Automated Reminders Enhance Mailed Fecal Immunochemical Test Completion Among Veterans: a Randomized Controlled Trial.

BACKGROUND: The Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans. OBJECTIVE: We sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates. DESIGN: We conducted a prospective, randomized quality improvement trial ( ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder. PARTICIPANTS: A total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45-75 and had an average risk of colorectal cancer. INTERVENTIONS: A single automated telephone call or text message reminder prompting veterans to return the FIT kit. MAIN MEASURES: Our primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days. KEY RESULTS: Participant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001). CONCLUSIONS: Automated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources.

A Postcard Primer Prior to Mailed Fecal Immunochemical Test Among Veterans: a Randomized Controlled Trial.

BACKGROUND: Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans. OBJECTIVE: To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans. DESIGN: This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone. PARTICIPANTS: A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening. INTERVENTION: A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT. MAIN MEASURES: Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days. KEY RESULTS: Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37)). CONCLUSIONS: Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening.

Automatic medication refills to improve glycaemic control among patients with diabetes and low medication adherence.

BACKGROUND: Medication adherence impacts health outcomes. Healthcare organisations implementing system-level interventions have potential for greater spread and sustainability than individual-level interventions. Within the integrated US Veterans Health Administration, a multidisciplinary team developed and evaluated a pilot quality improvement programme to assess the feasibility of automatic mailed prescription refills for patients with diabetes and low medication adherence (assessed by medication possession ratio <80%). METHODS: Patients were randomised to usual care with self-initiated refills versus automatic mailed refills for 6 months. Process outcomes included glycaemic control measures (HgbA1C), medication possession ratios for both automatic and self-initiated (reference) refills of medications, patient satisfaction and workforce effort (pharmacist time). RESULTS: Overall, 199 patients were randomised to automatic refills (n=99; 40 of whom participated) versus usual care (n=100). In multivariable analysis adjusting for baseline differences, after 6 months there was no difference in the proportion of patients with follow-up HgbA1C <8% (60.8% automatic refills vs 60.5% usual care, p=0.96). In the automatic refill group, the medication possession ratio for reference medicines was significantly higher than usual care (63.9% vs 54.5%, 95% CI (for difference) 3.1% to 15.9%, p<0.01). CONCLUSIONS: Implications and lessons from this pilot programme include potential beneficial indirect effects from automatic medication refills on patient self-initiated refills of other medications; the importance of tailoring solutions to patient subgroups and specific adherence barriers; and recognition that the rapid deployment, iteration and evaluation of the project was facilitated by a multidisciplinary team embedded within an organisational learning health system.

Implementation of a mailed faecal immunochemical test programme for colorectal cancer screening among Veterans.

BACKGROUND: Screening for colorectal cancer (CRC) with faecal immunochemical test (FIT) is effective at reducing CRC mortality. Unfortunately, the COVID-19 pandemic has been associated with deferred care, especially screening for CRC. AIM: We sought to develop a mailed FIT programme (MFP) to increase CRC screening and make recommendations for adoption across the Veterans Health Administration (VHA) and for other large healthcare systems. SETTING: 2 regional VA medical centres in California and Washington state. PARTICIPANTS: 5667 average risk veterans aged 50-75 overdue or due within 90 days for CRC screening. PROGRAMME DESCRIPTION: A multidisciplinary implementation team collaborated to mail an FIT kit to eligible veterans. Both sites mailed a primer postcard, and one site added an automated reminder call. PROGRAMME EVALUATION: We monitored FIT return and positivity rate, as well as impact of the programme on clinical staff. 34% of FIT kits were returned within 90 days and 7.8% were abnormal. DISCUSSION: We successfully implemented a population-based MFP at multiple regional VA sites and recommend that these efforts be spread across VA. Our model of regional leadership, facility champions and using centralised resources can be adaptable to other large healthcare systems. MFPs support catch-up from disrupted care by addressing access to CRC screening, unburden primary care visits and conserve limited procedural resources.

Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017.

BACKGROUND: Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE: To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES: We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS: The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS: Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.

Provider Perceptions of Telemedicine Video Visits to Home in a Veteran Population.

Background: Clinical Video Telemedicine to Home (CVTH) allows primary care clinicians to conduct clinical encounters with patients in remote locations through a secure synchronous video connection, offering improved access to care and increased patient satisfaction. Introduction: Although implementation of CVTH continues to grow, little is known about clinician perceptions of clinical applicability or utilization barriers. We assessed provider attitudes and perceived barriers toward implementation of CVTH visits at the Seattle Veterans Affairs Primary Care Clinic. Materials and Methods: Data are presented from a cross-sectional survey. A total of 49 clinicians, including faculty, MD residents, nurse practitioner residents, and pharmacists, were surveyed with 13 questions gauging opinions of CVTH and prior experience with video telemedicine. Results: Forty-seven providers (96%) were interested in incorporating CVTH into their practice. Forty-one clinicians (83.7%) were concerned about patient technological competency, and 39 (79.6%) were worried about insufficient internet connectivity. A large majority of providers saw opportunities to provide medication reconciliation and improve access to care for geographically distant or homebound patients. Discussion: Although limited by its descriptive data and analysis, this study provides evidence that primary care providers are most likely to offer CVTH visits to patients who find it physically challenging to attend a clinic appointment or have chief complaints perceived as not requiring a physical examination. Conclusions: Although most providers are interested in using video visits to care for patients who live remotely, they are concerned about using CVTH visits for patients who might require a physical examination or technological assistance.

Leveraging an electronic health record note template to standardize screening and testing for COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic challenged health care organizations to develop ways to provide patient care with rapidly changing guidelines and scarce resources. Clinical leaders and informatics specialists partnered to rapidly develop an electronic health record (EHR) template for primary care staff to screen Veterans at Veterans Affairs (VA) Puget Sound. The template prompts categorization of patients by stability and suspicion for COVID-19, and provides just-in-time triaging advice for clinic staff. Each category is a discrete data element and this information was used by leadership to track screening and testing volumes. We found that a brief, practical EHR note template can be quickly adopted to inform guideline-based screening, direct patient care, and conserve resources.

Implementing a low-cost web-based clinical trial management system for community studies: a case study.

BACKGROUND: Clinical trials with multiple intervention locations and a single research coordinating center can be logistically difficult to implement. Increasingly, web-based systems are used to provide clinical trial support with many commercial, open source, and proprietary systems in use. New web-based tools are available which can be customized without programming expertise to deliver web-based clinical trial management and data collection functions. PURPOSE: To demonstrate the feasibility of utilizing low-cost configurable applications to create a customized web-based data collection and study management system for a five intervention site randomized clinical trial establishing the efficacy of providing evidence-based treatment via teleconferencing to children with attention-deficit hyperactivity disorder. The sites are small communities that would not usually be included in traditional randomized trials. A major goal was to develop database that participants could access from computers in their home communities for direct data entry. METHODS: Discussed is the selection process leading to the identification and utilization of a cost-effective and user-friendly set of tools capable of customization for data collection and study management tasks. RESULTS: An online assessment collection application, template-based web portal creation application, and web-accessible Access 2007 database were selected and customized to provide the following features: schedule appointments, administer and monitor online secure assessments, issue subject incentives, and securely transmit electronic documents between sites. Each tool was configured by users with limited programming expertise. As of June 2011, the system has successfully been used with 125 participants in 5 communities, who have completed 536 sets of assessment questionnaires, 8 community therapists, and 11 research staff at the research coordinating center. LIMITATIONS: Total automation of processes is not possible with the current set of tools as each is loosely affiliated, creating some inefficiency. This system is best suited to investigations with a single data source e.g., psychosocial questionnaires. CONCLUSIONS: New web-based applications can be used by investigators with limited programming experience to implement user-friendly, efficient, and cost-effective tools for multi-site clinical trials with small distant communities. Such systems allow the inclusion in research of populations that are not usually involved in clinical trials.

The UF family of hybrid phantoms of the developing human fetus for computational radiation dosimetry.

Historically, the development of computational phantoms for radiation dosimetry has primarily been directed at capturing and representing adult and pediatric anatomy, with less emphasis devoted to models of the human fetus. As concern grows over possible radiation-induced cancers from medical and non-medical exposures of the pregnant female, the need to better quantify fetal radiation doses, particularly at the organ-level, also increases. Studies such as the European Union's SOLO (Epidemiological Studies of Exposed Southern Urals Populations) hope to improve our understanding of cancer risks following chronic in utero radiation exposure. For projects such as SOLO, currently available fetal anatomic models do not provide sufficient anatomical detail for organ-level dose assessment. To address this need, two fetal hybrid computational phantoms were constructed using high-quality magnetic resonance imaging and computed tomography image sets obtained for two well-preserved fetal specimens aged 11.5 and 21 weeks post-conception. Individual soft tissue organs, bone sites and outer body contours were segmented from these images using 3D-DOCTOR™ and then imported to the 3D modeling software package Rhinoceros™ for further modeling and conversion of soft tissue organs, certain bone sites and outer body contours to deformable non-uniform rational B-spline surfaces. The two specimen-specific phantoms, along with a modified version of the 38 week UF hybrid newborn phantom, comprised a set of base phantoms from which a series of hybrid computational phantoms was derived for fetal ages 8, 10, 15, 20, 25, 30, 35 and 38 weeks post-conception. The methodology used to construct the series of phantoms accounted for the following age-dependent parameters: (1) variations in skeletal size and proportion, (2) bone-dependent variations in relative levels of bone growth, (3) variations in individual organ masses and total fetal masses and (4) statistical percentile variations in skeletal size, individual organ masses and total fetal masses. The resulting series of fetal hybrid computational phantoms is applicable to organ-level and bone-level internal and external radiation dosimetry for human fetuses of various ages and weight percentiles.

Research in child and adolescent telemental health.

Over the past decade telepsychiatry, and more broadly telemental health (TMH), services with children and adolescents have been implemented with diverse populations in many geographic areas across the United States. The feasibility and acceptability of child and adolescent TMH have been well demonstrated, but little research exists on the efficacy and effectiveness of TMH in improving the mental health care and outcomes for underserved youth. This article summarizes the state of research in child and adolescent telemental health TMH and examines studies in other areas of telemedicine that may inspire and guide child and adolescent telepsychiatrists to collect data on the process and outcomes of their own work.

Attention-deficit/hyperactivity disorder and telemental health.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders diagnosed in children and adolescents (youth). ADHD is equally distributed geographically, but services are not. Access to expert evaluation and treatment remains limited for youth with ADHD living in rural areas, as well as for ethnic and racial minority youth. Telepsychiatry is a service delivery model with the potential to reach these youth and to develop collaborative models of care among local primary care physicians, remote telepsychiatrists, and local families. Care delivered through telepsychiatry can readily adhere to the practice parameters of the American Academy of Child and Adolescent Psychiatry. Work to date indicates that ADHD is the most common disorder treated through telepsychiatry. This article reviews the status of child and adolescent telepsychiatry, with particular focus on its potential to improve the care and outcomes of underserved populations of youth diagnosed with ADHD.

Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.

Seattle Children's Hospital is a tertiary referral hospital that has provided telepsychiatry to seven partner sites in the north-west since 2001. Service utilization data, patient demographics and diagnoses were collected for the period from the service inception in October 2001 until November 2007. During the study period, 701 patients were treated with a mean of 2.8 appointments per patient (SD 1.9). Five psychiatrists and four psychologists provided care. Utilization varied across referring sites and was largely dependent upon the availability of telepsychiatrists, although the degree of support from administration and stakeholders also contributed to the success of the service. A total of 190 primary care practitioners referred patients to telepsychiatry, including 106 family physicians and 71 paediatricians. Paediatricians referred to the service more frequently than family physicians (t = 2.8, P < 0.05). Overall, telepsychiatry with young people is feasible, acceptable and increases access to mental health care. There appear to be four core components necessary to a successful telepsychiatry programme: psychiatrists who are interested in exploring new ways to reach underserved young people; clearly identified stakeholders who can collaborate with one another to make good use of the telepsychiatry service; a children's mental health 'champion' who represents these stakeholders and wants services for their community; and a stable administration that perceives telepsychiatry as valuable for their patients and their doctors.