Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study.

OBJECTIVE: To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. DESIGN: Difference-in-difference study. SETTING: US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. PARTICIPANTS: All individuals receiving primary care from 2009 to 2019. INTERVENTION: Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. MAIN OUTCOME MEASURES: The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. RESULTS: The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval -7.6% to -7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (-12.0% to -10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (-6.08% to -5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. CONCLUSIONS: The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.

Telehealth and delivery of alcohol use disorder treatment in the Veterans Health Administration.

BACKGROUND: The use of telehealth treatment of alcohol use disorder (AUD) has increased since the start of the COVID-19 pandemic. However, it is unclear which patients are using telehealth and how telehealth visits are associated with treatment duration. This study examined characteristics associated with telehealth use among Veterans Health Administration patients receiving AUD treatment. METHODS: Using a national retrospective cohort study, we examined data from March 01, 2020 to February 28, 2021 to: First, identify patient characteristics associated with (a) any telehealth versus only in-person care for AUD treatment, and (b) video (≥1 video visit) versus only telephone visits for AUD treatment (≥1 telephone visit, no video) among any telehealth users. This analysis used mixed-effects logistic regression models to adjust for potential correlation across patients treated at the same facility. Second, we assessed whether visit modality was associated with the amount of AUD treatment received (number of AUD psychotherapy visits or medication coverage days). This analysis used mixed-effects negative binomial regression models. RESULTS: Among 138,619 patients who received AUD treatment, 52.8% had ≥1 video visit, 38.1% had ≥1 telephone but no video visits, and 9.1% had only in-person visits. In the regression analyses, patients who were male or had an opioid or stimulant use disorder (compared to having no non-AUD substance use disorder) were less likely to receive any telehealth-delivered AUD treatment compared to only in-person AUD treatment. Among patients who received any telehealth-delivered AUD treatment, those who were ≥45 years old (compared to 18-29 years old), Black (compared to White), diagnosed with a cannabis or stimulant use disorder, or diagnosed with a serious mental illness were less likely to receive a video visit than only telephone visits. Receiving any AUD telehealth was associated with receiving more psychotherapy visits and medication coverage days than only in-person care. CONCLUSIONS: Telehealth, a common modality for AUD treatment, supported a greater number of psychotherapy visits and a longer duration of medication treatment for AUD. However, some groups were less likely to receive any video telehealth than telephone visits, suggesting that multiple treatment modalities should remain available to ensure treatment access.

A 4-week morning light treatment with stable sleep timing for individuals with fibromyalgia: a randomized controlled trial.

OBJECTIVES: Fibromyalgia is characterized by chronic widespread pain, mood, and sleep disturbance. Pharmacological treatments have modest efficacy and are associated with negative side effects, and alternative approaches are needed. Morning bright light treatment may assist in the management of fibromyalgia as it can reduce depressive symptoms, improve sleep, and advance circadian timing. METHODS: Sixty people with fibromyalgia (58 women, mean age 41.8 ± 13.3 years) were enrolled in a study comparing 4 weeks of a 1-hour daily morning bright light treatment (active treatment) to a morning dim light treatment (comparison treatment). Both light treatments included behavioral procedures to stabilize sleep timing. The morning bright light treatment was expected to produce larger improvements in pain and function than the dim light treatment and larger improvements in potential mediators (mood, sleep, and circadian timing). RESULTS: Both the bright and dim light treatment groups achieved significant but similar levels of improvement in pain intensity, pain interference, physical function, depressive symptoms, and sleep disturbance. Overall, the sample on average displayed a clinically meaningful improvement in the Fibromyalgia Impact Questionnaire-Revised score (mean reduction of 11.2 points), comparable to that reported following physical exercise treatments. Minimal side effects were observed. CONCLUSIONS: Findings indicate that the effects of a morning bright light treatment did not exceed those of a comparison dim light treatment; yet the changes on average in both conditions revealed clinically meaningful improvements. Future research is warranted to identify what elements of this trial may have contributed to the observed effects.

Morning light treatment for traumatic stress: The role of amygdala reactivity study protocol.

BACKGROUND: Exposure to trauma can result in various mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although psychotherapies and pharmacotherapies exist for the treatment of these disorders, many individuals fail to receive treatment and among those who do, many remain symptomatic. Therefore, it is critical to continue developing new interventions for traumatic stress that target underlying mechanisms of pathology and offer a safe and acceptable alternative to current treatments. Morning light treatment has good potential as a novel non-invasive, low risk treatment for traumatic stress. Evidence suggests that morning light may improve traumatic stress by reducing reactivity in the amygdala, a brain region implicated in the pathophysiology of PTSD and anatomically linked to circadian photoreceptors in the eye. METHODS: In this study, we aim to establish a significant dose-response relationship between duration of morning light treatment and reduction in amygdala reactivity among individuals with traumatic stress symptoms (NCT# 04117347). Using a transdiagnostic approach, sixty-six individuals with a history of a DSM-5 criterion A trauma and traumatic stress symptoms will be recruited to participate in a 5-week study. Participants will be randomized across three treatment arms based on morning light treatment duration: 15-minutes, 30-minutes, or 60-minutes of light treatment per day for four weeks. To evaluate amygdala activity, participants will undergo fMRI at pre-treatment, mid-treatment, and post-treatment. Participants will also complete clinical assessments and self-report measures of PTSD, depression, and anxiety at pre-treatment, mid-treatment, and post-treatment. DISCUSSION: Morning light therapy may be an acceptable, feasible, and effective treatment for individuals suffering from traumatic stress. Identifying mechanistically relevant targets, and the doses needed to impact them, are critical steps in developing this new treatment approach for the sequelae of traumatic stress.

Stepwise Approach for Ventricular Tachycardia Ablation in Patients With Predominantly Intramural Scar.

OBJECTIVES: The goal of this study was to assess the value of a stepwise, image-guided ablation approach in patients with cardiomyopathy and predominantly intramural scar. BACKGROUND: Few reports have focused on catheter-based ventricular tachycardia (VT) ablation strategies in patients with predominantly intramural scar. METHODS: The study included patients with predominantly intramural scar undergoing VT ablation. A stepwise strategy was performed consisting of a localized ablation guided by conventional mapping criteria followed by a more extensive ablation if VT remained inducible. The extensive ablation was guided by the location and extent of intramural scarring on delayed enhanced-cardiac magnetic resonance imaging. A historical cohort who did not undergo additional extensive ablation was identified for comparison. A novel measurement, the scar depth index (SDI), indicating the percent area of the scar at a given depth, was correlated with outcomes. RESULTS: Forty-two patients who underwent stepwise ablation (median age 61 years [interquartile range: 55 to 69 years], 35 male patients, median left ventricular ejection fraction 36.0% [25.0% to 55.0%], ischemic [n = 4] or nonischemic cardiomyopathy [n = 38]) were followed up for a median of 17 months (8 to 36 months). A stepwise approach resulted in a 1-year freedom from VT, death, or cardiac transplantation of 76% (32 of 42). Patients who underwent additional extensive ablation had a lower risk of events than a clinically similar historical cohort (N = 19) (hazard ratio: 0.30; 95% CI: 0.13 to 0.68; p < 0.004). SDI>5mm was associated with worse long-term outcomes (hazard ratio: 1.03; 95% CI: 1.01 to 1.06%; p = 0.03), SDI>5mm >16.5% was associated with failed ablation (area under the curve: 0.84; 95% CI: 0.71 to 0.97). CONCLUSIONS: Stepwise ablation using delayed enhanced-cardiac magnetic resonance guidance is a novel approach to VT ablation in patients with predominantly intramural scarring. The SDI correlates with immediate procedural and long-term outcomes.

Targeting Noninducible Clinical Ventricular Tachycardias in Patients With Prior Myocardial Infarctions Based on Stored Electrograms.

BACKGROUND: Ablation of postinfarction ventricular tachycardia (VT) has been shown to reduce VT recurrence and decrease mortality. However, VT recurrence can occur despite extensive ablation procedures. The lack of inducibility of clinical VTs during ablation procedures remains problematic and may be in part responsible for VT recurrences. In this prospective study, we targeted documented but noninducible clinical VTs based on stored implantable cardioverter-defibrillator (ICD) electrograms. METHODS: Radiofrequency ablation was performed in a consecutive group of 66 postinfarction patients (mean age, 67.5±9.2 years; men, 61; mean left ventricular ejection fraction, 25.1±10.8%) in whom clinical VTs were not inducible during an ablation procedure. In the first 33 patients (control group), only inducible VTs were targeted, and in the second 33 patients, noninducible clinical VTs were also targeted by pace-mapping based on stored ICD-electrograms (ICD-electrogram-guided ablation group). Procedural and clinical outcomes were compared at 24 months post-ablation. RESULTS: VT recurred in 5 patients (15%) in whom the ICD-electrogram-guided approach was performed and in 13 patients (39%) in the control group. Freedom from recurrent VT was higher (log-rank P=0.04) in the ICD-electrogram-guided group, but there was no difference in ventricular fibrillation or in total mortality between both groups. CONCLUSIONS: Ablation guided by pace-mapping of noninducible postinfarction clinical VTs based on ICD-electrograms is feasible and reduces the risk of recurrent VT.

Randomized Controlled Trial of a Collaborative Care Intervention for Mood Disorders by a National Commercial Health Plan.

OBJECTIVE: Few individuals with mood disorders have access to evidence-based collaborative chronic care models (CCMs) because most patients are seen in small-group practices (<20 providers) with limited capacity to deliver CCMs. In this single-blind randomized controlled trial, we determined whether a CCM delivered nationally in a U.S. health plan improved 12-month outcomes among enrollees with mood disorders compared with usual care. METHODS: Aetna insurance enrollees (N=238), mostly females (66.1%) with a mean age of 41.1 years, who were recently hospitalized for unipolar major depression or bipolar disorder provided informed consent, completed baseline assessments, and were randomly assigned to usual care or CCM. The CCM included 10 sessions of the Life Goals self-management program and brief contacts by phone by a care manager to determine symptom status. Primary outcomes were changes over 12 months in depression symptoms (nine-item Patient Health Questionnaire [PHQ-9]) and mental health-related quality of life (Short Form-12). RESULTS: Adjusted mean PHQ-9 scores were lower by 2.34 points (95% confidence level [CL]=-4.18 to -0.50, p=0.01), indicating improved symptoms, and adjusted mean SF-12 mental health scores were higher by 3.21 points (CL=-.97 to 7.38, p=0.10), indicating better quality of life, among participants receiving CCM versus usual care. CONCLUSIONS: Individuals receiving CCM compared with usual care had improved clinical outcomes, although substantial attrition may limit the impact of health plan-level delivery of CCMs. Further research on the use of health plan-level interventions, such as CCMs, as alternatives to practice-based models is warranted.

Integrating massage therapy within the palliative care of veterans with advanced illnesses: an outcome study.

AIMS: To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses. METHODS: Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time. RESULTS: All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients' sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001). CONCLUSION: Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients.

Spatial resolution of pace mapping of idiopathic ventricular tachycardia/ectopy originating in the right ventricular outflow tract.

BACKGROUND: Pace mapping has been used to identify the site of origin of focal ventricular arrhythmias. The spatial resolution of pace mapping has not been adequately quantified using currently available three-dimensional mapping systems. OBJECTIVE: The purpose of this study was to determine the spatial resolution of pace mapping in patients with idiopathic ventricular tachycardia or premature ventricular contractions originating in the right ventricular outflow tract. METHODS: In 16 patients with idiopathic ventricular tachycardia/ectopy from the right ventricular outflow tract, comparisons and classifications of pace maps were performed by two observers (good pace map: match >10/12 leads; inadequate pace map: match < or =10/12 leads) and a customized MATLAB 6.0 program (assessing correlation coefficient and normalized root mean square of the difference (nRMSd) between test and template signals). With an electroanatomic mapping system, the correlation coefficient of each pace map was correlated with the distance between the pacing site and the effective ablation site. The endocardial area within the 10-ms activation isochrone was measured. RESULTS: The ablation procedure was effective in all patients. Sites with good pace maps had a higher correlation coefficient and lower nRMSd than sites with inadequate pace maps (correlation coefficient: 0.96 +/- 0.03 vs 0.76 +/- 0.18, P <.0001; nRMSd: 0.41 +/- 0.16 vs 0.89 +/- 0.39, P <.0001). Using receiver operating characteristic curves, appropriate cutoff values were >0.94 for correlation coefficient (sensitivity 81%, specificity 89%) and < or =0.54 for nRMSd (sensitivity 76%, specificity 80%). Good pace maps were located a mean of 7.3 +/- 5.0 mm from the effective ablation site and had a mean activation time of -24 +/- 7 ms. However, in 3 (18%) of 16 patients, the best pace map was inadequate at the effective ablation site, with an endocardial activation time at these sites of -25 +/- 12 ms. Pace maps with correlation coefficient > or =0.94 were confined to an area of 1.8 +/- 0.6 cm2. The 10-ms isochrone measured 1.2 +/- 0.7 cm2. CONCLUSION: The spatial resolution of a good pace map for targeting ventricular tachycardia/ectopy is 1.8 cm2 in the right ventricular outflow tract and therefore is inferior to the spatial resolution of activation mapping as assessed by isochronal activation. In approximately 20% of patients, pace mapping is unreliable in identifying the site of origin, possibly due a deeper site of origin and preferential conduction via fibers connecting the focus to the endocardial surface.

Social connectedness and patient recovery after major operations.

BACKGROUND: Social connectedness is thought to play an important role in overall health and well being. We hypothesized that social network size and other measures of social connectedness would predict perceived pain intensity, unpleasantness, and anxiety in veterans recovering after major thoracic or abdominal operations and influence postoperative complications and length of stay. STUDY DESIGN: Six hundred five patients from two Veterans Affairs' medical centers who participated in a randomized controlled trial of massage as adjuvant treatment for postoperative pain were the subjects of this study. Subjects' social networks were assessed by the numbers of friends or relatives an individual had and how frequently contact was made with members of their social network. Subjective outcomes were rated with visual analogue scales for 5 postoperative days. Daily opiate use, postoperative complications, and length of stay were also recorded. RESULTS: Mean (+/-SD) age was 63.8 years (+/-10.2 years) and 98.5% of participants were men. Those reporting a greater social network were older and had lower preoperative pain intensity, unpleasantness, and state and trait anxiety (p < 0.001). Considerably less pain intensity, unpleasantness, and opiate use were associated with increasing social network size during the first 5 postoperative days. After adjusting for preoperative values of pain and anxiety, these relationships were no longer statistically significant. Smaller social network size was associated with the likelihood of length of stay >or= 7 days (p = 0.03). CONCLUSIONS: These findings suggest that the effect of social networks on surgical outcomes can be mediated by their effect on levels of preoperative pain and anxiety. Patients should be screened preoperatively for pain and anxiety because these are strong predictors of a more difficult postoperative recovery.

Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial.

HYPOTHESIS: Adjuvant massage therapy improves pain management and postoperative anxiety among many patients who experience unrelieved postoperative pain. Pharmacologic interventions alone may not address all of the factors involved in the experience of pain. DESIGN: Randomized controlled trial. SETTING: Department of Veterans Affairs hospitals in Ann Arbor, Michigan, and Indianapolis, Indiana. PATIENTS: Six hundred five veterans (mean age, 64 years) undergoing major surgery from February 1, 2003, through January 31, 2005. INTERVENTIONS: Patients were assigned to the following 3 groups: (1) control (routine care), (2) individualized attention from a massage therapist (20 minutes), or (3) back massage by a massage therapist each evening for up to 5 postoperative days. Main Outcome Measure Short- and long-term (> 4 days) pain intensity, pain unpleasantness, and anxiety measured by visual analog scales. RESULTS: Compared with the control group, patients in the massage group experienced short-term (preintervention vs postintervention) decreases in pain intensity (P = .001), pain unpleasantness (P < .001), and anxiety (P = .007). In addition, patients in the massage group experienced a faster rate of decrease in pain intensity (P = .02) and unpleasantness (P = .01) during the first 4 postoperative days compared with the control group. There were no differences in the rates of decrease in long-term anxiety, length of stay, opiate use, or complications across the 3 groups. CONCLUSION: Massage is an effective and safe adjuvant therapy for the relief of acute postoperative pain in patients undergoing major operations.

Pharyngeal anesthesia during sedated EGDs: is "the spray" beneficial? A meta-analysis and systematic review.

BACKGROUND: Pharyngeal anesthesia is widely used as an adjunct to sedation during upper endoscopy. Methemoglobinemia and anaphylactic reactions are rare but serious complications of topical anesthetic agents. Individual studies produce variable results about the effectiveness of pharyngeal anesthesia in improving patient tolerance. OBJECTIVE: A systematic review was performed to evaluate the effectiveness of pharyngeal anesthesia in improving patient tolerance and ease of endoscopy during sedated upper endoscopy. DESIGN: A MEDLINE search, an EMBASE search, and manual searches were performed to identify pertinent English language articles. Randomized controlled trials (RCT) comparing the efficacy of pharyngeal anesthesia to placebo or no treatment were identified. Duplicate data extraction about patient tolerance of the procedure and endoscopist assessment regarding the ease of endoscopy was performed. RESULTS: From a pool of 53 studies, 5 RCTs evaluated a total of 491 patients and provided interpretable data. Patients who rated their discomfort during the sedated procedure as none/minimal were more likely to have received pharyngeal anesthesia (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.13-3.12). Endoscopists were more likely to rate the procedure as "not difficult" for patients who received pharyngeal anesthesia (OR 2.60, 95% CI 1.63-4.17). LIMITATIONS: Lack of standardized outcome measurements and standardized sedation strategies led to heterogeneity in the patient-tolerance portion of the meta-analysis. CONCLUSIONS: Pharyngeal anesthesia before upper endoscopy improves ease of endoscopy and also improves patient tolerance.

Comparison of mapping criteria for hemodynamically tolerated, postinfarction ventricular tachycardia.

BACKGROUND: Mapping criteria for hemodynamically tolerated, postinfarction ventricular tachycardia (VT) have been evaluated in only small series of patients. OBJECTIVES: The purpose of this study was to evaluate the utility of various mapping criteria for identifying a critical VT circuit isthmus in a post hoc analysis. METHODS: Ninety VTs (cycle length 491 +/- 84 ms) were mapped in 48 patients with a prior myocardial infarction. The mapping catheter was positioned within a protected area of the reentrant circuit of the targeted VTs at 176 sites. All sites showed concealed entrainment. The predictive values of the following mapping criteria for a successful ablation site were compared: discrete isolated potential during VT, inability to dissociate the isolated potential from the VT, endocardial activation time >70 ms, matching electrogram-QRS and stimulus-QRS intervals, VT termination without global capture during pacing, stimulus-QRS/VT cycle length ratio

Massage as adjuvant therapy in the management of acute postoperative pain: a preliminary study in men.

BACKGROUND: Opioid analgesia alone may not fully relieve all aspects of acute postoperative pain. Complementary medicine techniques used as adjuvant therapies have the potential to improve pain management and palliate postoperative distress. STUDY DESIGN: This prospective randomized clinical trial compared pain relief after major operations in 202 patients who received one of three nursing interventions: massage, focused attention, or routine care. Interventions were performed twice daily starting 24 hours after the operation through postoperative day 7. Perceived pain was measured each morning. RESULTS: The rate of decline in the unpleasantness of postoperative pain was accelerated by massage (p = 0.05). Massage also accelerated the rate of decline in the intensity of postoperative pain but this effect was not statistically significant. Use of opioid analgesics was not altered significantly by the interventions. CONCLUSIONS: Massage may be a useful adjuvant therapy for the management of acute postoperative pain. Its greatest effect appears to be on the affective component (ie, unpleasantness) of the pain.