Increasing Primary Care Utilization of Medication-Assisted Treatment (MAT) for Opioid Use Disorder.

BACKGROUND: With increasing prevalence of opioid use disorders (OUDs) there is an urgent need for OUD trained front line primary care providers (PCPs) who can help improve patient adherence to addiction treatment. Unfortunately, most physicians have had limited training for treating patients with addiction, leaving clinicians under prepared. To address this need, we created a Medication-Assisted Treatment (MAT) training program specifically designed for PCPs. INTERVENTION: A 4-hour PCP focused buprenorphine office-based implementation training was designed to supplement the 8-hour SAMHSA DATA 2000 waiver training. The intent of the supplemental training is to increase PCP likelihood of implementing MAT through practical evidenced-based implementation, addressing barriers reported by waivered PCPs. METHODS: We developed and validated a new pre- and postsurvey instrument that assesses changes in participants knowledge, skills, and attitudes. Data were entered into REDCap, and composite scales were created and analyzed to determine pre-post differences. RESULTS: A total of 183 participants completed pre-post evaluations. Pre-post comparisons indicated substantial improvement in learner levels of confidence in implementing MAT care processes and in their interactions with MAT patients (df = 4, F = 203.518, P < .001). Participants described themselves as more comfortable identifying patients who would benefit from MAT (t = 15.04, P < .001), more competent in implementing MAT (t = 21.27, P < .001) and more willing (t = 15.56, P < .001) to implement MAT after training. CONCLUSION: Evidence suggests that a new MAT training program that supplements the SAMHSA waiver training increases confidence and willingness to implement MAT among PCPs. Efforts to replicate this success to allow for further generalization and policy recommendations are warranted.

The National Clinical Care Commission Report to Congress: Summary and Next Steps.

The U.S. is experiencing an epidemic of type 2 diabetes. Socioeconomically disadvantaged and certain racial and ethnic groups experience a disproportionate burden from diabetes and are subject to disparities in treatment and outcomes. The National Clinical Care Commission (NCCC) was charged with making recommendations to leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC determined that diabetes cannot be addressed simply as a medical problem but must also be addressed as a societal problem requiring social, clinical, and public health policy solutions. As a result, the NCCC's recommendations address policies and programs of both non-health-related and health-related federal agencies. The NCCC report, submitted to the U.S. Congress on 6 January 2022, makes 39 specific recommendations, including three foundational recommendations that non-health-related and health-related federal agencies coordinate their activities to better address diabetes, that all federal agencies and departments ensure that health equity is a guiding principle for their policies and programs that impact diabetes, and that all Americans have access to comprehensive and affordable health care. Specific recommendations are also made to improve general population-wide policies and programs that impact diabetes risk and control, to increase awareness and prevention efforts among those at high risk for type 2 diabetes, and to remove barriers to access to effective treatments for diabetes and its complications. Finally, the NCCC recommends that an Office of National Diabetes Policy be established to coordinate the activities of health-related and non-health-related federal agencies to address diabetes prevention and treatment. The NCCC urges Congress and the Secretary of Health and Human Services to implement these recommendations to protect the health and well-being of the more than 130 million Americans at risk for and living with diabetes.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes.

Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.

The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes.

The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.

The National Clinical Care Commission Report to Congress: Background, Methods, and Foundational Recommendations.

Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.

Lacking a Primary Care Physician Is Associated With Increased Suffering in Patients With Severe Mental Illness.

We evaluated the relationship between lack of a primary care physician (PCP) and patients with severe mental illness (SMI), who have poorer health and experience more suffering. Using a blinded retrospective record review of 137 patients with SMI, divided between inpatients (n = 70) and outpatients (n = 67), we compared the two groups to determine if lack of a PCP is associated with increased suffering and worse overall health. We included history of preventive services, having a PCP, and comorbid conditions. Multiple linear regressions determined the relationship between lacking a PCP and lifestyle problems, lack of preventive care, and Burden of Suffering. We found that in SMI patients, lack of a PCP is associated with increased lifestyle problems, lacking preventive care, increased Burden of Suffering and cervical dysplasia. Health policy changes are needed to improve outcomes for patients with SMI by increasing access to PCPs and preventive services.

Monoclonal gammopathy of undetermined significance: Using risk stratification to guide follow-up.

Varying combinations of 3 measurable factors determine a patient's risk of progressing toward multiple myeloma and influence monitoring decisions. This review--and accompanying algorithm--can guide your approach. For monoclonal gammopathy of undetermined significance (MGUS) patients at low risk, repeat serum protein electrophoresis (SPE) in 6 months. If no significant elevation of M-protein is found, repeat SPE every 2 to 3 years.

Skills-based residency training in alcohol screening and brief intervention: results from the Georgia-Texas "Improving Brief Intervention" Project.

Alcohol screening and brief intervention (SBI) is recommended for all primary care patients but is underutilized. This project trained 111 residents and faculty in 8 family medicine residencies to conduct SBI and implement SBI protocols in residency clinics, then assessed changes in self-reported importance and confidence in performing SBI and brief intervention (BI) rates. Clinicians reported significant increases in role security, confidence, and ability to help drinkers reduce drinking and decreased importance of factors that might dissuade them from performing SBI. Stage of change measures indicated 37% of clinicians progressed toward action or maintenance in performing SBI; however, numbers of reported BIs did not increase. At all time points, 33% to 36% of clinicians reported BIs with ≥10% of the last 50 patients. Future studies should focus on increasing intervention rates using more patient-centered BI approaches, quality improvement approaches, and systems changes that could increase opportunities for performing BIs.

Trends and clustering of cardiometabolic risk factors in American adolescents from 1999 to 2008.

AIM: To characterize trends and clustering of cardiometabolic risk factors in 12-17-year-old non-Hispanic white, non-Hispanic black (NHB), Mexican-American (MA), and multiracial American (MRA) adolescents. METHODS: Data from the 1999-2000 to 2007-2008 U.S. National Health and Nutrition Examination Surveys were used for this investigation. Clustering of cardiometabolic risk factors was determined using cardiometabolic risk factor clustering score (cMetS) computed by aggregating z scores of mean arterial blood pressure, triglycerides, fasting blood glucose, waist circumference, and high-density lipoprotein cholesterol. RESULTS: There were significant increases in waist circumference and high-density lipoprotein cholesterol, and decreases in low density lipoprotein cholesterol, triglycerides, and mean arterial blood pressure in the 10-year period between 1999-2000 and 2007-2008. There were gender and racial/ethnic differences in cMetS, with NHB having a more favorable cMetS for each studied time point. Overall, cMetS decreased by 93% in the 10-year period between 1999-2000 and 2007-2008. cMetS decreased by 98% and 77.3% for male and female adolescents, respectively, in the period between 1999-2000 and 2007-2008. With the exception of Mexican-American and multiracial American female adolescents, all racial/ethnic groups had improved cMetS values on comparing mean cMetS values of 1999-2000 with mean values of 2007-2008. Compared with other racial/ethnic groups, NHB male and female adolescents had the most improved cMetS. CONCLUSION: Because clustering of cardiometabolic risk factors is predictive of adult health status, early lifestyle intervention in adolescence may help slow down the progress and delay or prevent the onset of cardiovascular diseases in adulthood.

Translation of the National Institutes of Health Diabetes Prevention Program in African American churches.

OBJECTIVE: To translate the Diabetes Prevention Program (DPP) for delivery in African American churches. METHODS: Two churches participated in a 6-week church-based DPP and 3 churches participated in a 16-week church-based DPP, with follow-up at 6 and 12 months. The primary outcomes were changes in fasting glucose and weight. RESULTS: There were a total of 37 participants; 17 participated in the 6-session program and 20 participated in the 16-session program. Overall, the fasting glucose decreased from 108.1 to 101.7 mg/dL post intervention (p=.037), and this reduction persisted at the 12-month follow-up without any planned maintenance following the intervention. Weight decreased 1.7 kg post intervention with 0.9 kg regained at 12 months. Body mass index (BMI) decreased from 33.2 to 32.6 kg/m2 post intervention with a final mean BMI of 32.9 kg/m2 at the 12-month check (P<.05). Both the 6- and 16-session programs demonstrated similar reductions in glucose and weight; however, the material costs of implementing the modified 6-session DPP were $934.27 compared to $1075.09 for the modified 16-session DPP. CONCLUSION: Translation of DPP can be achieved in at-risk African Americans if research teams build successful community-based relationships with members of African American churches. The 6-session modified DPP was associated with decreased fasting glucose and weight similar to the 16-session program, with lowered material costs for implementation. Further trials are needed to test the costs and effectiveness of church-based DPPs across different at-risk populations.

Continuous metabolic syndrome risk score, body mass index percentile, and leisure time physical activity in American children.

The objective of this study was to determine independent and joint association of body mass index (BMI) percentile and leisure time physical activity (LTPA) with continuous metabolic syndrome (cMetS) risk score in 12- to 17-year-old American children. The 2003 to 2004 US National Health and Nutrition Examination Survey data were used for this investigation. LTPA was determined by self-report. cMetS risk score was calculated using standardized residuals of arterial blood pressure, triglycerides, glucose, waist circumference, and high-density lipoprotein cholesterol. Multiple linear regression analysis was used to evaluate association of BMI percentile and LTPA with cMetS risk score, adjusting for confounders. Increased BMI percentile and LTPA were each associated with increased and decreased cMetS risk score, respectively ((P<.01). There was a gradient of increasing cMetS risk score by BMI percentile cutpoints, from healthy weight (-0.77) to overweight (3.43) and obesity (6.40) ((P<.05). A gradient of decreasing cMetS risk score from sedentary (0.88) to moderate (0.17) and vigorous (-0.42) LTPA levels was also observed (P<.01). The result of this study suggests that promoting LTPA at all levels of weight status may help to reverse the increasing trends of metabolic syndrome in US children.

Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison.

BACKGROUND: Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates. METHODS: In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention. RESULTS: Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients. CONCLUSIONS: Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Clinical inquiries. Which strategies work best to prevent obesity in adults?

Physical activity and dietary modification work best. Family involvement, regular weight monitoring, and behavior modification also can help. Regular physical activity decreases long-term weight gain. Decreasing fat intake and increasing fruit and vegetable consumption also may decrease weight gain. Combined dietary and physical activity interventions prevent weight gain. Family involvement helps maintain weight. Daily or weekly weight monitoring reduces long-term weight gain. Clinic-based, direct-contact, and Web-based programs that include behavior modification may reduce weight gain in adults. Behavior modification delivered by personal contact is more effective than mail, Internet, or self-directed modification programs.

A qualitative inquiry into the community and programmatic dimensions associated with successful implementation of church-based diabetes prevention programs.

PURPOSE: This study explored church members' perspectives regarding implementation of a church-based diabetes prevention program (CBDPP) within African American churches. METHODS: Qualitative exploration of themes associated with planning for program implementation and good program outcomes was conducted using a series of four focus groups in churches located in the southeastern United States. Three of these focus groups were conducted with church leaders during the planning phases of program initiation and one focus group involved program participants who had realized the most weight loss and decrease in fasting glucose. Focus group transcripts were subject to content analysis. Participants discussed their views about how to implement a CBDPP within their church and how both the program and broader church community had helped them succeed. RESULTS: Two broad thematic domains emerged with respect to successful CBDPP implementation. The first domain covered church functions and program integration within the church. This was further divided into three thematic clusters relating to church organization, promotion from the pulpit and program visibility, and church service. The second domain addressed the motivational and relationship factors associated with successful program involvement. This was divided into three clusters relating to individuals' motives and beliefs, learning from others, and the support of others. CONCLUSIONS: Implementation of a CBDPP depends on the endorsement by the church leadership, congregational awareness of the program objectives, and active community and program support of CBDPP participants. These occur through a variety of formal and informal channels within the church community.

Self-reported and measured height and weight: impact on racial/ethnic differences in hypertension.

OBJECTIVE: We compare estimability of obesity from self-reported and measured height and weight in White, Black, and Hispanic Americans. We also sought to determine the effect of using self-reported and measured height and weight in determining the association of obesity with risk of hypertension in these population groups. METHODS: The 1999-2000 National Health and Nutrition Examination Survey (NHANES 1999-2000) participants' (n=4789) self-reported and measured height and weight were used for this study. Logistic regression adjusted for age, blood glucose level, total cholesterol level, smoking status, and exercise status to compare the association of obesity estimated from self-reported and measured height and weight on the prevalence odds of hypertension. RESULTS: Men tended to overestimate height and weight, and women tended to overestimate height and underestimate weight. Using self-reported values diminished the prevalence of obesity and odds of hypertension, and this effect related to ethnicity and sex. In men, self-report decreased the prevalence of hypertension by 9.1%, 11.8%, and 26.6% in Whites, Blacks, and Hispanics, respectively. The analogous values in women were 11.1%, 22.7%, and 7.7%. CONCLUSION: Public health researchers and practitioners who use self-reported height and weight should be aware of the potential for error when using self-reported values to estimate obesity so that they may make better decisions regarding obesity screening and prevention.

Mild-to-moderate ulcerative colitis: your role in patient compliance and health care costs.

BACKGROUND: Ulcerative colitis (UC) is a chronic relapsing disease necessitating lifelong treatment. Most patients present with mild-to-moderate disease characterized by alternating periods of remission and clinical relapse. Continued disease progression and relapse of UC over time are associated with an increased risk of colorectal cancer (CRC). OBJECTIVE: To discuss the latest treatment options for mild-to-moderate UC, to review the current data involving the economics of UC, and to demonstrate the relationship between treatment adherence, clinical relapse, inflammation severity, CRC risk, and treatment outcomes. SUMMARY: One of the main goals of therapy in UC is to induce and maintain a long-lasting remission of disease to reduce or avoid the high personal and financial costs of relapse. In recent studies, researchers have demonstrated a link between increased colonic inflammation and CRC risk, highlighting the importance of preventing relapse, which can lead to costly surgical procedures and hospital stays and thus increase the cost of treatment 2- to 20-fold. The risk of disease relapse is affected by several factors, of which the most prominent is nonadherence to maintenance therapy. Nonadherence to therapy can be associated with several other factors, including forgetfulness, male sex, complicated dosing regimens, treatment delivery methods (oral vs. rectal), and pill burden. In the treatment of mild-to-moderate UC, 5-aminosalicyclic acid (5-ASA) is the standard first-line therapy and the treatment of choice for maintaining remission of disease. Novel formulations of 5-ASA and newly devised high-dose 5-ASA regimens offer more options for the treatment of UC and thus may lead to improved treatment adherence, longer remission, and improved patient well-being. CONCLUSION: Periods of remission during UC treatment must be aggressively maintained to prevent relapse and decrease the risk of an unfavorable outcome. By controlling the risks and conditions that lead to therapeutic nonadherence and relapse among patients with UC, clinicians can increase the likelihood of long-term remission and ensure favorable long-term outcomes.

The effects of a patient-based risk assessment prompt on diabetes screening.

OBJECTIVE: Previous research has determined that nurse-based diabetes risk assessment increases screening and preventive services for patients at risk for type 2 diabetes. This pilot study tested the impact of a diabetes risk assessment completed by patients without nursing assistance. RESEARCH DESIGN AND METHODS: Patients from a family medicine residency clinic completed an American Diabetes Association Risk Assessment questionnaire. Intervention subjects presented completed questionnaires to their physicians. Control subjects returned the questionnaire to the research assistant. Primary endpoints were the number of persons receiving diabetes screening and the number of persons with newly diagnosed diabetes. The associations between the intervention and diabetes screening and diagnosis were assessed using univariate and multivariate logistic regression models. RESULTS: This study included 511 subjects (256 in the intervention group and 255 in the control group). Comparing intervention to control subjects, there was no difference in fasting glucose screening rates. However, odds of diabetes diagnoses were significantly higher using univariate analysis (OR 5.2; 95% CI 1.1-24.3, p=.036) and approached statistical significance after adjusting for other risk factors (OR 4.6; 95% CI 0.92-23.2, p=.063). CONCLUSIONS: A simple patient-based risk assessment used in the outpatient setting may represent a simple, economical method for discovering previously-undiagnosed type 2 diabetes.

A simple nurse-based prompt increases screening and prevention counseling for diabetes.

OBJECTIVE: To determine the impact of a simple nurse-based prompt on fasting glucose screening and counseling regarding diet, exercise and weight loss to persons at increased risk for type 2 diabetes. RESEARCH DESIGN AND METHODS: Patients at risk for diabetes were recruited from 10 primary care practices. Nurses were trained to score a diabetes risk assessment and prompt providers concerning all high-risk subjects. Both univariate and multivariate logistic regression models were used to determine the association between the nurse prompt and subsequent fasting glucose testing or receiving advice for diet, exercise, or weight loss. RESULTS: Of 1176 subjects, 597 were recruited from intervention practices and 579 from control practices. In both the univariate and multivariate models, the intervention group was more likely to receive fasting glucose testing and advice for diet, exercise and weight loss. In the multivariate model, patients in the intervention group were more likely to receive fasting glucose testing (odds ratio 9.3, 95% confidence interval 3.6-24.0), dietary advice (6.1, 3.5-10.7), exercise advice (7.4, 4.0-13.9), and weight loss advice (1.9, 1.1-3.7). CONCLUSIONS: A simple nurse-based prompt is an effective tool to increase screening and preventive services for people at risk for type 2 diabetes.