic control than measured nonmodifiable patient factors (C statistic, 0.661 vs 0.598; pseudo R2 = 0.11 vs 0.04). Conclusions and Relevance: These findings suggest that for patients with type 2 diabetes using insulin, the way in which care is delivered may be more strongly associated with achieving adequate control of HbA1c levels than patient factors that cannot be altered are. Given the potential for intervention, these care delivery factors could be the focus of efforts to improve diabetes outcomes.
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Terapias Complementares/métodos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/fisiopatologia , Índice Glicêmico/efeitos dos fármacos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Idoso , Glicemia/análise , Estudos de Coortes , Feminino , Hemoglobinas Glicadas/análise , Humanos , Masculino , Pessoa de Meia-Idade , New Jersey , Estudos RetrospectivosRESUMO
BACKGROUND: Temporary brigade trips to deliver international surgical care are increasingly common. For the purposes of this work, we use the term brigade to describe self-contained short-term medical or surgical mission trips where healthcare professionals are brought in from foreign regions to provide care to an underserved population. Many brigade programs have begun to collect and publish data on outcomes and complications, but few have examined their own patient education practices. METHODS: We used evidence-based readability and suitability analyses along with patient interviews to develop improved patient education materials for a total joint replacement surgical brigade in the Dominican Republic. RESULTS: Existing patient education materials required an eighth grade reading level and lacked suitability based on the principles of educational theory. The redesigned materials required fifth grade reading skills or less and had superior suitability. Pilot testing with patients from the target population suggested that the materials were appealing and appropriate. CONCLUSIONS: Patient education may play an important role in optimizing outcomes in the setting of medical or surgical brigades where resources and access to follow-up care are limited. More research is needed to bring attention to the importance of patient education during brigades, and programs should work with patients to develop educational materials that are suitable and effective.
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Artroplastia de Substituição , Educação de Pacientes como Assunto , Compreensão , Pessoal de Saúde , Humanos , InternacionalidadeRESUMO
Importance: Patient adherence to antidiabetic medications, especially insulin, remains poor, leading to adverse outcomes and increased costs. Most adherence interventions have only been modestly effective, partly because they are not targeted to patients who could benefit most. Objective: To evaluate whether delivering more intensive insulin-adherence interventions only to individuals with type 2 diabetes predicted to benefit most was more effective than delivering a lower-intensity intervention to a larger group of unselected individuals. Design, Setting, and Participants: This 3-arm pragmatic randomized clinical trial used data from Horizon, the largest health insurer in New Jersey, on 6000 participants 18 years or older with type 2 diabetes who were receiving basal insulin. Patients were excluded if they were insured by Medicaid or Medicare or had fewer than 3 months of continuous enrollment. The study was conducted from July 7, 2016, through October 5, 2017. Analyses were conducted from February 5 to September 24, 2018. Interventions: Eligible patients were randomized to 3 arms in a 1:1:1 ratio. Randomization was stratified based on baseline availability of 1 or more glycated hemoglobin A1c (HbA1c) test values. All arms were designed to cost the same, and each cohort received a tailored pharmacist telephone consultation varying based on (1) proportion receiving the intervention and (2) intensity, including follow-up frequency and cointerventions. Arm 1 offered a low-intensity intervention to all patients. Arm 2 offered a moderate-intensity intervention to 60% of patients based on their predicted risk of insulin nonadherence. Arm 3 offered a high-intensity intervention to 40% of patients based on glycemic control and predicted risk of insulin nonadherence. Main Outcomes and Measures: The primary outcome was insulin persistence. Secondary outcomes were changes in HbA1c level and health care utilization. Outcomes were evaluated in arms 2 and 3 vs arm 1 using claims data, intention-to-treat principles, and multiple imputation for missing values in the 12-month follow-up. Results: Among 6000 participants, mean (SD) age was 55.9 (11.0) years and 3344 (59.8%) were male. Compared with arm 1, insulin nonpersistence did not differ in arm 2 (relative risk, 0.88; 95% CI, 0.75-1.03) or arm 3 (relative risk, 0.91; 95% CI, 0.77-1.06). Glycemic control was similar in arm 2 and arm 1 (absolute HbA1c level difference, -0.15%; 95% CI, -0.34% to 0.05%) but was better in arm 3 (absolute HbA1c level difference, -0.25%; 95% CI, -0.43% to -0.06%). Total spending and office visits did not differ, but arm 2 (moderate intensity intervention) had more hospitalizations (odds ratio, 1.22; 95% CI, 1.06-1.41) and emergency department visits (odds ratio, 1.38; 95% CI, 1.24-1.53) than did arm 1 (low intensity intervention). Conclusions and Relevance: Compared with an untargeted low-intensity intervention, delivering a highly targeted high-intensity intervention did not improve insulin persistence but modestly improved mean glycemic control. A partially targeted moderate-intensity intervention did not change insulin persistence or HbA1c level but was associated with a small increase in hospitalizations. Trial Registration: ClinicalTrials.gov Identifier: NCT02846779.
Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Cooperação do Paciente/estatística & dados numéricos , Idoso , Glicemia/análise , Feminino , Hemoglobinas Glicadas/análise , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Many factors contribute to suboptimal diabetes control including insufficiently-intensive treatment and non-adherence to medication and lifestyle. Determining which of these is most relevant for individual patients is challenging. Patient engagement techniques may help identify contributors to suboptimal adherence and address barriers (using motivational interviewing) and help facilitate choices among treatment augmentation options (using shared decision-making). These methods have not been used in combination to improve diabetes outcomes. OBJECTIVE: To evaluate the impact of a telephone-based patient-centered intervention on glycosylated hemoglobin (HbA1c) control for individuals with poorly-controlled diabetes. DESIGN: Two-arm pragmatic randomized control trial within an explanatory sequential mixed-methods design. SUBJECTS: 1,400 participants 18-64 years old with poorly-controlled type 2 diabetes. INTERVENTION: The intervention was delivered over the telephone by a clinical pharmacist and consisted of a 2-step process that integrated brief negotiated interviewing and shared decision-making to identify patient goals and options for enhancing diabetes management. MAIN MEASURES: The primary outcome was change in HbA1c. Secondary outcomes were medication adherence measures. Outcomes were evaluated using intention-to-treat principles; multiple imputation was used for missing values in the 12-month follow-up. We used information from pharmacist notes to elicit factors to potentially explain the intervention's effectiveness. KEY RESULTS: Participants had a mean age of 54.7 years (SD:8.3) and baseline HbA1c of 9.4 (SD:1.6). Change in HbA1c from baseline was -0.79 (SD:2.01) in the control arm and -0.75 (SD:1.76) in the intervention arm (difference:+0.04, 95%CI: -0.22, 0.30). There were no significant differences in adherence. In as-treated analyses, the intervention significantly improved diabetes control (-0.48, 95%CI: -0.91, -0.05). Qualitative findings provided several potential explanations for the findings, including insufficiently addressing patient barriers. CONCLUSIONS: A novel telephone-based patient-centered intervention did not improve HbA1c among individuals with poorly-controlled diabetes, though as-treated analyses suggest that the intervention was effective for those who received it. TRIAL REGISTRATION: ClinicalTrials.gov NCT02910089.
Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Entrevista Motivacional , Adolescente , Adulto , Controle Comportamental , Diabetes Mellitus Tipo 2/psicologia , Feminino , Hemoglobinas Glicadas/análise , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Farmacêuticos , Telefone , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Individuals with hypertrophic cardiomyopathy (HCM), even when asymptomatic, are at-risk for sudden cardiac death and stroke from arrhythmias, making it imperative to identify individuals affected by this familial disorder. Consensus guidelines recommend that first-degree relatives (FDRs) of a person with HCM undergo serial cardiovascular evaluations. METHODS: We determined the uptake of family screening in patients with HCM and developed an online video intervention to facilitate family communication and screening. Family screening and genetic testing data were collected through a prospective quality improvement initiative, a standardized clinical assessment and management plan (SCAMP), utilized in an established cardiovascular genetics clinic. Patients were prescribed an online video if screening of their FDRs was incomplete and a pilot study on video utilization and family communication was conducted. RESULTS: Two-hundred and sixteen probands with HCM were enrolled in SCAMP Phase I and 190 were enrolled in SCAMP Phase II. In both phases, probands reported that 51% of FDRs had been screened (382/749 in Phase I, 258/504 in Phase II). Twenty patients participated in a pilot study on video utilization and family communication. Nine participants reported watching the video and six participants reported sharing the video with relatives; however only one participant reported sharing the video with relatives who were not yet aware of the diagnosis of HCM in the family. CONCLUSION: Despite care in a specialized cardiovascular genetics clinic, approximately one half of FDRs of patients with HCM remained unscreened. Online interventions and videos may serve as supplemental tools for patients communicating genetic risk information to relatives.
Assuntos
Cardiomiopatia Hipertrófica/diagnóstico , Predisposição Genética para Doença , Testes Genéticos/métodos , Educação em Saúde/métodos , Programas de Rastreamento/psicologia , Sistemas On-Line , Participação do Paciente/psicologia , Cardiomiopatia Hipertrófica/genética , Cardiomiopatia Hipertrófica/psicologia , Família , Feminino , Seguimentos , Testes Genéticos/tendências , Comunicação em Saúde , Promoção da Saúde/métodos , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Participação do Paciente/estatística & dados numéricos , Projetos Piloto , Prognóstico , Estudos ProspectivosRESUMO
The influenza ('flu') vaccination is low cost1 and effective, typically reducing the likelihood of infection by 50-60%2. It is recommended for nearly everyone older than 6 months of age3; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it4. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success5-7. Of the attempts that are successful, most are expensive-limiting scalability-and have not been evaluated in the elderly8. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to one of five versions of letters intended to motivate vaccination, including versions with an implementation intention prompt and an enhanced active choice implementation prompt. We found that a single mailed letter significantly increased influenza vaccination rates compared with no letter. However, there was no difference in vaccination rates across the four different letters tailored with behavioural science techniques.
Assuntos
Influenza Humana , Serviços Postais , Sistemas de Alerta , Vacinação , Idoso , Ciências do Comportamento/métodos , Feminino , Humanos , Programas de Imunização/métodos , Programas de Imunização/estatística & dados numéricos , Influenza Humana/prevenção & controle , Influenza Humana/psicologia , Masculino , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Estados Unidos , Vacinação/métodos , Vacinação/psicologia , Vacinação/estatística & dados numéricosRESUMO
BACKGROUND: Medical missions to low and middle-income countries are increasingly frequent, with an estimated 6,000 trips sponsored by U.S. organizations accounting for approximately 200,000 surgical cases and $250 million in costs annually. However, these missions have received little critical evaluation. This paper describes the research program Operation Walk (Op-Walk) Boston, and proposes an evaluation model for similar surgical missions. METHODS: We propose an evaluation model, borrowing from the work of Donabedian and enriched by evidence from our research program. The model calls for evaluation of the salient contextual factors (culture and beliefs), system management (structure, process, and outcomes), and sustainability of the program's interventions. We used these domains to present findings from the quantitative and qualitative research work of Op-Walk Boston. RESULTS: Op-Walk's qualitative research findings demonstrated that cultural factors are important determinants of patients' perceptions of arthritis etiology, physical activity patterns, and treatment preferences. Quantitative assessments documented that Dominican patients had worse lower-extremity functional status (mean Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function score of 33.6) and pain preoperatively than patients undergoing total hip or knee replacement in the U.S. (WOMAC function score of 43.3 to 54), yet they achieved excellent outcomes (50-point improvement), comparable to those of their U.S. counterparts. Assessments of the quality and sustainability of the Op-Walk program showed that the quality of care provided by Op-Walk Boston meets Blue Cross Blue Shield Centers of Excellence (Blue Distinction) criteria, and that sustainable changes were transferred to the host hospital. CONCLUSIONS: Our proposed model offers a method for formal assessment of medical missions that addresses the call for evidence of their merit. We suggest that surgical missions adopt quantitative and qualitative strategies to document their impact, identify areas of improvement, and justify program continuation, growth, and support.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Missões Médicas , Modelos Teóricos , Boston , República Dominicana , Humanos , Avaliação de Programas e Projetos de Saúde , Pesquisa QualitativaRESUMO
Background Cardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline-directed medical therapy, this study aims to measure and explain apparent deviations in heart failure ( HF ) guideline adherence by clinicians at hospital discharge and describe any impact on readmission rates. Methods and Results The extent of decongestion and prescription of neurohormonal therapy were recorded prospectively for 226 HF discharges, including 132 (58%) from an academic hospital and 94 (42%) from a community hospital. Among all discharges, 25% were discharged with residual congestion (30% academic versus 18% community, P=0.070). Among discharges of patients with HF with reduced ejection fraction, 37% (45% academic versus 18% community, P<0.001) were discharged without ß-blocker therapy or with lower doses than at admission. Moreover, 46% of patients with HF with reduced ejection fraction (48% academic versus 39% community, P=0.390) were discharged without an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker or with lower doses than at admission. Renal dysfunction was the most common reason for discharge with congestion, and hypotension the most common reason for discharge with no or decreased neurohormonal therapy. There was a trend toward higher 90-day readmission rates after discharge with residual congestion. Conclusions Clinicians frequently deviate from guidelines in both academic and community hospitals; however, this deviation may not always indicate poor quality. Application of guidelines recommended for stable populations is increasingly limited for hospitalized patients by hypotension, renal dysfunction, and inotrope use. Patients with renal dysfunction, hypotension, and recent inotrope use merit further study to determine best practices and possibly to adjust quality metrics for HF severity.
Assuntos
Edema Cardíaco/terapia , Fidelidade a Diretrizes , Insuficiência Cardíaca/terapia , Guias de Prática Clínica como Assunto , Centros Médicos Acadêmicos , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Bloqueadores do Receptor Tipo 2 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Comorbidade , Edema Cardíaco/epidemiologia , Edema Cardíaco/etiologia , Edema Cardíaco/fisiopatologia , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Hospitais Comunitários , Humanos , Hipotensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Insuficiência Renal/epidemiologia , Volume Sistólico/fisiologiaRESUMO
Importance: Medication nonadherence accounts for up to half of uncontrolled hypertension. Smartphone applications (apps) that aim to improve adherence are widely available but have not been rigorously evaluated. Objective: To determine if the Medisafe smartphone app improves self-reported medication adherence and blood pressure control. Design, Setting, and Participants: This was a 2-arm, randomized clinical trial (Medication Adherence Improvement Support App For Engagement-Blood Pressure [MedISAFE-BP]). Participants were recruited through an online platform and were mailed a home blood pressure cuff to confirm eligibility and to provide follow-up measurements. Of 5577 participants who were screened, 412 completed consent, met inclusion criteria (confirmed uncontrolled hypertension, taking 1 to 3 antihypertensive medications), and were randomized in a ratio of 1:1 to intervention or control. Interventions: Intervention arm participants were instructed to download and use the Medisafe app, which includes reminder alerts, adherence reports, and optional peer support. Main Outcomes and Measures: Co-primary outcomes were change from baseline to 12 weeks in self-reported medication adherence, measured by the Morisky medication adherence scale (MMAS) (range, 0-8, with lower scores indicating lower adherence), and change in systolic blood pressure. Results: Participants (n = 411; 209 in the intervention group and 202 controls) had a mean age of 52.0 years and mean body mass index, calculated as weight in kilograms divided by height in meters squared, of 35.5; 247 (60%) were female, and 103 (25%) were black. After 12 weeks, the mean (SD) score on the MMAS improved by 0.4 (1.5) among intervention participants and remained unchanged among controls (between-group difference: 0.4; 95% CI, 0.1-0.7; P = .01). The mean (SD) systolic blood pressure at baseline was 151.4 (9.0) mm Hg and 151.3 (9.4) mm Hg, among intervention and control participants, respectively. After 12 weeks, the mean (SD) systolic blood pressure decreased by 10.6 (16.0) mm Hg among intervention participants and 10.1 (15.4) mm Hg among controls (between-group difference: -0.5; 95% CI, -3.7 to 2.7; P = .78). Conclusions and Relevance: Among individuals with poorly controlled hypertension, patients randomized to use a smartphone app had a small improvement in self-reported medication adherence but no change in systolic blood pressure compared with controls. Trial Registration: clinicaltrials.gov Identifier: NCT02727543.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Aplicativos Móveis , Adulto , Anti-Hipertensivos/farmacologia , Pressão Sanguínea/efeitos dos fármacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , SmartphoneRESUMO
BACKGROUND: Poor glycemic control among patients with diabetes may stem from poor medication and lifestyle adherence or a failure to appropriately intensify therapy. A patient-centered approach could discern the most likely possibility and would then, as appropriate, address patient barriers to non-adherence (using behavioral interviewing methods such as motivational interviewing) or help facilitate choices among treatment augmentation options (using methods such as shared decision-making). OBJECTIVE: To test the impact of a novel telephone-based patient-centered intervention on glycemic control for patients with poorly-controlled diabetes. METHODS/DESIGN: ENGAGE-DM (ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus) is a pragmatic trial of patients with poorly-controlled diabetes receiving treatment with an oral hypoglycemic agent. We randomized 1400 patients in a large health insurer to intervention or usual care. The intervention is delivered over the telephone by a pharmacist and consists of a 2-step process that integrates brief negotiated interviewing and shared decision-making to identify patient-concordant goals and options for enhancing patients' diabetes management. The trial's primary outcome is disease control, assessed using glycosylated hemoglobin values. Secondary outcomes include medication adherence measures, assessed using pharmacy claims data. CONCLUSIONS: This trial will determine whether a novel highly-scalable patient engagement strategy improves disease control and adherence to medications among individuals with poorly-controlled diabetes.