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1.
JMIR Serious Games ; 8(2): e16096, 2020 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-32347811

RESUMO

BACKGROUND: The United States spends more than US $100 billion annually on the impact of medication misuse. Serious games are effective and innovative digital tools for educating patients about positive health behaviors. There are limited systematic reviews that examine the prevalence of serious games that incorporate medication use. OBJECTIVE: This systematic review aimed to identify (1) serious games intended to educate patients about medication adherence, education, and safety; (2) types of theoretical frameworks used to develop serious games for medication use; and (3) sampling frames for evaluating serious games on medication use. METHODS: PubMed, Scopus, and Web of Science databases were searched for literature about medication-based serious games for patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for article selection. RESULTS: Using PRISMA guidelines, 953 publications and 749 unique titles were identified from PubMed, Scopus, and Web of Science. A total of 16 studies featuring 12 unique serious games were included with components of medication adherence, education, and safety, published from 2003 to 2019. Of the 12 games included, eight serious games were tested in adolescents, three games were tested in young adults, and one game was tested in adults. Most studies (n=11) used small sample sizes to test the usability of serious games. Theoretical frameworks identified in the 12 serious games included information, motivation, and behavior theory; social cognitive theory; precede-proceed model; middle-range theory of chronic illness; adult learning theory; experiential learning theory; and the theory of reasoned action. Existing reviews explore serious games focused on the management of specific disease states, such as HIV, diabetes, and asthma, and on the positive impact of serious game education in each respective disease state. Although other reviews target broad topics such as health care gamification and serious games to educate health care workers, no reviews focus solely on medication use. Serious games were mainly focused on improving adherence, whereas medication safety was not widely explored. Little is known about the efficacy and usability of medication-focused serious games often because of small and nonrepresentative sample sizes, which limit the generalizability of existing studies. CONCLUSIONS: Limited studies exist on serious games for health that incorporate medication use. The findings from these studies focus on developing and testing serious games that teach patients about medication use and safety. Many of these studies do not apply a theoretical framework in the design and assessment of these games. In the future, serious game effectiveness could be improved by increasing study sample size and diversity of study participants, so that the results are generalizable to broader populations. Serious games should describe the extent of theoretical framework incorporated into game design and evaluate success by testing the player's retention of learning objectives.

2.
Implement Sci ; 15(1): 26, 2020 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-32334632

RESUMO

BACKGROUND: Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics. METHODS/DESIGN: The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics. DISCUSSION: Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices. TRIAL REGISTRATION: NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019.

4.
J Addict Med ; 2020 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-32032207

RESUMO

OBJECTIVES: Although unhealthy substance use and addiction contribute to 1 in 4 deaths and are estimated to cost the US more than $740 billion annually, fewer than 12 hours of physician education over the 7 years of medical school and primary residency training specifically address alcohol and other drug-related issues. Addiction Medicine was formally recognized as a medical subspecialty in 2016 to address the need for physicians trained in prevention, treatment, and management of substance use. This study examines the characteristics of the Addiction Medicine fellowships in operation during this critical period in the subspecialty's development to identify needs and potential. METHODS: This study is a cross-sectional survey of Addiction Medicine Fellowship Directors from 46 fellowships accredited as of 2017 (43 in the United States and 3 in Canada). The response rate was 100%. RESULTS: Directors estimated significant growth in available fellowship slots between 2016 to 2017 and 2017 to 2018 (F = 49.584, P < .001). The majority of Directors reported that demand for their graduates was high (79.5%). Fellow training in screening, brief intervention, and referral to treatment spanned many substances and age groups, although fewer programs focused on nicotine and on adolescent populations. Notably, most directors reported that graduates completed waiver training to prescribe buprenorphine-naloxone (77.5%) and gained clinical experience in an opioid treatment setting (89.1%). Funding was the #1 need among 56.8% of Directors. CONCLUSIONS: Despite significant growth in Addiction Medicine fellowships over the past 6 years, meeting future workforce demands for Addiction Medicine specialists depends on access to funding to support fellowships.

5.
Subst Abus ; : 1-12, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31729933

RESUMO

Background: Exercise has been examined as an adjunctive treatment for substance use disorders (SUDs), yet few exercise interventions have been conducted among patients undergoing intensive outpatient (IOP) treatment, who may be the most vulnerable to relapse and for whom exercise could provide the most benefits. This study examined the effects of aerobic exercise, in addition to IOP treatment, on psychological variables and endocannabinoids in individuals with SUDs. Methods: Twenty-one SUD patients (mean age 35 years) were recruited from local IOPs. Participants were randomized to either treatment-as-usual (TAU, at their outpatient clinic) or TAU plus aerobic exercise training (EX). EX participants engaged in supervised, moderate-intensity exercise for 30 min, 3 times/week for 6 weeks. TAU participants came into the laboratory once per week for assessments and a 30-min quiet rest session. Participants provided blood samples and completed questionnaires evaluating substance use, mood states, depression, anxiety, perceived stress, self-efficacy to abstain from substance use, and craving. Data were analyzed with Mann-Whitney U tests or mixed model ANOVAs to determine group differences in outcomes acutely and over 6 weeks. Results: Over 6 weeks, there were reductions in perceived stress (p < 0.01) and craving (p < 0.05) for both groups. There were no group differences in abstinence rates or changes from baseline in self-efficacy, depression, or anxiety (p > 0.05). Acutely, both exercise and quiet rest sessions led to reductions in craving, tension, depression, anger, confusion, and total mood disturbance (all ps < 0.05). In addition, the EX group experienced acute increases in vigor and circulating concentrations of the endocannabinoid, anandamide (p < 0.01). Conclusions: An adjunctive aerobic exercise program during SUD treatment was associated with similar reductions in perceived stress and drug craving as standard care. Thirty minutes of exercise or quiet rest led to acute improvements in mood, but exercise produced the additional benefit of increases in vigor and circulating anandamide.

6.
WMJ ; 118(2): 84-87, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31532934

RESUMO

BACKGROUND: Factors surrounding opioid overdose and naloxone use must be explored from the user perspective in order to more effectively combat the current opioid crisis. METHODS: AIDS Resource Center of Wisconsin needle exchange clients were surveyed regarding overdose victim demographics, interventions, experience with naloxone, and overdose outcomes. RESULTS: Most respondents (102/108, 94.4%) reported either experiencing or witnessing an overdose. While naloxone was often used (64/102, 62.7%), other recommended interventions, such as calling 911 (44/102, 43.1%) and rescue breathing (31/102, 30.4%) often were not. Potential legal consequences were cited as a major barrier for contacting emergency medical services (42.3%). DISCUSSION/CONCLUSION: There appears to be a need for education and/or policy change to facilitate appropriate overdose prevention and use of emergency medical services in the setting of opioid overdose.


Assuntos
Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Naloxona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Programas de Troca de Agulhas , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Adulto , Serviços Médicos de Emergência , Tratamento de Emergência , Feminino , Humanos , Masculino , Inquéritos e Questionários , Wisconsin
7.
Addict Sci Clin Pract ; 14(1): 24, 2019 07 10.
Artigo em Inglês | MEDLINE | ID: mdl-31291996

RESUMO

BACKGROUND: Despite the high prevalence of alcohol use disorders (AUDs), in 2016, only 7.8% of individuals meeting diagnostic criteria received any type of AUD treatment. Developing options for treatment within primary care settings is imperative to increase treatment access. As part of a trial to implement AUD pharmacotherapy in primary care settings, this qualitative study analyzed pre-implementation provider interviews using the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. METHODS: Three large Veterans Health Administration facilities participated in the implementation intervention. Local providers were trained to serve as implementation/clinical champions and received external facilitation from the project team. Primary care providers received a dashboard of patients with AUD for case identification, educational materials, and access to consultation from clinical champions. Veterans with AUD diagnoses received educational information in the mail. Prior to the start of implementation activities, 24 primary care providers (5-10 per site) participated in semi-structured interviews. Transcripts were analyzed using common coding techniques for qualitative data using the CFIR codebook Innovation/Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals domains. Number and type of barriers identified were compared to quantitative changes in AUD pharmacotherapy prescribing rates. RESULTS: Four major barriers emerged across all three sites: complexity of providing AUD pharmacotherapy in primary care, the limited compatibility of AUD treatment with existing primary care processes, providers' limited knowledge and negative beliefs about AUD pharmacotherapy and providers' negative attitudes toward patients with AUD. Site specific barriers included lack of relative advantage of providing AUD pharmacotherapy in primary care over current practice, complaints about the design quality and packaging of implementation intervention materials, limited priority of addressing AUD in primary care and limited available resources to implement AUD pharmacotherapy in primary care. CONCLUSIONS: CFIR constructs were useful for identifying pre-implementation barriers that informed refinements to the implementation intervention. The number and type of pre-implementation barriers identified did not demonstrate a clear relationship to the degree to which sites were able to improve AUD pharmacotherapy prescribing rate. Site-level implementation process factors such as leadership support and provider turn-over likely also interacted with pre-implementation barriers to drive implementation outcomes.

8.
Res Social Adm Pharm ; 15(7): 841-844, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30655180

RESUMO

Misuse of prescription opioids and associated negative health outcomes is a leading public health crisis among adolescents in the US. Opioid prescription rates, misuse, and overdose deaths have increased among adolescents in the last twenty years. This commentary highlights trends in prescribing opioids and medication misuse among adolescents in the US and sheds light on reasons and motives for misuse of prescription opioids among adolescents. It discusses recent educational initiatives which promote medication safety, describes current practices, and recommends effective strategies to enhance prescription opioid safety among adolescents. Opportunities to enhance opioid medication safety among adolescents are frequently overlooked. A critical strategy to combat opioid misuse and overdose deaths among adolescents involves increasing awareness and knowledge about safe medication use.

9.
J Asthma ; 56(3): 273-284, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29641357

RESUMO

OBJECTIVE: Adverse cross-cultural interactions are a persistent problem within medicine impacting minority patients' use of services and health outcomes. To test whether 1) enhancing the evidence-based Physician Asthma Care Education (PACE), a continuing medical education program, with cross cultural communication training (PACE Plus) would improve the asthma outcomes of African American and Latino/Hispanic children; and 2) whether PACE is effective in diverse groups of children. METHODS: A three-arm randomized control trial was used to compare PACE Plus, PACE, and usual care. Participants were primary care physicians (n = 112) and their African American or Latino/Hispanic pediatric patients with persistent asthma (n = 867). The primary outcome of interest included changes in emergency department visits for asthma overtime, measured at baseline, and 9 and 21 months following the intervention. Other outcomes included hospitalizations, asthma symptom experience, caregiver asthma-related quality of life, and patient-provider communication measures. RESULTS: Over the long term, PACE Plus physicians reported significant improvements in confidence and use of patient-centered communication and counseling techniques (p < 0.01) compared to PACE physicians. No other significant benefit in primary and secondary outcomes was observed in this trial. CONCLUSION: PACE Plus did not show significant benefit in asthma-specific clinical outcomes. More trials and multi-component strategies continue to be needed to address complex risk factors and reduce disparities in asthma care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01251523 December 1, 2010.

10.
Eval Rev ; : 193841X18815817, 2018 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-30537865

RESUMO

BACKGROUND:: Policy makers seek to replace the "thumbs up-thumbs down" of conventional hypothesis testing with statements about the probability that program effects on key outcomes exceed policy-relevant thresholds. OBJECTIVE:: We develop a Bayesian model that addresses the shortcomings of a typical frequentist approach to estimating the effects of the Comprehensive Primary Care (CPC) initiative, a Centers for Medicare and Medicaid Services demonstration. We compare findings from the two approaches to illustrate the relative merits of introducing additional assumptions through Bayesian methods. RESEARCH DESIGN:: We apply Bayesian and frequentist methods to estimate the effects of CPC on total Medicare expenditures per beneficiary per month for Medicare beneficiaries attributed to participating practices. Under both paradigms, we estimated program effects using difference-in-differences regressions comparing the change in Medicare expenditures between baseline and follow-up for Medicare patients attributed to 497 primary care practices participating in CPC to Medicare patients attributed to 908 propensity score-matched comparison practices. RESULTS:: Results from the Bayesian and frequentist models are comparable for the overall sample, but in regional subsamples, the Bayesian model produces more precise etimates that exhibit less variation over time. The Bayesian results also permit probabilistic inference about the magnitudes of effects, offering policy makers the ability to draw conclusions about practically meaningful thresholds. CONCLUSIONS:: Carefully developed Bayesian models can enhance precision and plausibility and offer a more nuanced understanding of where and when program effects occur, without imposing undue assumptions. At the same time, these methods frame conclusions in flexible, intuitive terms that respond directly to policy makers' needs.

11.
Am J Manag Care ; 24(12): 607-613, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30586494

RESUMO

OBJECTIVES: To determine how the multipayer Comprehensive Primary Care (CPC) initiative that transformed primary care delivery affected patient experience of Medicare fee-for-service beneficiaries. The study examines whether patient experience changed during the 4-year initiative, whether ratings of CPC practices changed relative to ratings of comparison practices, and areas in which practices still have an opportunity to improve patient experience. STUDY DESIGN: Prospective study using 2 cross-sectional samples of more than 25,000 Medicare fee-for-service beneficiaries attributed to 490 CPC practices and more than 8000 beneficiaries attributed to 736 comparison practices. METHODS: We analyzed patient experience 8 to 12 months and 45 to 48 months after CPC began, measured using 5 domains of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey with Patient-Centered Medical Home items, version 2.0. A regression-adjusted analysis compared differences in the proportion of beneficiaries giving the best responses (and, as a sensitivity test, mean responses) to survey questions over time and between CPC and comparison practices. RESULTS: Patient ratings of care over time were generally comparable for CPC and comparison practices. CPC had favorable effects on measures of follow-up care after hospitalizations and emergency department visits. CONCLUSIONS: Practice transformation did not alter patient experience. The lack of favorable findings raises questions about how future efforts in primary care can succeed in improving patient experience.


Assuntos
Inovação Organizacional , Atenção Primária à Saúde/organização & administração , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados Unidos
12.
J Opioid Manag ; 14(3): 159-163, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30044480

RESUMO

OBJECTIVE: To examine associations between Pain Catastrophizing Scale (PCS) scores and daily opioid dosage in traumatic injury patients. DESIGN: This was a prospective cohort study with patient assessments at baseline and 1-month following discharge. SETTING: Study visits were conducted at a Regional Level I Trauma Center and by phone at follow-up. PATIENTS: Forty-nine injured inpatients completed baseline PCS. A subsample of 23 patients continued to take prescribed opioid medication at 1-month postdischarge and were included in the current analyses. MAIN OUTCOME MEASURED: Associations between baseline PCS and morphine equivalent daily dose (MEDD) at 1-month follow-up. RESULTS: Controlling for baseline MEDD, baseline PCS score was positively associated with MEDD at 1-month postdischarge (ß= 0.577 [0.399, 1.535]; p = 0.002; R2 of PCS = 0.395). CONCLUSIONS: In the current sample of traumatic injury inpatients, findings indicated that a baseline measure of pain catastrophizing predicts ongoing opioid medication use and dosage at 1-month postdischarge from an inpatient trauma unit.


Assuntos
Analgésicos Opioides/uso terapêutico , Catastrofização/tratamento farmacológico , Ferimentos e Lesões/tratamento farmacológico , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ferimentos e Lesões/fisiopatologia
13.
IEEE J Biomed Health Inform ; 22(6): 1847-1853, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29990227

RESUMO

Falls are a major threat for senior citizens' independent living. Motion sensor technologies and automatic fall detection systems have emerged as a reliable low-cost solution to this challenge. We develop a hidden Markov model (HMM) based fall detection system to detect falls automatically using a single motion sensor for real-life home monitoring scenarios. We propose a new representation for acceleration signals in HMMs to avoid feature engineering and developed a sensor orientation calibration algorithm to resolve sensor misplacement issues (misplaced sensor location and misaligned sensor orientation) in real-world scenarios. HMM classifiers are trained to detect falls based on acceleration signal data collected from motion sensors. We collect a dataset from experiments of simulated falls and normal activities and acquired a dataset from a real-world fall repository (FARSEEING) to evaluate our system. Our system achieves positive predictive value of 0.981 and sensitivity of 0.992 on the experiment dataset with 200 fall events and 385 normal activities, and positive predictive value of 0.786 and sensitivity of 1.000 on the real-world fall dataset with 22 fall events and 2618 normal activities. Our system's results significantly outperform benchmark systems, which shows the advantage of our HMM-based fall detection system with sensor orientation calibration. Our fall detection system is able to precisely detect falls in real-life home scenarios with a reasonably low false alarm ratet.


Assuntos
Acidentes por Quedas , Serviços de Assistência Domiciliar , Monitorização Ambulatorial/instrumentação , Processamento de Sinais Assistido por Computador/instrumentação , Dispositivos Eletrônicos Vestíveis , Acelerometria/instrumentação , Algoritmos , Calibragem , Desenho de Equipamento , Humanos , Cadeias de Markov , Movimento/fisiologia
14.
J Biomed Inform ; 84: 148-158, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30004019

RESUMO

Ensuring the health and safety of independent-living senior citizens is a growing societal concern. Researchers have developed sensor based systems to monitor senior citizens' Activity of Daily Living (ADL), a set of daily activities that can indicate their self-caring ability. However, most ADL monitoring systems are designed for one specific sensor modality, resulting in less generalizable models that is not flexible to account variations in real-life monitoring settings. Current classic machine learning and deep learning methods do not provide a generalizable solution to recognize complex ADLs for different sensor settings. This study proposes a novel Sequence-to-Sequence model based deep-learning framework to recognize complex ADLs leveraging an activity state representation. The proposed activity state representation integrated motion and environment sensor data without labor-intense feature engineering. We evaluated our proposed framework against several state-of-the-art machine learning and deep learning benchmarks. Overall, our approach outperformed baselines in most performance metrics, accurately recognized complex ADLs from different types of sensor input. This framework can generalize to different sensor settings and provide a viable approach to understand senior citizen's daily activity patterns with smart home health monitoring systems.


Assuntos
Atividades Cotidianas , Aprendizado Profundo , Monitorização Ambulatorial/métodos , Idoso , Algoritmos , Moradias Assistidas , Mineração de Dados , Progressão da Doença , Serviços de Saúde para Idosos , Humanos , Reconhecimento Automatizado de Padrão/métodos
15.
J Psychopharmacol ; 32(7): 770-778, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29945469

RESUMO

AIM: The aim of the current study was to investigate the relationship between escalating higher doses of psilocybin and the potential psilocybin occasioned positive subjective effects. METHODS: Healthy participants ( n=12) were given three escalating doses of oral psilocybin (0.3 mg/kg; 0.45 mg/kg; 0.6 mg/kg) or (18.8-36.6 mg; 27.1-54.0 mg; 36.3-59.2 mg) a minimum of four weeks apart in a supervised setting. Blood and urine samples, vital signs, and electrocardiograms were obtained. Subjective effects were assessed using the Mystical Experience Questionnaire and Persisting Effects Questionnaire. RESULTS: There was a significant linear dose-related response in Mystical Experience Questionnaire total score and the transcendence of time and space subscale, but not in the rate of a complete mystical experience. There was also a significant difference between dose 3 compared to dose 1 on the transcendence of time and space subscale, while no dose-related differences were found for Mystical Experience Questionnaire total scores or rate of a mystical experience. Persisting Effects Questionnaire positive composite scores 30 days after completion of the last dose were significantly higher than negative composite scores. Persisting Effects Questionnaire results revealed a moderate increase in sense of well-being or life satisfaction on average that was associated with the maximum Mystical Experience Questionnaire total score. Pharmacokinetic measures were associated with dose but not with Mystical Experience Questionnaire total scores or rate of a mystical experience. CONCLUSIONS: High doses of psilocybin elicited subjective effects at least as strong as the lower doses and resulted in positive persisting subjective effects 30 days after, indicating that a complete mystical experience was not a prerequisite for positive outcomes.


Assuntos
Alucinógenos/administração & dosagem , Misticismo/psicologia , Psilocibina/administração & dosagem , Administração Oral , Adulto , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Alucinógenos/farmacocinética , Alucinógenos/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação Pessoal , Psilocibina/farmacocinética , Psilocibina/farmacologia , Inquéritos e Questionários , Fatores de Tempo , Adulto Jovem
16.
Int J Chron Obstruct Pulmon Dis ; 13: 1901-1912, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29942123

RESUMO

Background: COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE™) uses five questions and peak expiratory flow (PEF) thresholds (males ≤350 L/min; females ≤250 L/min) to identify patients with a forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <0.70 and FEV1 <60% predicted or exacerbation risk requiring further evaluation for COPD. This study tested CAPTURE's ability to identify symptomatic patients with mild-to-moderate COPD (FEV1 60%-80% predicted) who may also benefit from diagnosis and treatment. Methods: Data from the CAPTURE development study were used to test its sensitivity (SN) and specificity (SP) differentiating mild-to-moderate COPD (n=73) from no COPD (n=87). SN and SP for differentiating all COPD cases (mild to severe; n=259) from those without COPD (n=87) were also estimated. The modified Medical Research Council (mMRC) dyspnea scale and COPD Assessment Test (CAT™) were used to evaluate symptoms and health status. Clinical Trial Registration: NCT01880177, https://ClinicalTrials.gov/ct2/show/NCT01880177?term=NCT01880177&rank=1. Results: Mean age (+SD): 61 (+10.5) years; 41% male. COPD: FEV1/FVC=0.60 (+0.1), FEV1% predicted=74% (+12.4). SN and SP for differentiating mild-to-moderate and non-COPD patients (n=160): Questionnaire: 83.6%, 67.8%; PEF (≤450 L/min; ≤350 L/min): 83.6%, 66.7%; CAPTURE (Questionnaire+PEF): 71.2%, 83.9%. COPD patients whose CAPTURE results suggested that diagnostic evaluation was warranted (n=52) were more likely to be symptomatic than patients whose results did not (n=21) (mMRC >2: 37% vs 5%, p<0.01; CAT>10: 86% vs 57%, p<0.01). CAPTURE differentiated COPD from no COPD (n=346): SN: 88.0%, SP: 83.9%. Conclusion: CAPTURE (450/350) may be useful for identifying symptomatic patients with mild-to-moderate airflow obstruction in need of diagnostic evaluation for COPD.


Assuntos
Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Inquéritos e Questionários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos Transversais , Progressão da Doença , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Sensibilidade e Especificidade , Avaliação de Sintomas , Capacidade Vital
17.
Health Aff (Millwood) ; 37(6): 890-899, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29791190

RESUMO

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.


Assuntos
Assistência Integral à Saúde/organização & administração , Assistência à Saúde/economia , Gastos em Saúde , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde , /organização & administração , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Assistência Centrada no Paciente/economia , Padrões de Prática Médica/economia , Avaliação de Programas e Projetos de Saúde , Análise de Regressão , Mecanismo de Reembolso , Estados Unidos
18.
Am J Manag Care ; 24(4): 197-202, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29668210

RESUMO

OBJECTIVES: To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care. STUDY DESIGN: Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care. METHODS: We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. RESULTS: We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts. CONCLUSIONS: States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.


Assuntos
Serviços de Saúde da Criança/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Crianças com Deficiência , Medicaid/organização & administração , Medicare/organização & administração , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Planejamento de Assistência ao Paciente , Estados Unidos
19.
WMJ ; 117(1): 34-37, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29677413

RESUMO

BACKGROUND: There is a national opioid misuse and overdose crisis. Consensus guidelines seek to inform practice and reduce risk; however, effect on clinician attitudes and knowledge remains unclear. METHODS: We surveyed 228 medical students and physicians in Wisconsin to assess their knowledge regarding at-risk patients, alternatives to opioids, and best treatment practices for opioid addiction. We also assessed attitudes about prescribing naloxone, relapse likelihood, and responsibility for the crisis. DISCUSSION: Enhancement of opioid-related education is both necessary to address knowledge gaps and desired by students and physicians.


Assuntos
Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Médicos , Estudantes de Medicina , Humanos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/terapia , Inquéritos e Questionários , Wisconsin/epidemiologia
20.
J Med Internet Res ; 20(1): e37, 2018 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-29382624

RESUMO

BACKGROUND: Despite the near ubiquity of mobile phones, little research has been conducted on the implementation of mobile health (mHealth) apps to treat patients in primary care. Although primary care clinicians routinely treat chronic conditions such as asthma and diabetes, they rarely treat addiction, a common chronic condition. Instead, addiction is most often treated in the US health care system, if it is treated at all, in a separate behavioral health system. mHealth could help integrate addiction treatment in primary care. OBJECTIVE: The objective of this paper was to report the effects of implementing an mHealth system for addiction in primary care on both patients and clinicians. METHODS: In this implementation research trial, an evidence-based mHealth system named Seva was introduced sequentially over 36 months to a maximum of 100 patients with substance use disorders (SUDs) in each of three federally qualified health centers (FQHCs; primary care clinics that serve patients regardless of their ability to pay). This paper reports on patient and clinician outcomes organized according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS: The outcomes according to the RE-AIM framework are as follows: Reach-Seva reached 8.31% (268/3226) of appropriate patients. Reach was limited by our ability to pay for phones and data plans for a maximum of 100 patients per clinic. Effectiveness-Patients who were given Seva had significant improvements in their risky drinking days (44% reduction, (0.7-1.25)/1.25, P=.04), illicit drug-use days (34% reduction, (2.14-3.22)/3.22, P=.01), quality of life, human immunodeficiency virus screening rates, and number of hospitalizations. Through Seva, patients also provided peer support to one another in ways that are novel in primary care settings. Adoption-Patients sustained high levels of Seva use-between 53% and 60% of the patients at the 3 sites accessed Seva during the last week of the 12-month implementation period. Among clinicians, use of the technology was less robust than use by patients, with only a handful of clinicians using Seva in each clinic and behavioral health providers making most referrals to Seva in 2 of the 3 clinics. Implementation-At 2 sites, implementation plans were realized successfully; they were delayed in the third. Maintenance-Use of Seva dropped when grant funding stopped paying for the mobile phones and data plans. Two of the 3 clinics wanted to maintain the use of Seva, but they struggled to find funding to support this. CONCLUSIONS: Implementing an mHealth system can improve care among primary care patients with SUDs, and patients using the system can support one another in their recovery. Among clinicians, however, implementation requires figuring out how information from the mHealth system will be used and making mHealth data available in the electronic health (eHealth) record. In addition, paying for an mHealth system remains a challenge.


Assuntos
Comportamento Aditivo/terapia , Atenção Primária à Saúde/normas , Telemedicina/normas , Adulto , Humanos , Pessoa de Meia-Idade , Adulto Jovem
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