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BACKGROUND: Dimension reduction methods do not always reduce their underlying indicators to a single composite score. Furthermore, such methods are usually based on optimality criteria that require discarding some information. We suggest, under some conditions, to use the joint probability density function (joint pdf or JPD) of p-dimensional random variable (the p indicators), as an index or a composite score. It is proved that this index is more informative than any alternative composite score. In two examples, we compare the JPD index with some alternatives constructed from traditional methods. METHODS: We develop a probabilistic unsupervised dimension reduction method based on the probability density of multivariate data. We show that the conditional distribution of the variables given JPD is uniform, implying that the JPD is the most informative scalar summary under the most common notions of information. B. We show under some widely plausible conditions, JPD can be used as an index. To use JPD as an index, in addition to having a plausible interpretation, all the random variables should have approximately the same direction(unidirectionality) as the density values (codirectionality). We applied these ideas to two data sets: first, on the 7 Brief Pain Inventory Interference scale (BPI-I) items obtained from 8,889 US Veterans with chronic pain and, second, on a novel measure based on administrative data for 912 US Veterans. To estimate the JPD in both examples, among the available JPD estimation methods, we used its conditional specifications, identified a well-fitted parametric model for each factored conditional (regression) specification, and, by maximizing the corresponding likelihoods, estimated their parameters. Due to the non-uniqueness of conditional specification, the average of all estimated conditional specifications was used as the final estimate. Since a prevalent common use of indices is ranking, we used measures of monotone dependence [e.g., Spearman's rank correlation (rho)] to assess the strength of unidirectionality and co-directionality. Finally, we cross-validate the JPD score against variance-covariance-based scores (factor scores in unidimensional models), and the "person's parameter" estimates of (Generalized) Partial Credit and Graded Response IRT models. We used Pearson Divergence as a measure of information and Shannon's entropy to compare uncertainties (informativeness) in these alternative scores. RESULTS: An unsupervised dimension reduction was developed based on the joint probability density (JPD) of the multi-dimensional data. The JPD, under regularity conditions, may be used as an index. For the well-established Brief Pain Interference Inventory (BPI-I (the short form with 7 Items) and for a new mental health severity index (MoPSI) with 6 indicators, we estimated the JPD scoring. We compared, assuming unidimensionality, factor scores, Person's scores of the Partial Credit model, the Generalized Partial Credit model, and the Graded Response model with JPD scoring. As expected, all scores' rankings in both examples were monotonically dependent with various strengths. Shannon entropy was the smallest for JPD scores. Pearson Divergence of the estimated densities of different indices against uniform distribution was maximum for JPD scoring. CONCLUSIONS: An unsupervised probabilistic dimension reduction is possible. When appropriate, the joint probability density function can be used as the most informative index. Model specification and estimation and steps to implement the scoring were demonstrated. As expected, when the required assumption in factor analysis and IRT models are satisfied, JPD scoring agrees with these established scores. However, when these assumptions are violated, JPD scores preserve all the information in the indicators with minimal assumption.
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Probabilidad , Humanos , Dolor/diagnóstico , Índice de Severidad de la Enfermedad , Dimensión del Dolor/métodos , Dimensión del Dolor/estadística & datos numéricos , Trastornos Mentales/diagnóstico , Modelos Estadísticos , AlgoritmosRESUMEN
BACKGROUND: Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability. OBJECTIVE: We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing. DESIGN: Convergent mixed-methods design. PARTICIPANTS: Thirty-nine providers and leaders from eight VHA facilities. APPROACH: Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period. KEY RESULTS: Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access. CONCLUSIONS: Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.
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Buprenorfina , Trastornos Relacionados con Opioides , Humanos , Ansiedad , Trastornos de Ansiedad , Miedo , Liderazgo , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/terapiaRESUMEN
BACKGROUND: Altering cover letter information to reduce non-response bias in trauma research could inadvertently leave survey participants unprepared for potentially upsetting questions. In an unsolicited, mailed survey, we assessed participants' change in affect post-survey after altering key cover letter information and promising different incentives. We tested direct and indirect effects of participants carefully reading the cover letter on changes in their affect post-survey. METHODS: In a 3X2X2 randomized, factorial trial, 480 male and 480 female, nationally representative Veterans who were applying for posttraumatic stress disorder disability benefits were randomized to receive one of 12 different cover letters. The cover letters provided general versus more explicit information about the survey's trauma content and how their names were selected for study; we also promised different incentives for returning the survey. The main outcome was change in affect post-survey. We examined five potential moderators: combat or military sexual trauma exposure, posttraumatic stress disorder or serious mental illness diagnosis, and recency of military service. Mediators between reading the cover letter carefully and post-survey affect included how participants rated the cover letters' information and whether they thought the cover letters prepared them for the survey's content. A Bonferroni corrected alpha of 0.003 was the threshold for statistical significance. RESULTS: One hundred ninety men and 193 women reported their pre-and post-survey affect. Across all study conditions, out of 16 possible points, the net change in affect post-survey was less than a quarter-point for men and women. Mean changes in post-survey affect did not differ statistically significantly across any of the study factors (ps > 0.06); nor were there statistically significant interactions between any of the study factors and the 5 moderators after accounting for multiple comparisons (ps > 0.02). After controlling for pre-survey affect, reading the cover letter carefully had small effects on changes in post-survey affect, with larger associations seen in the women compared to men. Mediators' effects were often in opposite directions for men and women. CONCLUSION: General descriptions of a survey's trauma content appear ethically defensible. Research on cover letters' impacts on survey participants' emotional reactions and how those impacts differ by gender is needed.
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Personal Militar , Trastornos por Estrés Postraumático , Veteranos , Femenino , Masculino , Humanos , Motivación , EmocionesRESUMEN
BACKGROUND: Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. METHODS: A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey's topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans' names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents' and sampling frame's characteristics on 8 administrative variables, including Veterans' receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. RESULTS: Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men's variance and 0.6 to 30.5% of women's variance in combat non-response bias and 10.2 to 43.0% of men's variance and 0.4 to 31.9% of women's variance in military sexual trauma non-response bias. Non-random assumptions showed that men's self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women's self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. CONCLUSIONS: Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness.
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Trastornos por Estrés Postraumático , Veteranos , Campaña Afgana 2001- , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Motivación , Trastornos por Estrés Postraumático/terapia , Estados Unidos , United States Department of Veterans AffairsRESUMEN
Implementation studies evaluate strategies to move evidence-based practices into routine clinical practice. Often, implementation scientists use healthcare quality measures to evaluate the integration of an evidence-based clinical practice into real-world healthcare settings. Healthcare quality measures have standardized definitions and are a method to operationalize and monitor guideline-congruent care. Implementation scientists can access existing data on healthcare quality measures through various sources (e.g. operations-calculated), or they can calculate the measures directly from healthcare claims and administrative data (i.e. researcher-calculated). Implementation scientists need a better understanding of the advantages and disadvantages of these methods of obtaining healthcare quality data for designing, planning and executing an implementation study. The purpose of this paper is to describe the advantages, risks and lessons learned when using operations- versus researcher-calculated healthcare quality measures in site selection, implementation monitoring and implementation outcome evaluation. A key lesson learned was that relying solely on operations-calculated healthcare quality measures during an implementation study poses risks to site selection, accurate feedback on implementation progress to stakeholders, and the integrity of study results. A possible solution is using operations-calculated quality measures for monitoring of evidence-based practice uptake and researcher-calculated measures for site section and outcomes evaluation. This approach provides researchers greater control over the data and consistency of the measurement from site selection to outcomes evaluation while still retaining measures that are familiar and understood by key stakeholders whom implementation scientists need to engage in practice change efforts.
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Evaluación de Resultado en la Atención de Salud , HumanosRESUMEN
To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .
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Trastornos por Estrés Postraumático , Veteranos , Humanos , Estudios Prospectivos , Psicoterapia , Trastornos por Estrés Postraumático/terapia , Estados Unidos , United States Department of Veterans Affairs , Salud de los VeteranosRESUMEN
PURPOSE: The aim of this study was to quantify the distribution, frequency, and clinical significance of incidental findings (IFs) on initial lung cancer screening (LCS) and the association of report characteristics with subsequent assessment. METHODS: Health records of patients undergoing initial LCS from 2015 to 2018 in the Minneapolis VA Health Care System were retrospectively reviewed for demographics, Lung CT Screening Reporting & Data System coding, IFs, and subsequent clinical assessment. IFs were considered potentially significant if they were likely to require any follow-up. High-risk significant IFs (SIFs) were potentially malignant. The primary outcome was the SIF being addressed. Outcomes were analyzed using a mixed-effects model. RESULTS: Patients (n = 901) were primarily male (94.1%) smokers (62.1%) with a mean age of 65.2 years. IFs were extremely common (93.9%), with an average of 2.6 IFs per scan (n = 2,296). Seven hundred eighty-six IFs (34.2%) were deemed likely SIFs, of which 58 (7.4%) were high risk. Two hundred twenty-two (28.2%) were addressed by clinicians, of which 104 (13.2%) underwent testing. Reporting of SIFs varied among radiologists, with at least one SIF in the impression in 24% to 78% of low-dose CT studies with the S modifier, used to indicate the presence of a SIF, applied to 0% to 51% of reports. In the mutually adjusted model, radiologist recommendation (adjusted odds ratio [OR], 4.67; 95% confidence interval [CI], 2.23-9.76), high-risk finding (adjusted OR, 4.35; 95% CI, 1.81-10.45), and reporting in the impression (adjusted OR, 2.58; 95% CI, 1.28-5.18) were associated with increased odds of the SIF's being addressed. CONCLUSIONS: Radiologists vary in their reporting of IFs on LCS. Further standardization of reporting of SIFs may improve this process, with the simultaneous goals of generating appropriate testing when needed and minimizing low-value care.
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Neoplasias Pulmonares , Humanos , Masculino , Anciano , Neoplasias Pulmonares/diagnóstico por imagen , Detección Precoz del Cáncer , Hallazgos Incidentales , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.
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Tutoría , Trastornos por Estrés Postraumático , Humanos , Trastornos por Estrés Postraumático/terapia , Salud de los Veteranos , Mentores , Mejoramiento de la Calidad , PsicoterapiaRESUMEN
Background: Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD. Methods: This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach. Results: There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites. Conclusion: Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted.
Medication treatment of opioid use disorder (MOUD) is a key element in addressing the opioid epidemic. The development, approval, and effectiveness of buprenorphine and naltrexone have expanded access to MOUD from specialty opioid treatment programs to office-based treatment. However, uptake of these evidence-based treatments across the Veterans Health Administration (VHA) is variable. To address this gap in care within the VHA, The Advancing Pharmacological Treatment for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy aimed at facility-level barriers at low-adopting VHA facilities while the VHA Pharmacy Benefits Management Academic Detailing Services Opioid Agonist Treatment of OUD Campaign implemented academic detailing with the goal to address clinician-level barriers. This article evaluates the effect these two co-occurring and independent initiatives had on each other and MOUD reach. The results suggest a trend toward a positive synergistic relationship between the two initiatives, that warrants further study and evaluation to inform further implementation efforts.
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BACKGROUND: The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS: We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS: The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS: Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.
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Importance: Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited. Objective: To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse. Design, Setting, and Participants: This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021. Interventions: Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation. Main Outcomes and Measures: Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment. Results: A cohort of 199â¯836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415â¯123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach. Conclusions and Relevance: This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose.
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Sobredosis de Opiáceos , Trastornos Relacionados con Opioides , Prevención del Suicidio , Anciano , Analgésicos Opioides/efectos adversos , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Trastornos Relacionados con Opioides/tratamiento farmacológico , Estados Unidos/epidemiologíaRESUMEN
The need for cognitive closure describes the extent to which a person, faced with a decision, prefers any answer in lieu of continued uncertainty. This construct may be relevant in lung cancer screening, which can both reduce and increase uncertainty. We examined whether individual differences in need for cognitive closure are associated with Veterans' completion of lung cancer screening using a self-administered survey (N = 361). We also assessed whether need for cognitive closure moderates an association between screening completion and lung cancer risk perception. Contrary to our main hypothesis, high need for cognitive closure Veterans were not more likely to complete lung cancer screening and need for cognitive closure did not have a moderating role.
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Cognición , Detección Precoz del Cáncer/psicología , Individualidad , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/psicología , Incertidumbre , Anciano , Femenino , Humanos , Masculino , Riesgo , Encuestas y Cuestionarios , Veteranos/psicologíaRESUMEN
INTRODUCTION: This study examines the presence and correlates of gender disparities in smoking cessation among lower income smokers prescribed nicotine replacement medication. METHODS: We examined quit rates (7-day abstinence point prevalence) among a cohort of smokers who filled prescriptions for nicotine replacement (N = 1,782), using Minnesota Health Care Programs' (e.g., Medicaid) pharmacy claims databases (2005-2006) and mixed-mode survey protocols. A cohort of smokers who recently filled a prescription for nicotine replacement was stratified by race, and then subjects were selected by simple random sample from each race, oversampling the nonWhite groups (N = 1,782). The primary outcome was point prevalence of 7-day abstinence, and outcomes were assessed about 8 months after the nicotine replacement therapy (NRT) index prescription fill date using a mixed-mode survey protocol. Final interaction models were constructed using backward elimination. RESULTS: Abstinence rates were 11.4% among women and 19.2% among men (p = .02) and remained marginally significant after controlling for demographics, mental and physical health, period of cigarette abstinence, social environment, religious attendance, perceived stress, and NRT prescription type (p = .08). There was a significant Gender x Employment interaction (p = .02). Among men, quit rates were higher among the employed (26%) compared with the unemployed (16%); among women, quit rates were lower among those who were employed (8%) compared with those who were unemployed (14%). DISCUSSION: Results suggest the need for research on factors specific to women's work roles or workplaces that inhibit cessation as well as cessation programs tailored to low-income, employed female smokers. On-site workplace interventions and flexible counseling programs may be especially beneficial.
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Empleo/organización & administración , Pobreza/estadística & datos numéricos , Cese del Hábito de Fumar/psicología , Fumar/psicología , Tabaquismo/terapia , Salud de la Mujer , Adulto , Estudios de Cohortes , Consejo/organización & administración , Empleo/psicología , Femenino , Promoción de la Salud/organización & administración , Humanos , Relaciones Interpersonales , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Nicotina/uso terapéutico , Agonistas Nicotínicos/uso terapéutico , Distribución por Sexo , Fumar/epidemiología , Cese del Hábito de Fumar/métodos , Cese del Hábito de Fumar/estadística & datos numéricos , Prevención del Hábito de Fumar , Medio Social , Tabaquismo/epidemiología , Resultado del Tratamiento , Lugar de Trabajo/organización & administración , Adulto JovenRESUMEN
INTRODUCTION: Female veterans smoke cigarettes at high rates compared with both male veterans and nonveteran women. Proactive outreach to smokers may reduce gender disparities in cessation care. The objectives of this study were to compare baseline experiences with VA smoking cessation care for men and women and to assess for gender differences in response to a proactive outreach intervention. METHODS: We conducted a post hoc subgroup analysis of a pragmatic, multisite randomized, controlled trial comparing proactive outreach with usual care (UC). Baseline experiences included physician advice to quit, satisfaction with care, and past-year treatment use. At the 1-year follow-up, treatment use, quit attempts, and 6-month prolonged abstinence for women and men randomized to proactive outreach versus UC were compared using logistic regression. RESULTS: Baseline and follow-up surveys were returned by 138 women and 2,516 men. At baseline, women were less likely than men to report being very or somewhat satisfied with the process of obtaining smoking cessation medications in the VA (47% of women vs. 62% of men), but no less likely to report having used cessation medications from the VA in the past year (39% of women vs. 34% of men). After the intervention, phone counseling and combined therapy increased among both women and men in proactive outreach as compared with UC. At the 1-year follow-up, men in proactive outreach were significantly more likely to report prolonged abstinence than those in UC (odds ratio, 1.65; 95% CI, 1.28-2.14); results for women were in the same direction but not statistically significant (odds ratio, 1.39; 95% CI, 0.48-3.99). CONCLUSIONS: Satisfaction with cessation care in VA remains low. Proactive outreach to smokers was associated with an increased use of cessation therapies, and increased odds of achieving prolonged abstinence. A subgroup analysis by gender did not reveal significant differences in the treatment effect.
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Consejo/métodos , Cese del Hábito de Fumar/métodos , Cese del Hábito de Fumar/psicología , Fumar/psicología , Fumar/terapia , Veteranos/estadística & datos numéricos , Adulto , Femenino , Hospitales de Veteranos , Humanos , Masculino , Estudios Multicéntricos como Asunto/métodos , Médicos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Cese del Hábito de Fumar/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologíaRESUMEN
INTRODUCTION: Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention. METHODS: This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up. RESULTS: Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0). CONCLUSIONS: In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00608426.
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Consejo/métodos , Cese del Hábito de Fumar/psicología , Fumar/terapia , Factores Socioeconómicos , Veteranos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Fumar/psicología , Teléfono , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologíaRESUMEN
OBJECTIVES: To describe participation rates, results, and lessons learned from a lung cancer screening (LCS) demonstration project. STUDY DESIGN: Prospective observational study at 1 of 8 centers participating in a national Veterans Health Administration LCS demonstration project. METHODS: An electronic health record (EHR) algorithm and tobacco pack-year (TPY) information prompt identified patients potentially eligible for LCS. LCS invitation was planned to consist of shared decision-making materials, an invitation letter to call the LCS manager, a reminder letter, and an outreach phone call for nonresponders. The outreach call was subsequently dropped due to time constraints on the LCS manager. Lung nodules and incidental findings on LCS low-dose computed tomography (LDCT) were recorded in templated radiology reports and tracked with EHR notes. RESULTS: Of 6133 potentially eligible patients, we identified 1388 patients with eligible TPY information: 918 were invited for LCS and 178 (19%) completed LCS. LCS completion was more likely in patients in the mailing-plus-call outreach group (phase I) compared with the mail-only group (phase II) (22% vs 9%; P <.001). Among those completing an LDCT, 61% had lung nodules requiring follow-up: 43% of the nodules were less than 4 mm in diameter, 12 patients required further diagnostic evaluation, and 2 had lung malignancies. There were 179 incidental LDCT findings in 116 patients, and 20% were clinically significant. CONCLUSIONS: Important considerations in LCS are accurate identification of eligible patients, balancing invitation approaches with resource constraints, and establishing standardized methods for tracking numerous small lung nodules and incidental findings detected by LDCT.
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Hospitales de Veteranos , Neoplasias Pulmonares/diagnóstico por imagen , Tamizaje Masivo/métodos , Fumadores , Tomografía Computarizada por Rayos X , Anciano , Toma de Decisiones , Registros Electrónicos de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Estados UnidosRESUMEN
RATIONALE: Adults with chronic lower respiratory disease differ in their barriers to smoking cessation but also suffer from tobacco-related health concerns, which may motivate quit attempts. Few studies have examined differences in tobacco treatment response between smokers with and without chronic lower respiratory disease. OBJECTIVE: We examined the effectiveness of a proactive outreach program for cessation among smokers with and without chronic lower respiratory disease. METHODS: Subgroup analysis of the Veterans Victory over Tobacco Study, a pragmatic randomized controlled trial that demonstrated the effectiveness of proactive outreach and the choice of tobacco treatments compared with usual care. Smokers identified via the electronic medical record were proactively offered phone-based counseling and care coordination to receive medication from their Veterans Affairs providers or in-person care. We compared the response among those with and without an International Classification of Diseases, 9th Revision diagnosis of a chronic lower respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma). We used stratification by propensity scores to adjust for imbalanced covariates between groups with and without chronic lower respiratory disease within each treatment arm, using complete case analysis accounting for the stratified sampling by site. RESULTS: The study participants were predominantly older, white, male smokers. Overall, 19.6% had chronic lower respiratory disease. A total of 3,307 had outcome data with the following assignments to the intervention: proactive care: n = 1,272 without chronic lower respiratory disease, n = 301 with chronic lower respiratory disease; usual care: n = 1,387 without chronic lower respiratory disease, n = 347 with chronic lower respiratory disease. A total of 1,888 had both complete baseline and outcome data and were included in the primary analysis. In unadjusted analyses (n = 3,307), among individuals with chronic lower respiratory disease, 13.1% in the proactive group reported 6-month prolonged abstinence compared with 8.7% of those in the usual care group (odds ratio, 1.57; 95% confidence interval, 0.93-2.65). Among individuals without chronic lower respiratory disease, 13.1% quit in the proactive group compared with 11.0% in the usual care group (odds ratio, 1.22; 95% confidence interval, 0.95-1.55). In adjusted analyses (n = 1,888), the association between treatment arm and quit rate varied by the presence of chronic lower respiratory disease, with a stronger association between allocation to the proactive group and quit rate among those with chronic lower respiratory disease (odds ratio, 3.45; 95% confidence interval, 1.59-7.47) than those without chronic lower respiratory disease (odds ratio, 1.34; 95% confidence interval, 0.95-1.88; P for interaction with chronic lower respiratory disease = 0.03). CONCLUSIONS: Smokers with chronic lower respiratory disease may be more likely to respond to a proactive outreach intervention for tobacco cessation treatment than those without chronic lower respiratory disease. Clinical trial registered with www.clinicaltrials.gov (NCT 00608426).
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Enfermedades Respiratorias/epidemiología , Fumadores/estadística & datos numéricos , Cese del Hábito de Fumar/métodos , Tabaquismo/terapia , Adolescente , Adulto , Anciano , Enfermedad Crónica , Consejo , Registros Electrónicos de Salud , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Tabaquismo/complicaciones , Estados Unidos/epidemiología , Veteranos/estadística & datos numéricos , Adulto JovenRESUMEN
OBJECTIVE: It has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability. METHODS: This observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability. RESULTS: Sustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability. CONCLUSIONS: There was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.
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Práctica Clínica Basada en la Evidencia/educación , Implementación de Plan de Salud/métodos , Psicoterapia/métodos , Trastornos por Estrés Postraumático/terapia , Carga de Trabajo , Adulto , Competencia Clínica , Femenino , Hospitales de Veteranos , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
BACKGROUND: Prior research suggests that racial/ethnic minority smokers experience more difficulty with cessation than white smokers and access formal treatment less often. Minority smokers may respond differently to treatment interventions than white smokers. This prospective, observational cohort study compared long-term cessation outcomes among four racial/ethnic groups after an aided quit attempt using nicotine replacement therapy (NRT). METHODS: A random cohort of smokers (N=1782) who recently filled a prescription for NRT was selected, stratified by race, using Minnesota Health Care Programs (e.g., Medicaid) pharmacy claims databases between July 2005 and September 2006. The primary outcome was 7-day point prevalence abstinence, which was assessed about 8 months after the NRT index prescription fill date using a mixed-mode survey protocol. RESULTS: The overall survey response was 58.2%. Overall, abstinence outcomes did not significantly vary by race. Unadjusted comparisons show that among survey respondents, at 8 months, 7-day point prevalence abstinence was 13.8% among whites, 13.6% among blacks, 14.1% among American Indians/Alaska Natives, and 20.7% among Asians (p=0.42). Similarly, the 30-day duration abstinence was 10.0% among whites, 11.5% among blacks, 8.9% among American Indians/Alaska Natives, and 18.3% among Asians (p=0.14). In multivariate analysis using propensity adjustment for potential confounding and response bias, there was no evidence that the effectiveness of NRT was lower for racial/ethnic minority smokers compared to white smokers. CONCLUSIONS: These findings indicate that racial/ethnic minorities are as likely to quit smoking at a level similar to whites when using cessation treatment that includes NRT. Given documented disparities in the use of evidence-based cessation treatments such as NRT, interventions are sorely needed to improve access and utilization of these treatments in racial/ethnic minority groups.
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Nicotina/uso terapéutico , Evaluación de Resultado en la Atención de Salud , Pobreza , Grupos Raciales , Tabaquismo/tratamiento farmacológico , Adulto , Estudios de Cohortes , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , MinnesotaRESUMEN
Menthol may make cigarettes more addictive and rates of menthol cigarette smoking are disproportionately higher among Black. However, few studies have examined the association between menthol cigarette smoking and cessation, and the studies to date have produced conflicting findings. The present study examines the effect of menthol cigarette smoking on cessation among a multi-ethnic sample of smokers making a pharmacotherapy-aided quit attempt. We hypothesized that menthol cigarette smoking would be associated with lower smoking abstinence rates and conducted a secondary analysis of data from a multi-site randomized controlled trial of an intervention designed to facilitate repeat tobacco cessation treatment (N = 1,343). The intervention consisted of a patient phone call and a computerized provider prompt. The primary outcome for this analysis was 7-day point prevalence smoking abstinence. The average age of the sample was 56 years old. Overall, 25% of the sample smoked menthol cigarettes: 19% of Whites, 62% of Blacks, and 25% of other ethnicity (p<.001). We observed no significant effects for menthol cigarette smoking or ethnicity on smoking abstinence rates. In conclusion, combined with findings from previous research, this study suggests that smoking menthol cigarettes does not decrease smoking cessation among older smokers during a quit attempt aided with pharmacotherapy.