Real-World Evidence from the Integrative Medicine Primary Care Trial (IMPACT): Assessing Patient-Reported Outcomes at Baseline and 12-Month Follow-Up.

PURPOSE: The University of Arizona Integrative Health Center (UAIHC) was an innovative membership-supported integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC delivered healthcare using an integrative medicine model that combined conventional and complementary medical treatments, including nutrition, mind-body medicine, acupuncture, manual medicine, health coaching, educational classes, and groups. Results from pre-post evaluation of patient-reported outcomes on several standardized measures are presented here. METHODS: UAIHC patients completed surveys at baseline and after 12 months of continuous integrative primary care. Patients reported on perceived changes in health outcomes as measured by Short-Form Health Survey (SF-12 general, mental, and physical health), Perceived Stress Scale (PSS4), Work Productivity and Activity Impairment Questionnaire (WPAI), World Health Organization Well-Being Index (WHO-5), Pain Visual Analog Scale (VAS), Fatigue Severity Scale (VAS; FSS), Generalized Anxiety Disorder Scale (GAD2), Patient Health Questionnaire for depression (PHQ2), Pittsburgh Sleep Quality Index (PSQI) global rating of sleep quality, and the Behavioral Risk Factor Surveillance System (BRFSS; nutrition, exercise, and physical activity). Overall differences between time points were assessed for statistical significance. Patient demographics are also described. RESULTS: 177 patients completed baseline and follow-up outcome measures. Patients were predominantly white, female, college-educated, and employed. Baseline to one-year follow-up results indicate statistically significant improvements (p <.05) on all but perceived stress (PSS-4) and work absenteeism (WPAI). Clinical impact and/or practical effects are reported as percent change or standardized effect sizes whenever possible. Other demographic and descriptive information is summarized. CONCLUSIONS: Following one year of IM primary care at UAIHC, patient-reported outcomes indicated positive impacts in several areas of patients' lives: mental, physical, and overall health; work productivity; sleep quality; pain; fatigue; overall well-being; and physical activity.

Integrative medicine primary care: assessing the practice model through patients' experiences.

BACKGROUND: The University of Arizona Integrative Health Center (UAIHC) was an innovative integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC used a hybrid payment model to deliver comprehensive healthcare that includes conventional and complementary medical treatments. METHODS: Fidelity measures were collected to evaluate how well the IM care delivery process matched ideals for IM. Patient experiences are presented here. Patients visiting UAIHC on 1 of 10 randomly selected days between September 2013 and February 2015 were surveyed. Patients were asked about their experience with: holistic care; promotion of health, self-care, and well-being; relationship and communication with practitioners; and overall satisfaction. RESULTS: Eighty-three patients completed surveys. Based on patient-reported experiences, UAIHC delivered IM care as defined by the practice model. CONCLUSIONS: Patients received holistic care, established positive caring relationships with providers who promoted their self-care and well-being, and reported high overall satisfaction with UAIHC.

IMPACT--Integrative Medicine PrimAry Care Trial: protocol for a comparative effectiveness study of the clinical and cost outcomes of an integrative primary care clinic model.

BACKGROUND: Integrative medicine (IM) is a patient-centered, healing-oriented clinical paradigm that explicitly includes all appropriate therapeutic approaches whether they originate in conventional or complementary medicine (CM). While there is some evidence for the clinical and cost-effectiveness of IM practice models, the existing evidence base for IM depends largely on studies of individual CM therapies. This may in part be due to the methodological challenges inherent in evaluating a complex intervention (i.e., many interacting components applied flexibly and with tailoring) such as IM. METHODS/DESIGN: This study will use a combination of observational quantitative and qualitative methods to rigorously measure the health and healthcare utilization outcomes of the University of Arizona Integrative Health Center (UAIHC), an IM adult primary care clinic in Phoenix, Arizona. There are four groups of study participants. The primary group consists of clinic patients for whom clinical and cost outcomes will be tracked indicating the impact of the UAIHC clinic (n = 500). In addition to comparing outcomes pre/post clinic enrollment, where possible, these outcomes will be compared to those of two matched control groups, and for some self-report measures, to regional and national data. The second and third study groups consist of clinic patients (n = 180) and clinic personnel (n = 15-20) from whom fidelity data (i.e., data indicating the extent to which the IM practice model was implemented as planned) will be collected. These data will be analyzed to determine the exact nature of the intervention as implemented and to provide covariates to the outcomes analyses as the clinic evolves. The fourth group is made up of patients (n = 8) whose path through the clinic will be studied in detail using qualitative (periodic semi-structured interviews) methods. These data will be used to develop hypotheses regarding how the clinic works. DISCUSSION: The US health care system needs new models of care that are more patient-centered and empower patients to make positive lifestyle changes. These models have the potential to reduce the burden of chronic disease, lower the cost of healthcare, and offer a sustainable financial paradigm for our nation. This protocol has been designed to test whether the UAIHC can achieve this potential. TRIAL REGISTRATION: Clinical Trials.gov NCT01785485.

When a whole practice model is the intervention: developing fidelity evaluation components using program theory-driven science for an integrative medicine primary care clinic.

Integrative medicine (IM) is a clinical paradigm of whole person healthcare that combines appropriate conventional and complementary medicine (CM) treatments. Studies of integrative healthcare systems and theory-driven evaluations of IM practice models need to be undertaken. Two health services research methods can strengthen the validity of IM healthcare studies, practice theory, and fidelity evaluation. The University of Arizona Integrative Health Center (UAIHC) is a membership-supported integrative primary care clinic in Phoenix, AZ. A comparative effectiveness evaluation is being conducted to assess its clinical and cost outcomes. A process evaluation of the clinic's practice theory components assesses model fidelity for four purposes: (1) as a measure of intervention integrity to determine whether the practice model was delivered as intended; (2) to describe an integrative primary care clinic model as it is being developed and refined; (3) as potential covariates in the outcomes analyses, to assist in interpretation of findings, and for external validity and replication; and (4) to provide feedback for needed corrections and improvements of clinic operations over time. This paper provides a rationale for the use of practice theory and fidelity evaluation in studies of integrative practices and describes the approach and protocol used in fidelity evaluation of the UAIHC.

Trapping Phyllophaga spp. (Coleoptera: Scarabaeidae: Melolonthinae) in the United States and Canada using sex attractants.

The sex pheromone of the scarab beetle, Phyllophaga anxia, is a blend of the methyl esters of two amino acids, L-valine and L-isoleucine. A field trapping study was conducted, deploying different blends of the two compounds at 59 locations in the United States and Canada. More than 57,000 males of 61 Phyllophaga species (Coleoptera: Scarabaeidae: Melolonthinae) were captured and identified. Three major findings included: (1) widespread use of the two compounds [of the 147 Phyllophaga (sensu stricto) species found in the United States and Canada, males of nearly 40% were captured]; (2) in most species intraspecific male response to the pheromone blends was stable between years and over geography; and (3) an unusual pheromone polymorphism was described from P. anxia. Populations at some locations were captured with L-valine methyl ester alone, whereas populations at other locations were captured with L-isoleucine methyl ester alone. At additional locations, the L-valine methyl ester-responding populations and the L-isoleucine methyl ester-responding populations were both present, producing a bimodal capture curve. In southeastern Massachusetts and in Rhode Island, in the United States, P. anxia males were captured with blends of L-valine methyl ester and L-isoleucine methyl ester.

Acoustic identification and measurement of activity patterns of white grubs in soil.

Activity patterns of Phyllophaga crinita (Burmeister), Phyllophaga congrua (LeConte), Phyllophaga crassissima (Blanchard), and Cyclocephala lurida (Bland) grubs were monitored with acoustic sensors in small pots of bluegrass, Poa arachnifera Torr, at varying and constant temperatures over multiple-day periods. Experienced listeners readily distinguished three types of sound with distinct differences in frequency and temporal patterns, intensities, and durations. Of approximately 3,000 sounds detected from P. crinita larvae, 7% were identifiable as snaps, with large amplitudes and short durations typically associated with root breakage or clipping activity. Approximately 60% were identifiable as rustles, suggestive of surfaces sliding or rubbing past each other during general movement activity. Another 2% of sounds contained patterns of repeated pulses suggestive of surfaces scraping across a pointed ridge. The remaining 31% had spectral or temporal patterns that fell outside the ranges of easily recognizable sound types. Because the behavioral significance of the different sound types has not yet been fully established, the classified and unclassified sounds were pooled together in analyses of the effects of species, temperature, weight, and time of day. Grubs of all four species produced detectable sounds at rates that increased with temperature [0.45 sounds/((min)(degrees C))] and larval weight [6.3 sounds/((min)(g))]. Mean sound rates were independent of species and time of day. At temperatures <9 degrees C, mean sound rates fell below the typical levels of background noise observed under field conditions. This reduced activity at low temperatures is likely to reduce the effectiveness of acoustic monitoring in the field in cold weather. The consistency of results obtained in these tests over multiple-day periods suggests that acoustic systems have potential as tools for nondestructive monitoring of the efficacy of insect management treatments as well as for biological and ecological studies.

Acoustic estimation of infestations and population densities of white grubs (Coleoptera: Scarabaeidae) in turfgrass.

Incidental sounds produced by Phyllophaga crinita (Burmeister) and Cyclocephala lurida (Bland) (Coleoptera: Scarabaeidae) white grubs were monitored with single- and multiple-sensor acoustic detection systems in turf fields and golf course fairways in Texas. The maximum detection range of an individual acoustic sensor was measured in a greenhouse as approximately the area enclosed in a 26.5-cm-diameter perimeter (552 cm2). A single-sensor acoustic system was used to rate the likelihood of white grub infestation at monitored sites, and a four-sensor array was used to count the numbers of white grubs at sites where infestations were identified. White grub population densities were acoustically estimated by dividing the estimated numbers of white grubs by the area of the detection range. For comparisons with acoustic monitoring methods, infestations were assessed also by examining 10-cm-diameter soil cores collected with a standard golf cup-cutter. Both acoustic and cup-cutter assessments of infestation and estimates of white grub population densities were verified by excavation and sifting of the soil around the sensors after each site was monitored. The single-sensor acoustic method was more successful in assessing infestations at a recording site than was the cup-cutter method, possibly because the detection range was larger than the area of the soil core. White grubs were recovered from >90% of monitored sites rated at medium or high likelihood of infestation. Infestations were successfully identified at 23 of the 24 sites where white grubs were recovered at densities >50/m2, the threshold for economic damage. The four-sensor array yielded the most accurate estimates of the numbers of white grubs in the detection range, enabling reliable, nondestructive estimation of white grub population densities. However, tests with the array took longer and were more difficult to perform than tests with the single sensor.