A Randomized Controlled Trial of Animal-assisted Activities for Pediatric Oncology Patients: Psychosocial and Microbial Outcomes.

INTRODUCTION: Evidence about the effectiveness and safety of dog visits in pediatric oncology is limited. METHOD: We conducted a randomized controlled trial (n=26) of dog visits versus usual care among pediatric oncology inpatients. Psychological functioning and microbial load from hand wash samples were evaluated. Parental anxiety was a secondary outcome. RESULTS: We did not observe a difference in the adjusted mean present functioning score (-3.0; 95% confidence interval [CI], -12.4 to 6.4). The difference in microbial load on intervention versus control hands was -0.04 (95% CI, -0.60 to 0.52) log10 CFU/mL, with an upper 95% CI limit below the prespecified noninferiority margin. Anxiety was lower in parents of intervention versus control patients. DISCUSSION: We did not detect an effect of dog visits on functioning; however, our study was underpowered by low recruitment. Visits improved parental anxiety. With hand sanitization, visits did not increase hand microbial levels. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT03471221.

Integrating Alcohol-Related Prevention and Treatment Into Primary Care: A Cluster Randomized Implementation Trial.

Importance: Unhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment. Objective: To test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration. Design, Setting, and Participants: The Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021. Interventions: The implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice's intervention period. Main Outcomes and Measures: Coprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression. Results: A total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P < .001). The proportion with AUD treatment engagement did not differ during intervention and usual care (1.4 vs 1.8 per 10 000 patients; P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P < .001), new AUD diagnosis (33.8 vs 28.8 per 10 000; P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04). Conclusions and Relevance: In this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation. Trial Registration: ClinicalTrials.gov Identifier: NCT02675777.

The impact of primary care behavioral health services on patient behaviors: A randomized controlled trial.

INTRODUCTION: Greater understanding of the impact of low intensity psychosocial interventions delivered by behavioral health clinicians (BHCs) working in an integrated care program (ICP) may promote better depression care. METHOD: In a randomized controlled trial, 153 participants identified as depressed by their primary care provider (PCP) were assigned to ICP or usual care (UC, management by PCP, including specialty referral). In the ICP condition, BHCs worked collaboratively with PCPs and liaison psychiatrists. RESULTS: ICP participants with lower and higher severity symptoms reported significantly greater use of coping strategies than UC participants at the 1-month follow up (lower: p = .002; higher: p = .016). ICP participants with lower severity continued to report significantly greater use of coping strategies than UC participants at the 4-month (p = .024), and 7-month (p = .012) follow ups. ICP participants were more likely to be following relapse preventions plans at the 4-month follow up (lower: 89.5% vs. 50%, p = .0.000; higher 74.1% vs. 33%, p = .0001). ICP participants also reported use of antidepressant medications on more days than UC participants at the 4-month follow up (lower: 21.27 vs. 14.49 days, p = .049; higher: 24.61 vs. 17.08 days, p = .035). Patient retention in the ICP was high, and ICP participants were significantly more satisfied with depression care than UC participants at follow-up assessments. DISCUSSION: Delivery of low intensity psychosocial interventions by BHCs was associated with improvements to behavior charge targets. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Integration of screening, assessment, and treatment for cannabis and other drug use disorders in primary care: An evaluation in three pilot sites.

BACKGROUND: This pilot study evaluated whether use of evidence-based implementation strategies to integrate care for cannabis and other drug use into primary care (PC) as part of Behavioral Health Integration (BHI) increased diagnosis and treatment of substance use disorders (SUDs). METHODS: Patients who visited the three pilot PC sites were eligible. Implementation strategies included practice coaching, electronic health record decision support, and performance feedback (3/2015-4/2016). BHI introduced annual screening for past-year cannabis and other drug use, a Symptom Checklist for DSM-5 SUDs, and shared decision-making about treatment options. Main analyses tested whether the proportions of PC patients diagnosed with, and treated for, new cannabis or other drug use disorders (CUDs and DUDs, respectively), differed significantly pre- and post-implementation. RESULTS: Of 39,599 eligible patients, 57% and 59% were screened for cannabis and other drug use, respectively. Among PC patients reporting daily cannabis use (2%) or any drug use (1%), 51% and 37%, respectively, completed an SUD Symptom Checklist. The proportion of PC patients with newly diagnosed CUD increased significantly post-implementation (5 v 17 per 10,000 patients, p < 0.0001), but not other DUDs (10 vs 13 per 10,000, p = 0.24). The proportion treated for newly diagnosed CUDs did not increase post-implementation (1 vs 1 per 10,000, p = 0.80), but did for those treated for newly diagnosed other DUDs (1 vs 3 per 10,000, p = 0.038). CONCLUSIONS: A pilot implementation of BHI to increase routine screening and assessment for SUDs was associated with increased new CUD diagnoses and a small increase in treatment of new other DUDs.

Systematic Multi-Domain Alzheimer's Risk Reduction Trial (SMARRT): Study Protocol.

This article describes the protocol for the Systematic Multi-domain Alzheimer's Risk Reduction Trial (SMARRT), a single-blind randomized pilot trial to test a personalized, pragmatic, multi-domain Alzheimer's disease (AD) risk reduction intervention in a US integrated healthcare delivery system. Study participants will be 200 higher-risk older adults (age 70-89 years with subjective cognitive complaints, low normal performance on cognitive screen, and ≥ two modifiable risk factors targeted by our intervention) who will be recruited from selected primary care clinics of Kaiser Permanente Washington, oversampling people with non-white race or Hispanic ethnicity. Study participants will be randomly assigned to a two-year Alzheimer's risk reduction intervention (SMARRT) or a Health Education (HE) control. Randomization will be stratified by clinic, race/ethnicity (non-Hispanic white versus non-white or Hispanic), and age (70-79, 80-89). Participants randomized to the SMARRT group will work with a behavioral coach and nurse to develop a personalized plan related to their risk factors (poorly controlled hypertension, diabetes with evidence of hyper or hypoglycemia, depressive symptoms, poor sleep quality, contraindicated medications, physical inactivity, low cognitive stimulation, social isolation, poor diet, smoking). Participants in the HE control group will be mailed general health education information about these risk factors for AD. The primary outcome is two-year cognitive change on a cognitive test composite score. Secondary outcomes include: 1) improvement in targeted risk factors, 2) individual cognitive domain composite scores, 3) physical performance, 4) functional ability, 5) quality of life, and 6) incidence of mild cognitive impairment, AD, and dementia. Primary and secondary outcomes will be assessed in both groups at baseline and 6, 12, 18, and 24 months.

Impact of initiatives to reduce prescription opioid risks on medically attended injuries in people using chronic opioid therapy.

PURPOSE: The purpose of the study is to determine whether initiatives to improve the safety of opioid prescribing decreased injuries in people using chronic opioid therapy (COT). METHODS: We conducted an interrupted time series analysis using data from Group Health (GH), an integrated health care delivery system in the United States. In 2007, GH implemented initiatives which substantially reduced daily opioid dose and increased patient monitoring. Among GH members age 18 or older receiving COT between 2006 and 2014, we compared injury rates for patients in GH's integrated group practice (IGP; exposed to the initiatives) vs patients cared for by contracted providers (not exposed). Injuries were identified using a validated algorithm. We calculated injury incidence during the baseline (preintervention) period from 2006 to 2007; the dose reduction period, 2008 to 2010; and the risk stratification and monitoring period, 2010 to 2014. Using modified Poisson regression, we estimated adjusted relative risks (RRs) representing the relative change per year in injury rates. RESULTS: Among 21 853 people receiving COT in the IGP and 8260 in contracted care, there were 2679 injuries during follow-up. The baseline injury rate was 1.0% per calendar quarter in the IGP and 0.9% in contracted care. Risk reduction initiatives did not decrease injury rates: Within the IGP, the RR in the dose reduction period was 1.01 (95% CI, 0.95-1.07) and in the risk stratification and monitoring period, 0.99 (95% CI, 0.95-1.04). Injury trends did not differ between the two care settings. CONCLUSIONS: Risk reduction initiatives did not decrease injuries in people using COT.

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives.

BACKGROUND: To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care. OBJECTIVE: To identify what patients with multiple chronic conditions describe as most important to their well-being and health. DESIGN: We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory. PARTICIPANTS: A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state. APPROACH: Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation. KEY RESULTS: Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation. CONCLUSIONS: The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Integrated medical care management and behavioral risk factor reduction for multicondition patients: behavioral outcomes of the TEAMcare trial.

PURPOSE: The purpose of the study was to compare behavioral outcomes (physical activity, sedentary behavior, smoking cessation, diet) between the intervention and usual care conditions from the TEAMcare trial. METHODS: TEAMcare was a randomized trial among 214 adults with depression and poorly controlled diabetes and/or coronary heart disease that promoted health behavior change and pharmacotherapy to improve health. Behavioral outcomes were measured with the International Physical Activity Questionnaire (physical activity, sitting time) and the Summary of Diabetes Self-Care Activities Measure (smoking, diet, exercise). Poisson regression models among completers (N=185) were conducted adjusting for age, education, smoking status and depression. RESULTS: Intervention participants had more days/week following a healthy eating plan [relative rate=1.2, 95% confidence interval (CI)=1.1-1.4] and more days of participation in 30 min of physical activity (relative rate=1.2, 95% CI=1.1-2.0) compared to usual care. Intervention participants were more likely to meet physical activity guidelines (7.5% increase) compared to usual care (12% decrease; P=.053). CONCLUSION: Diet and activity generally improved for those receiving the intervention, while there were no differences in some aspects of diet (fruit and vegetable and high-fat food intake), smoking status and sitting time between conditions in the TEAMcare trial.

Perspectives of cancer survivors on the role of different healthcare providers in an integrated delivery system.

PURPOSE: The purpose of this paper is to describe patient perspectives on survivorship care 1 year after cancer diagnosis. METHODS: The study was conducted at an integrated healthcare delivery system in western Washington State. Participants were patients with breast, colorectal, and lung cancer who had enrolled in a randomized control trial (RCT) of oncology nurse navigation to improve early cancer care. Those alive and enrolled in the healthcare system 1 year after diagnosis were eligible for this analysis. Participants completed surveys by phone. Questions focused on receipt of treatment summaries and care plans; discussions with different providers; patient opinions on who does and should provide their care; and patient perspectives primary care providers' (PCP) knowledge and skills related to caring for cancer survivors RESULTS: Of the 251 participants in the RCT, 230 (91.6%) responded to the 12-month phone survey and were included in this analysis; most (n = 183, 79.6%) had breast cancer. The majority (84.8%) considered their cancer specialist (e.g., medical, radiation, surgical or gynecological oncologist) to be their main provider for cancer follow-up and most (69.4%) had discussed follow-up care with that provider. Approximately half of patients were uncertain how well their PCP communicated with the oncologist and how knowledgeable s/he was in caring for cancer survivors. CONCLUSIONS: One year after diagnosis, cancer survivors continue to view cancer specialists as their main providers and are uncertain about their PCP's skills and knowledge in managing their care. Our findings present an opportunity to help patients understand what their PCPs can and cannot provide in the way of cancer follow-up care. IMPLICATIONS FOR CANCER SURVIVORS: Additional research on care coordination and delivery is necessary to help cancer survivors manage their care between primary care and specialty providers.

Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?

OBJECTIVE As use of standard depression questionnaires in clinical practice increases, clinicians will frequently encounter patients reporting thoughts of death or suicide. This study examined whether responses to the Patient Health Questionnaire for depression (PHQ-9) predict subsequent suicide attempt or suicide death. METHODS Electronic records from a large integrated health system were used to link PHQ-9 responses from outpatient visits to subsequent suicide attempts and suicide deaths. A total of 84,418 outpatients age ≥13 completed 207,265 questionnaires between 2007 and 2011. Electronic medical records, insurance claims, and death certificate data documented 709 subsequent suicide attempts and 46 suicide deaths in this sample. RESULTS Cumulative risk of suicide attempt over one year increased from .4% among outpatients reporting thoughts of death or self-harm "not at all" to 4% among those reporting thoughts of death or self-harm "nearly every day." After adjustment for age, sex, treatment history, and overall depression severity, responses to item 9 of the PHQ-9 remained a strong predictor of suicide attempt. Cumulative risk of suicide death over one year increased from .03% among those reporting thoughts of death or self-harm ideation "not at all" to .3% among those reporting such thoughts "nearly every day." Response to item 9 remained a moderate predictor of subsequent suicide death after the same factor adjustments. CONCLUSIONS Response to item 9 of the PHQ-9 for depression identified outpatients at increased risk of suicide attempt or death. This excess risk emerged over several days and continued to grow for several months, indicating that suicidal ideation was an enduring vulnerability rather than a short-term crisis.

Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial.

CONTEXT: Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. OBJECTIVE: To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. DESIGN: Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. SETTING: Fourteen primary care clinics of an integrated health care system. PATIENTS: Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. INTERVENTION: Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. MAIN OUTCOME MEASURES: Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months. RESULTS: Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, -$3241 to $2053) relative to UC patients. CONCLUSIONS: For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00468676

Impact of deductibles on initiation and continuation of psychotherapy for treatment of depression.

OBJECTIVE: To estimate the impact of deductibles on the initiation and continuation of psychotherapy for depression. DATA SOURCES/STUDY SETTING: Data from health care encounters and claims from Group Health Cooperative, a large integrated health care system in Washington State, was merged with information from a centralized behavioral health triage call center to conduct study analyses. STUDY DESIGN: A retrospective observational design using a hierarchical logistic regression model was used to estimate initiation and continuation probabilities for use of psychotherapy, adjusting for key sociodemographic/economic factors and prior use of behavioral health services relevant to individual decisions to seek mental health care. DATA COLLECTION/EXTRACTION METHODS: Analyses were based on merged datasets on patient enrollment, insurance benefits, use of mental health and general medical services and information collected by a triage specialist at a centralized behavioral health call center. PRINCIPAL FINDINGS: Among individuals with unmet deductibles between $100 and $500, we found a statistically significant lower likelihood of making an initial visit, but there was no statistically significant effect on making an initial or subsequent visit among individuals that had met their deductible. CONCLUSIONS: Unmet deductibles appear to influence the likelihood of initiating psychotherapy for treating depression.

Functional outcomes of multi-condition collaborative care and successful ageing: results of randomised trial.

OBJECTIVE: To evaluate the effectiveness of integrated care for chronic physical diseases and depression in reducing disability and improving quality of life. DESIGN: A randomised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and/or risk factors for coronary heart disease compared with usual care among middle aged and elderly people SETTING: Fourteen primary care clinics in Seattle, Washington. PARTICIPANTS: Patients with diabetes or coronary heart disease, or both, and blood pressure above 140/90 mm Hg, low density lipoprotein concentration >3.37 mmol/L, or glycated haemoglobin 8.5% or higher, and PHQ-9 depression scores of ≥ 10. INTERVENTION: A 12 month intervention to improve depression, glycaemic control, blood pressure, and lipid control by integrating a "treat to target" programme for diabetes and risk factors for coronary heart disease with collaborative care for depression. The intervention combined self management support, monitoring of disease control, and pharmacotherapy to control depression, hyperglycaemia, hypertension, and hyperlipidaemia. MAIN OUTCOME MEASURES: Social role disability (Sheehan disability scale), global quality of life rating, and World Health Organization disability assessment schedule (WHODAS-2) scales to measure disabilities in activities of daily living (mobility, self care, household maintenance). RESULTS: Of 214 patients enrolled (106 intervention and 108 usual care), disability and quality of life measures were obtained for 97 intervention patients at six months (92%) and 92 at 12 months (87%), and for 96 usual care patients at six months (89%) and 92 at 12 months (85%). Improvements from baseline on the Sheehan disability scale (-0.9, 95% confidence interval -1.5 to -0.2; P = 0.006) and global quality of life rating (0.7, 0.2 to 1.2; P = 0.005) were significantly greater at six and 12 months in patients in the intervention group. There was a trend toward greater improvement in disabilities in activities of daily living (-1.5, -3.3 to 0.4; P = 0.10). CONCLUSIONS: Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life. Trial registration Clinical Trials NCT00468676.

Collaborative care for patients with depression and chronic illnesses.

BACKGROUND: Patients with depression and poorly controlled diabetes, coronary heart disease, or both have an increased risk of adverse outcomes and high health care costs. We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients. METHODS: We conducted a single-blind, randomized, controlled trial in 14 primary care clinics in an integrated health care system in Washington State, involving 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression. Patients were randomly assigned to the usual-care group or to the intervention group, in which a medically supervised nurse, working with each patient's primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases. The primary outcome was based on simultaneous modeling of glycated hemoglobin, low-density lipoprotein (LDL) cholesterol, and systolic blood-pressure levels and Symptom Checklist-20 (SCL-20) depression outcomes at 12 months; this modeling allowed estimation of a single overall treatment effect. RESULTS: As compared with controls, patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels (difference, 0.58%), LDL cholesterol levels (difference, 6.9 mg per deciliter [0.2 mmol per liter]), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points) (P<0.001). Patients in the intervention group also were more likely to have one or more adjustments of insulin (P=0.006), antihypertensive medications (P<0.001), and antidepressant medications (P<0.001), and they had better quality of life (P<0.001) and greater satisfaction with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001). CONCLUSIONS: As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression. (Funded by the National Institute of Mental Health; ClinicalTrials.gov number, NCT00468676.).

Brief telephone intervention increases soy intake in peri- and postmenopausal US women: the Herbal Alternatives Trial (HALT).

OBJECTIVE: Effective dietary intervention strategies that can be widely disseminated and have the potential for sustainable dietary modifications are needed. The purpose of this study was to describe and evaluate the effectiveness of a telephone-based soy intervention. DESIGN: A randomized controlled trial comparing self-reported intake and serum measures of soy during a 1-year dietary soy (Soy) to fruit and vegetable (Placebo) intervention conducted in two of five arms from the Herbal Alternatives Trial between May 2001 and September 2004. SUBJECTS/SETTING: One hundred sixty-three peri- and postmenopausal women (mean age=52 years) consuming self-selected diets in the Pacific Northwest, United States. INTERVENTION: Five telephone contacts with a registered dietitian during a 12-month intervention with the goal to increase soy food consumption to two servings daily. MAIN OUTCOME MEASURES: Change from baseline in self-reported soy servings and serum isoflavone (daidzein and genistein) concentrations were estimated using analysis of variance and generalized estimating equations. Proportions of participants achieving the intervention goal were compared using chi(2) tests. RESULTS: Ninety-four percent (n=74) of participants in the Soy arm and 89% (n=75) in the Placebo arm completed the trial, and slightly more than one third (n=27) received five phone contacts. Mean (+/-standard deviation) intakes of soy were similar for the Soy and Placebo arms at baseline (0.6+/-1.0 vs 0.4+/-0.8 servings/day; P>0.05). At 12-month follow-up visit, mean+/-standard deviation servings of soy per day were 1.6+/-1.4 for the Soy intervention compared to 0.5+/-0.9 within the Placebo arm (P<0.001). There were concomitant increases in serum isoflavones at 3 and 6 months from baseline in the Soy arm only, with approximately twofold increases in both daidzein (mean=66.4 nmol/L, 95% confidence interval [CI]: 39.0 to 93.9 [mean 16.9 ng/mL, 95% CI: 9.9 to 23.8]) and genistein (mean=100.4 nmol/L, 95% CI: 60.9 to 139.9 [mean 27.1 ng/mL, 95% CI: 16.5 to 37.8]) concentrations. Mean weight changed by <1 kg during the 12-month period in each group and physical activity remained stable, suggesting that participants incorporated soy foods into their diet by substituting for non soy foods rather than adding them to their diet. CONCLUSIONS: A brief telephone-based intervention with a focused message delivered by a registered dietitian is a feasible approach for encouraging targeted dietary changes, such as an increase in soy intake among peri- and postmenopausal women.

Hormone therapy discontinuation: physician practices after the Women's Health Initiative.

OBJECTIVE: No guidelines or randomized trials address best practices for hormone therapy (HT) discontinuation. METHODS: We conducted a survey study to explore HT discontinuation practices at Group Health and Harvard Vanguard, large integrated health systems in the Northwest and Northeast United States, focusing on differences between specialties and study site. RESULTS: The response rate to the written questionnaire (mailed between December 2005 and May 2006) was 78.5% (736/928); this article reports the results for 483 eligible physicians. To discontinue oral HT, most physicians (91%) advised tapering, not immediate cessation (8%), and most (60%) suggested decreasing both dose and days per week. Almost 60% of physicians reported no experience with tapering patches. Harvard Vanguard physicians were more likely than Group Health physicians to encourage discontinuing HT and less likely to recommend resuming HT when a woman's symptoms returned after discontinuing HT. Physicians were most strongly influenced by their own experience (48%), advice from colleagues (25%), and the woman's preference (19%) when choosing a discontinuation strategy; only 2% relied on research evidence. Physicians endorsed various approaches to manage symptoms after HT discontinuation, most often behavioral changes (44%) and increased exercise (37%), and these approaches were more often endorsed by Harvard Vanguard physicians and obstetrician/gynecologists than Group Health physicians or family practitioners or internists. CONCLUSIONS: Two health plans in the Northwestern and Northeastern United States have no standard protocol for HT discontinuation. Physicians customized approaches, influenced by their location, colleagues, and specialty. Research is needed to guide approaches to HT discontinuation.

Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study.

Diabetes and coronary heart disease (CHD) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20% of these patients. Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations. However, the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure, LDL cholesterol, or blood sugar. Comorbid depression has been shown to adversely affect self-care of diabetes and CHD, and is associated with an increased risk of complications and mortality. Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care, improved disease control or morbidity and mortality. This paper describes the design and development of a new biopsychosocial intervention (TEAMcare) aimed at improving both medical disease control and depression in patients with poor control of diabetes and/or CHD who met the criteria for comorbid depression. A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician. This intervention is being tested in an NIMH-funded randomized controlled trial in a large integrated health plan.

Breast and cervical cancer screening specific effects of depression and obesity.

BACKGROUND: Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them. PURPOSE: This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening. METHODS: A stratified sampling design was used to recruit women aged 40-65 years with information on BMI from an integrated health plan in Washington State in 2003-2005. A telephone survey included the Patient Health Questionnaire-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged > or =51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests. RESULTS: In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model. CONCLUSIONS: Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Effectiveness of therapeutic massage for generalized anxiety disorder: a randomized controlled trial.

BACKGROUND: Although massage is one of the most popular complementary and alternative medical (CAM) treatments for anxiety, its effectiveness has never been rigorously evaluated for a diagnosed anxiety disorder. This study evaluates the effectiveness of therapeutic massage for persons with generalized anxiety disorder (GAD). METHODS: Sixty-eight persons with GAD were randomized to therapeutic massage (n=23), thermotherapy (n=22), or relaxing room therapy (n=23) for a total of 10 sessions over 12 weeks. Mean reduction in anxiety was measured by the Hamilton Anxiety Rating Scale (HARS). Secondary outcomes included 50% reduction in HARS and symptom resolution of GAD, changes in depressive symptoms (Patient Health Questionnaire (PHQ-8)), worry and GAD-related disability. We compared changes in these outcomes in the massage and control groups posttreatment and at 6 months using generalized estimating equation (GEE) regression. RESULTS: All groups had improved by the end of treatment (adjusted mean change scores for the HARS ranged from -10.0 to -13.0; P<.001) and maintained their gains at the 26-week followup. No differences were seen between groups (P=.39). Symptom reduction and resolution of GAD, depressive symptoms, worry and disability showed similar patterns. CONCLUSIONS: Massage was not superior to the control treatments, and all showed some clinically important improvements, likely due to some beneficial but generalized relaxation response. Because the relaxing room treatment is substantially less expensive than the other treatments, a similar treatment packaged in a clinically credible manner might be the most cost effective option for persons with GAD who want to try relaxation-oriented CAM therapies.

Physician support for diabetes patients and clinical outcomes.

BACKGROUND: Physician practical support (e.g. setting goals, pro-active follow-up) and communicative support (e.g., empathic listening, eliciting preferences) have been hypothesized to influence diabetes outcomes. METHODS: In a prospective observational study, patients rated physician communicative and practical support using a modified Health Care Climate Questionnaire. We assessed whether physicians' characteristic level of practical and communicative support (mean across patients) and each patients' deviation from their physician's mean level of support was associated with glycemic control outcomes. Glycosylated haemoglobin (HbA1c) levels were measured at baseline and at follow-up, about 2 years after baseline. RESULTS: We analysed 3897 patients with diabetes treated in nine primary care clinics by 106 physicians in an integrated health plan in Western Washington, USA. Physicians' average level of practical support (based on patient ratings of their provider) was associated with significantly lower HbA1c at follow-up, controlling for baseline HbA1c (p = .0401). The percentage of patients with "optimal" and "poor" glycemic control differed significantly across different levels of practical support at follow (p = .022 and p = .028). Communicative support was not associated with differences in HbA1c at follow-up. CONCLUSION: This observational study suggests that, in community practice settings, physician differences in practical support may influence glycemic control outcomes among patients with diabetes.