Development and Implementation of a Telemental Health Program for Caregivers in a Children's Hospital Setting.

Introduction: Caregivers of children with chronic illness, such as hematology-oncology conditions, face numerous stressors, and a subset experience persistent distress and poor psychological outcomes. Many logistical and ethical barriers complicate the provision of mental health care to caregivers in children's hospital settings. Telemental health (TMH) is one method to increase access and reduce barriers. Methods: A partnership was established with an outside TMH agency to provide mental health care to caregivers of children with hematology-oncology conditions. Development and implementation strategies are described, and feasibility was measured on four dimensions. Results: One hundred twenty-seven (n = 127) caregivers were referred for TMH services in the first 28 months of program implementation. Of the total, 63/127 (49%) received TMH services for at least one session. Most caregivers had a child in active medical treatment (89%). A small portion (11%) of caregivers were bereaved or had a child in hospice care. Program feasibility was enhanced by hospital leadership support and availability of staffing, financial, and technology resources. Available resources also contributed to the practicality of program development and swift implementation and integration within the defined hospital system. Discussion: Partnership with an outside TMH agency increased access to care and reduced barriers to treating caregivers in a children's hospital setting. Offering mental health interventions to caregivers aligns with evidence-based standards of care. Future research will elucidate caregiver satisfaction with this modality of treatment and whether use of TMH reduces disparities in caregiver receipt of mental health care in children's hospital settings.

Chronic opioid use emerging after bariatric surgery.

PURPOSE: Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery. METHODS: This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days' supply. RESULTS: Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days' supply was strongly associated with chronic use post-surgery (1-29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24-2.88]; 90-119 days OR, 14.29 [95%CI, 6.94-29.42] compared with no days). Other factors associated with increased likelihood of post-surgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39-3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12-2.50]), and tobacco (OR, 1.44 [95%CI, 1.03-2.02]). Older age (OR, 0.84 [95%CI, 0.73-0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25-0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery. CONCLUSIONS: Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery.

Chronic use of opioid medications before and after bariatric surgery.

IMPORTANCE: Obesity is associated with chronic noncancer pain. It is not known if opioid use for chronic pain in obese individuals undergoing bariatric surgery is reduced. OBJECTIVES: To determine opioid use following bariatric surgery in patients using opioids chronically for pain control prior to their surgery and to determine the effect of preoperative depression, chronic pain, or postoperative changes in body mass index (BMI) on changes in postoperative chronic opioid use. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in a distributed health network (10 demographically and geographically varied US health care systems) of 11,719 individuals aged 21 years and older, who had undergone bariatric surgery between 2005 and 2009, and were assessed 1 year before and after surgery, with latest follow-up by December 31, 2010. MAIN OUTCOMES AND MEASURES: Opioid use, measured as morphine equivalents 1 year before and 1 year after surgery, excluding the first 30 postoperative days. Chronic opioid use is defined as 10 or more opioid dispensings over 90 or more days or as dispensings of at least a 120-day supply of opioids during the year prior to surgery. RESULTS: Before surgery, 8% (95% CI, 7%-8%; n = 933) of bariatric patients were chronic opioid users. Of these individuals, 77% (95% CI, 75%-80%; n = 723) continued chronic opioid use in the year following surgery. Mean daily morphine equivalents for the 933 bariatric patients who were chronic opioid users before surgery were 45.0 mg (95% CI, 40.0-50.1) preoperatively and 51.9 mg (95% CI, 46.0-57.8) postoperatively (P < .001). For this group with chronic opiate use prior to surgery, change in morphine equivalents before vs after surgery did not differ between individuals with loss of more than 50% excess BMI vs those with 50% or less (>50% BMI loss: adjusted incidence rate ratio [adjusted IRR, 1.17; 95% CI, 1.07-1.28] vs ≤50% BMI loss [adjusted IRR, 1.03; 95% CI, 0.93-1.14] model interaction, P = .06). In other subgroup analyses of preoperative chronic opioid users, changes in morphine equivalents before vs after surgery did not differ between those with or without preoperative diagnosis of depression or chronic pain (depression only [n = 75; IRR, 1.08; 95% CI, 0.90-1.30]; chronic pain only [n = 440; IRR, 1.17; 95% CI, 1.08-1.27]; both depression and chronic pain [n = 226; IRR, 1.11; 95% CI, 0.96-1.28]; neither depression nor chronic pain [n = 192; IRR, 1.22; 95% CI, 0.98-1.51); and P values for model interactions when compared with neither were P = .42 for depression, P = .76 for pain, and P = .48 for both. CONCLUSIONS AND RELEVANCE: In this cohort of patients who underwent bariatric surgery, 77% of patients who were chronic opioid users before surgery continued chronic opioid use in the year following surgery, and the amount of chronic opioid use was greater postoperatively than preoperatively. These findings suggest the need for better pain management in these patients following surgery.

The effect of bariatric surgery on psychiatric course among patients with bipolar disorder.

OBJECTIVE: Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder. METHODS: A matched cohort study (2006-2009) with mean follow-up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups. RESULTS: A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow-up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83-1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (-0.4 visits/year, 95% CI: -0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: -0.1 to 1.0). CONCLUSIONS: Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.

A comparison of lifestyle and behavioral cardiovascular disease risk factors between Asian Indian and White non-Hispanic men.

OBJECTIVE: We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. DESIGN/SETTING/PARTICIPANTS: Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men's Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). MAIN OUTCOME MEASURES: Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. RESULTS: Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. CONCLUSIONS: We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.

Perceptions of middle school educators in Hawai'i about school-based gardening and child health.

BACKGROUND: Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health. METHODS: Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai'i were conducted. Data were analyzed using a grounded theory approach. RESULTS: Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health. CONCLUSIONS: In order to be effective at obesity prevention, school-based gardening programs in Hawai'i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.

Surgical treatment of morbid obesity among patients with bipolar disorder: a research agenda.

INTRODUCTION: Persons with bipolar disorder (BD) have an increased risk of obesity and associated diseases. Success of current behavioral treatment for obesity in patients with BD is inadequate. METHODS: Existing literature on bariatric surgery outcomes in populations with BD were reviewed, and needed areas of research were identified. RESULTS: Knowledge about bariatric surgery outcomes among patients with BD is limited. Available evidence indicates that bariatric surgery is a uniquely effective intervention for achieving and sustaining significant weight loss and improving metabolic parameters. Notwithstanding the benefits of bariatric surgery in nonpsychiatric samples, individuals with BD (and other serious and persistent mental illnesses) have decreased access to this intervention. Areas of needed research include: (1) current practice patterns; (2) metabolic course after bariatric surgery; (3) psychiatric course after bariatric surgery; and (4) mechanisms of psychiatric effect. CONCLUSION: The considerable hazards posed by obesity in BD, as measured by illness complexity and premature mortality, provide the basis for hypothesizing that bariatric surgery may prevent and improve morbidity in this patient population. In addition to physical health benefits, bariatric surgery may exert a robust and favorable effect on the course and outcome of BD and reduce obesity-associated morbidity, the most frequent cause of premature mortality in this patient population.

Heterogeneity of diabetes outcomes among asians and pacific islanders in the US: the diabetes study of northern california (DISTANCE).

OBJECTIVE: Ethnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted. RESULTS: Pacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites. CONCLUSIONS: Incidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.

The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study.

BACKGROUND: Use of four or more prescription medications is considered a risk factor for falls in older people. It is unclear whether this polypharmacy-fall relationship differs for adults with diabetes. OBJECTIVE: We evaluated the association between number of prescription medications and incident falls in a multi-ethnic population of type-2 diabetes patients in order to establish an evidence-based medication threshold for fall risk in diabetes. DESIGN: Baseline survey (1994-1997) with 5 years of longitudinal follow-up. PARTICIPANTS: Eligible subjects (N = 46,946) had type-2 diabetes, were >or=18 years old, and enrolled in the Kaiser Permanente Northern California Diabetes Registry. MEASUREMENTS AND MAIN RESULTS: We identified clinically recognized incident falls based on diagnostic codes (ICD-9 codes: E880-E888). Relative to regimens of 0-1 medications, regimens including 4 or more prescription medications were significantly associated with an increased risk of falls [4-5 medications adjusted HR 1.22 (1.04, 1.43), 6-7 medications 1.33 (1.12, 1.58), >7 medications 1.59 (1.34, 1.89)]. None of the individual glucose-lowering medications was found to be significantly associated with a higher risk of falls in predictive models. CONCLUSIONS: The prescription of four or more medications was associated with an increased risk of falls among adult diabetes patients, while no specific glucose-lowering agent was linked to increased risk. Baseline risk of falls and number of baseline medications are additional factors to consider when deciding whether to intensify diabetes treatments.