Cost-effectiveness of Tele-delivered behavioral activation by Lay counselors for homebound older adults with depression.

BACKGROUND: Low-income homebound older adults have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages. Little is known about cost effectiveness of lay-counselor-delivered, videoconferenced, short-term behavioral activation on this study population. The objective of this study was to assess the cost-effectiveness of lay-counselor-delivered, videoconferenced, short-term behavioral activation (Tele-BA) compared to clinician-delivered, videoconferenced problem-solving therapy (Tele-PST) and telephone support calls (attention control; AC) for low-income homebound older adults. METHODS: We performed a cost-effectiveness analysis based on data from a recently completed, 3-group (Tele-BA, Tele-PST, and AC) randomized controlled trial with 277 participants aged 50+. We measured total costs of (1) intervention and (2) outpatient care, ED visits, and inpatient care using the Cornell Services Index. The effectiveness outcome was quality-adjusted life-years (QALY). We used EuroQol's EQ-5D-5L to assess each participant's health-related quality of life (HRQoL) at baseline and at 12, 24, and 36 weeks. The end-point measure of cost-effectiveness was the incremental cost-effectiveness ratio (ICER) of (1) Tele-BA versus AC, (2) Tele-PST versus AC, and (3) Tele-BA versus Tele-PST. RESULTS: Relative to AC, both Tele-BA and Tele-PST are cost-saving treatment options. The ICERs for both Tele-BA and Tele-PST were well below $50,000, the lower-bound threshold for cost-effectiveness. Relative to AC, both Tele-PST, Tele-BA are cost-saving treatment options (i.e. lower costs and more QALYs). CONCLUSION: Costs of tele- and lay-counselor-delivered depression treatment are modest and cost effective relative to providing telephone support. Though our results show that Tele-BA may not be cost effective relative to Tele-PST, a clinician-delivered psychotherapy, when a low bound ICER threshold of $50,000 would be used, lay counselors can fill the professional geriatric mental health workforce shortage gap and Tele-BA by lay counselors can improve homebound older adults' access to evidence-and skills-based, cost effective depression care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02600754 (11/09/2015).

Aspiration Risk Factors in Hospitalized Patients Following Trauma.

Introduction: Risk factors for aspiration are not well characterized in the trauma patient population. Improved understanding is important due to features of this patient population that place them at high risk for morbidity and mortality with aspiration. Methods: In a retrospective analysis of patients who suffered a traumatic injury from 2016 to 2018, potential risk factors were recorded and analyzed with logistic regression to evaluate the trauma patient at risk for aspiration. Results: Of the 146 patient charts analyzed, 56 (38%) had at least one documented aspiration event, while 90 (62%) patients had none. Multivariate logistic regression found a significant association between impaired consciousness and aspiration events (p = 0.012). Conclusions: This study was a novel characterization of trauma patients likely to have experienced an aspiration event while hospitalized. The results suggested candidate risk factors for aspiration exist in a trauma-specific population. Impaired consciousness is likely to show a significant association with aspiration in trauma patients in future studies.

Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound: A Randomized Clinical Trial.

Importance: Older adults who are homebound and have low income have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages. Objective: To evaluate clinical effectiveness of a brief, aging service-integrated, videoconferenced behavioral activation (tele-BA) treatment delivered by lay counselors compared with videoconferenced problem-solving therapy (tele-PST) delivered by licensed clinicians and attention control (AC; telephone support calls). Design, Setting, and Participants: This 3-group randomized clinical trial using a randomization prior to consent approach included individuals aged 50 years or older who were homebound and had 24-item Hamilton Depression Rating Scale (HAMD) scores of 15 or greater between February 15, 2016, and April 15, 2019. Tele-BA and tele-PST participants received 5 weekly treatment sessions. Assessments were performed at baseline and 12, 24, and 36 weeks after baseline. Intention-to-treat statistical analyses were performed from January 1, 2020, to February 15, 2020. Interventions: Tele-BA participants were taught 5 steps for reinforcing healthy behaviors to improve mood, physical functioning, and social engagement. Tele-PST participants were taught a 7-step approach for problem solving coping skills. Main Outcomes and Measures: The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD <10) rates and effect sizes for clinically meaningful differences were examined. Secondary outcomes were disability, social engagement and activity frequency, and satisfaction with participation in social roles. Results: A total of 277 participants were enrolled, including 193 (69.7%) women, 83 (30.0%) who were Black, 81 (29.2%) who were Hispanic, and 255 (92.1%) with income of $35 000 or less. The mean (SD) age was 67.5 (8.9) years. Among these, 90 participants were randomized to tele-BA, 93 participants were randomized to tele-PST, and 94 participants were randomized to the AC. Compared with participants in the AC group, participants in the tele-BA and tele-PST groups had significantly higher response and remission rates and medium to large effect sizes (tele-BA: raw growth modeling analysis d = 0.62 [95% CI, 0.35 to 0.89]; P < .001; tele-PST: raw growth modeling analysis d = 1.00 [95% CI, 0.73 to 1.26]; P < .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (t258 = -2.79; P = .006), there was no difference between tele-BA and tele-PST on secondary outcomes. Conclusions and Relevance: In this randomized clinical trial, participants who received tele-BA by lay counselors achieved statistically and clinically meaningful changes in depressive symptoms. Given shortages of licensed mental health clinicians, tele- and lay counselor-delivered services may help improve access to evidence-based depression treatment for large numbers of underserved older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT02600754.

Comparison of noninvasive blood pressure monitoring with invasive arterial pressure monitoring in medical ICU patients with septic shock.

OBJECTIVE: In the critically ill, the insertion of peripheral arterial catheters to monitor hemodynamics is a low-risk procedure, but carries the potential for complications. This study was designed to compare invasive and noninvasive blood pressure measurements in patients with septic shock in a medical ICU. PATIENTS AND METHODS: We carried out a prospective observational study of patients admitted with septic shock and a radially inserted peripheral arterial catheter in the medical ICU with 31 adult patients who underwent four pairs of simultaneous noninvasive and invasive blood pressure measurements (124 comparisons), with the invasive blood pressure taken as the gold standard. Agreements between invasive and noninvasive blood pressure methods were assessed using Bland-Altman analysis, and clinical significance was determined by the European Society of Hypertension criteria. RESULTS: In all patients, noninvasive systolic (P=0.0385), diastolic (P<0.0001), and mean arterial pressures (P<0.0001) did correlate statistically with invasive measurements; however, all noninvasive pressure measurements did not correlate clinically according to the European Society of Hypertension criteria. CONCLUSION: In our patients admitted to the medical ICU with septic shock, noninvasive blood pressure monitoring did not clinically correlate with invasive blood pressure measurements.