Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 4: Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients.

OBJECTIVES: This paper focuses on the methods of a single study, incorporating data from chiropractic clinics into an evidenced-based investigation of the appropriateness of manipulation for chronic back pain. METHODS: A cluster sample of clinics (125) from 6 sites across the United States was chosen for this observation study. Patients with chronic low-back and neck pain were recruited using iPads, completed a series of online questionnaires, and gave permission for their patient records to be scanned. Patient records for a random sample were also obtained. The RAND staff and clinic personnel collected record data. RESULTS: We obtained survey data from 2024 patients with chronic low back pain, chronic neck pain, or both. We obtained patient record data from 114 of 125 clinics. These included the records of 1475 of the individuals who had completed surveys (prospective sample), and a random sample of 2128 patients. Across 114 clinics, 22% of clinics had patient records that were fully electronic, 32% had paper files, and 46% used a combination. Of the 114 clinics, about 47% scanned the records themselves with training from RAND. We obtained a total of 3603 scanned records. The patient survey data were collected from June 2016 to February 2017, the provider surveys from June 2016 to March 2017, and the chart pull from April 2017 to December 2017. CONCLUSIONS: Clinics can be successfully recruited for practice-based studies, and patients can be recruited using iPads. Obtaining patient records presents considerable challenges, and clinics varied in whether they had electronic files, nonelectronic records, or a mixture. Clinic staff can be trained to select and scan samples of charts to comply with randomization and data protection protocols in transferring records for research purposes.

Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use.

BACKGROUND: Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES: To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS: A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES: Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS: The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS: This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.

Sustaining alcohol and opioid use disorder treatment in primary care: a mixed methods study.

BACKGROUND: Efforts to integrate substance use disorder treatment into primary care settings are growing. Little is known about how well primary care settings can sustain treatment delivery to address substance use following the end of implementation support. METHODS: Data from two clinics operated by one multi-site federally qualified health center (FQHC) in the US, including administrative data, staff surveys, interviews, and focus groups, were used to gather information about changes in organizational capacity related to alcohol and opioid use disorder (AOUD) treatment delivery during and after a multi-year implementation intervention was executed. Treatment practices from the intervention period were compared to practices after the intervention period to examine whether the practices were sustained. Data from staff surveys and interviews were used to examine the factors related to sustainment. RESULTS: The two clinics sustained multiple components of AOUD care 1 year following the end of implementation support, including care coordination, psychotherapy, and medication-assisted treatment. Some of the practices were modified over time, for example, screening became less frequent by design, while use of care coordination and psychotherapy for AOUDs expanded. Participants identified staff training and funding for medications as key challenges to sustaining treatment. CONCLUSIONS: Following a multi-year implementation intervention, a large FQHC continued to deliver AOUD treatment. Access to external funding and staff support appeared to be critical elements for sustaining care over time. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01810159.

Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities.

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This study provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Quality of Care for PTSD and Depression in the Military Health System: Final Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This study is a comprehensive assessment of the quality of care delivered by the MHS in 2013-2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012-2013 and 2013-2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 2: What Every Researcher and Practitioner Should Know About the Health Insurance Portability and Accountability Act and Practice-based Research in the United States.

OBJECTIVE: This paper describes a process for ensuring and documenting Health Insurance Portability and Accountability Act (HIPAA) compliance in clinical practice-based research. METHODS: The Center of Excellence for Research in Complementary and Alternative Medicine was funded by National Center for Complementary and Integrative Health to develop the methods for researching the appropriateness of care in complementary and integrative health, which previously was known as complementary and alternative medicine. We recruited 125 participating chiropractic clinics for enrolling patients and gathering their data via the online surveys. Chiropractic clinics completed the following: (1) obtained the files of patients who provided prior consent (the prospective sample), (2) obtained the files of the patients selected randomly using specified randomization procedures (the retrospective sample), and (3) transferred all patient data to the RAND Corporation via an encrypted file. RESULTS: Most of the doctors of chiropractic from clinical practices had no concerns about obtaining and transferring the files of patients who provided informed consent. However, some doctors were uneasy about allowing the researchers to access the randomly selected files of patients who had not provided prior authorization. This led us to develop a set of forms to provide clinics about HIPAA compliance. CONCLUSION: For this study, we provided clinics with information about the rules under HIPAA, demonstrated how the study complied with those rules, explained the logic behind the necessity for collecting files from both the prospective and retrospective samples, and, if requested, provided clinics with a confidentiality agreement signed by the study principal investigator and an organizational contracts representative. The process we developed may assist other complementary and integrative health researchers and practitioners in future studies.

Demographic and Mental Health Characteristics of Individuals Who Present to Community Health Clinics With Substance Misuse.

INTRODUCTION: Community health clinics (CHCs) are an opportune setting to identify and treat substance misuse. This study assessed the characteristics of patients who presented to a CHC with substance misuse. METHODS: Personnel at a large CHC administered a 5-question screener to patients between June 3, 2014, and January 15, 2016, to assess past 3-month alcohol use, prescription opioid misuse, or illicit drug use. We stratified screen-positive patients into 4 diagnostic groups: (1) probable alcohol use disorder (AUD) and no comorbid opioid use disorder (OUD); (2) probable heroin use disorder; (3) probable prescription OUD, with or without comorbid AUD; and (4) no probable substance use disorder. We describe substance use and mental health characteristics of screen-positive patients and compare the characteristics of patients in the diagnostic groups. RESULTS: Compared to the clinic population, screen-positive patients (N = 733) included more males (P < .0001) and had a higher prevalence of probable bipolar disorder (P < .0001) and schizophrenia (P < .0001). Eighty-seven percent of screen-positive patients had probable AUD or OUD; only 7% were currently receiving substance use treatment. The prescription opioid and heroin groups had higher rates of past bipolar disorder and consequences of mental health conditions than the alcohol only or no diagnosis groups (P < .0001). CONCLUSIONS: Patients presenting to CHCs who screen positive for alcohol or opioid misuse have a high likelihood of having an AUD or OUD, with or without a comorbid serious mental illness. Community health clinics offering substance use treatment may be an important resource for addressing unmet need for substance use treatment and comorbid mental illness.

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study.

Untreated substance use disorders remain a pervasive public health problem in the United States, especially among medically-underserved and low-income populations, with opioid and alcohol use disorders (OAUD) being of particular concern. Primary care is an underutilized resource for delivering treatment for OAUD, but little is known about the organizational capacity of community-based primary care clinics to integrate treatment for OAUD. The objective of this study was to use an organizational capacity framework to examine perceived barriers to implementing the continuum of care for OAUD in a community-based primary care organization over three time points: pre-implementation (preparation), early implementation (practice), and full implementation. Clinic administrators and medical and mental health providers from two clinics participated in interviews and focus groups. Barriers were organized by type and size, and are presented over the three time points. Although some barriers persisted, most barriers decreased over time, and respondents reported feeling more efficacious in their ability to successfully deliver OAUD treatment. Findings contribute to the needed literature on building capacity to implement OAUD treatment in primary care and suggest that while barriers may be sizable and inevitable, successful implementation is still possible.

Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial.

Importance: Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD. Objective: To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. Design, Setting, and Participants: A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months. Interventions: Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. Main Outcomes and Measures: The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD. Results: At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (ß = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, ß = 0.13; 95% CI, 0.03-0.23; P = .01). Conclusions and Relevance: Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care. Trial Registration: clinicaltrials.gov Identifier: NCT01810159.