Search

BackgroundType 2 diabetes affects 9.4% of US adults with higher rates among racial and ethnic minorities and individuals of low socioeconomic status. The National Diabetes Prevention Program (NDPP) is an evidence-based and widely disseminated behavioral intervention to reduce diabetes incidence through modest weight loss. However, retention in the yearlong NDPP is problematic and leads to suboptimal weight loss, especially among diverse, underserved populations. Strategies to improve NDPP engagement and weight loss are needed urgently. Pilot results of the pre-NDPP, a novel enhancement to enrollment in the NDPP based on the Health Belief Model, were highly successful in a nonrandomized cohort study among 1140 racially diverse, predominately low-income participants. A total of 75 presession participants had doubled attendance and weight loss as compared with earlier participants who did not receive presessions. On the basis of these promising results, we are conducting a randomized controlled trial (RCT) to determine whether pre-NDPP reliably improves NDPP outcomes, as reported on ClinicalTrials.gov. ObjectiveThis study aims to (1) conduct an RCT comparing NDPP attendance and weight loss outcomes between participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care), (2) examine potential effect mediators (perceived risk for developing diabetes and self-efficacy and readiness for weight control) and moderators (race and ethnicity; income level), and (3) evaluate implementation factors, including cost and projected return on investment. MethodsThis two-arm RCT will compare outcomes among diverse, predominately low-income participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care). This is a type 1 hybrid effectiveness-implementation design to determine clinical effectiveness through an RCT, while assessing factors that may impact future pre-NDPP dissemination and implementation, including cost. Our primary research question is whether pre-NDPP improves NDPP attendance and weight loss compared with standard NDPP delivery. ResultsThis project was funded in April 2019. Recruitment is underway as of July 2019. Initial participants began the intervention in October 2019. Data analysis and results reporting are expected to be completed in 2024. ConclusionsThis RCT of pre-NDPP may lead to future dissemination of a scalable, evidence-based strategy to improve success of the NDPP, reduce disparities in NDPP effectiveness, and help prevent type 2 diabetes across the country. Trial RegistrationClinicalTrials.gov NCT04022499; https://clinicaltrials.gov/ct2/show/NCT04022499. International Registered Report Identifier (IRRID)PRR1-10.2196/15499

BackgroundCell phone text messaging is gaining increasing recognition as an important tool that can be harnessed for prevention and intervention programs across a wide variety of health research applications. Despite the growing body of literature reporting positive outcomes, very little is available about the design decisions that scaffold the development of text messaging-based health interventions. What seems to be missing is documentation of the thought process of investigators in the initial stages of protocol and content development. This omission is of particular concern because many researchers seem to view text messaging as the intervention itself instead of simply a delivery mechanism. Certainly, aspects of this technology may increase participant engagement. Like other interventions, however, the content is a central driver of the behavior change. ObjectiveTo address this noted gap in the literature, we discuss the protocol decisions and content development for SMS Turkey (or Cebiniz birakin diyor in Turkish), a smoking cessation text messaging program for adult smokers in Turkey. MethodsContent was developed in English and translated into Turkish. Efforts were made to ensure that the protocol and content were grounded in evidence-based smoking cessation theory, while also reflective of the cultural aspects of smoking and quitting in Turkey. ResultsMethodological considerations included whether to provide cell phones and whether to reimburse participants for texting costs; whether to include supplementary intervention resources (eg, personal contact); and whether to utilize unidirectional versus bidirectional messaging. Program design considerations included how messages were tailored to the quitting curve and one’s smoking status after one’s quit date, the number of messages participants received per day, and over what period of time the intervention lasted. ConclusionThe content and methods of effective smoking cessation quitline programs were a useful guide in developing SMS Turkey. Proposed guidelines in developing text messaging-based behavior change programs are offered.

PURPOSE To describe the characteristics of patients and practice of clinicians during standard-of-care for weight management in a large, multiclinic health system before the implementation of PATHWEIGH, a pragmatic weight management intervention. METHODS We analyzed baseline characteristics of patients, clinicians, and clinics during standard-of-care for weight management before the implementation of PATHWEIGH, which will be evaluated for effectiveness and implementation in primary care using an effectiveness-implementation hybrid type-1 cluster randomized stepped-wedge clinical trial design. A total of 57 primary care clinics were enrolled and randomized to 3 sequences. Patients included in the analysis met the eligibility requirements of age [greater than or equal to] 18 years and body mass index (BMI) [greater than or equal to] 25 kg/[m.sup.2] and had a weight-prioritized visit (defined a priori) during the period March 17, 2020 to March 16, 2021. RESULTS A total of 12% of patients aged [greater than or equal to] 18 years and with a BMI [greater than or equal to] 25 kg/[m.sup.2] seen in the 57 practices during the baseline period (n = 20,383) had a weight-prioritized visit. The 3 randomization sequences of 20, 18, and 19 sites were similar, with an overall mean patient age of 52 (SD 16) years, 58% women, 76% non-Hispanic White patients, 64% with commercial insurance, and with a mean BMI of 37 (SD 7) kg/[m.sup.2]. Documented referral for anything weight related was low ( CONCLUSIONS Of patients aged [greater than or equal to] 18 years and with a BMI [greater than or equal to] 25 kg/[m.sup.2] in a large health system, 12% had a weight-prioritized visit during the baseline period. Despite most patients being commercially insured, referral to any weight-related service or prescription of antiobesity drug was uncommon. These results fortify the rationale for trying to improve weight management in primary care. Key words: body mass index; primary care; weight management https://doi.org/10.1370/afm.2966, INTRODUCTION Obesity remains one of the greatest current public health challenges, contributing to 4,000,000 deaths and 120,000,000 disability-adjusted life-years globally in 2015. (1) Despite the human and economic costs of [...]

Conducting research in primary care during the COVID-19 pandemic is hard, due to baseline stresses on primary care, which have been compounded by the pandemic. We acknowledge and validate primary care researchers' frustrations. Using our experience on over 15 individual projects during the pandemic we identify 3 key challenges to conducting primary care research: (1) practice delivery trickle-down effects, (2) limited/changing resources and procedures for research, and (3) a generally tense milieu in US society during the pandemic. We present strategies, informed by a set of questions, to help researchers decide how to address these challenges observed during our studies. In order to overcome and grow from these challenging times we encourage normalization and self-compassion, and encourage researchers and funders to embrace pragmatic and adaptive research designs as the circumstances with COVID-19 evolve over time. https://doi.org/10.1370/afm.2889, INTRODUCTION Research has been difficult during the COVID-19 pandemic and may continue to be hard for quite a while. As researchers who are focused on studying primary care, we wrote [...]

Integrated and collaborative care models, in which mental/behavioral health providers work closely with primary care providers within a primary care setting, help support the quadruple aim of improved health outcomes, patient satisfaction, provider experience, and lower cost. In this paper, we describe patients' general perspectives of integrated care and their unique experiences accessing this care within one health system. Qualitative (interviews with patients) and quantitative (surveys with patients) methods were used to collect and analyze these results separately and together. The results highlight important features to the provision of integrated care from the perspective of patients using integrated care. They include the importance and experience of access, whole-person care and a team-based approach, the availability and use of telehealth when appropriate, having high quality mental health providers, scheduling and service usage suggestions, and means to connect with longer-term services for ongoing mental health care when needed. [ABSTRACT FROM AUTHOR]

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

PURPOSE Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado. METHODS Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training. RESULTS Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P CONCLUSIONS The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado. Key words: buprenorphine; education; opioid-related disorders; primary health care; rural health, INTRODUCTION The United States has an epidemic of opioid use disorder (OUD). Over 4 million Americans report using prescription pain medicine for nonmedical reasons. (1) First-time heroin users increased from [...]

Context: Self-management, including diet, exercise, use of medications, and stress management, is essential for good outcomes in Type 2 Diabetes Mellitus (T2DM). Shared medical appointments (SMAs) are an avenue for primary care practices to support development of self- management, but implementation of SMAs is context dependent and often requires adaptations for each practice. Objective: To describe adaptations made by practices participating in the Invested in Diabetes (IID) project during implementation of SMAs. Study Design and Analysis: IID is a pragmatic cluster-randomized, comparative effectiveness trial designed to compare two different approaches to delivery of diabetes shared medical appointments (SMAs). Key informant interviews with traditional qualitative thematic analysis, thematic analysis of coach notes and session observations; multi-step process to categorize adaptations using FRAME. Population studied: primary care team members involved in delivering SMAs including medical and behavioral health providers, health educators, coordinators. Intervention/Measurement: Semi-structured interview guide, session observation guide. Outcome measures: Emergent themes pertaining to adaptations made by participating practices Results: Four dominant themes emerged: 1) Adaptations are common in implementation of SMAs. 2) Implementation challenges can be improved or overcome through actively identifying those challenges and making changes in response. Specific challenges identified include recruitment and retention, physical space, staff involvement and turnover, and scheduling 3) Content changes in the classes were often planned and enacted to better address the contextual circumstances such as patient needs and culture. 4) Adaptation components tend to cluster together in certain types that may reveal ways to improve on desired implementation outcomes. Conclusions: SMA implementation in real-world primary care settings requires adaptations related to practice-specific contexts. Practices benefit from support to identify and address areas that need adaptation for successful implementation., Presenters Dennis Gurfinkel, MPH, Jodi Summers Holtrop, PhD, MCHES, Bethany Kwan, PhD, MSPH, Phoutdavone Phimphasone-Brady, PhD, Jeanette Waxmonsky, PhD, Andrea Nederveld, MD, [...]

Context: Integrating behavioral health care into primary care has increased access to care for patients with behavioral health needs. Within primary care there is a broad range of need, including traditional mental health diagnoses as well as support in disease management and health-related behavior change. Most BHPs report spending a majority of their clinical time addressing traditional mental health diagnoses. Objective: Understanding current BHP practice with traditional diagnoses as well as supporting health-related behavior change may illuminate new approaches that could be undertaken in primary care to improve patient outcomes. Study Design and Analysis: Survey research using Qualtrics. Results were analyzed using simple statistics as well as simple correlations (chi-squared and Spearman's rank correlation). Setting: Practices participating in the State Innovation Model in Colorado, a CMS supported behavioral health integration project. Population: Behavioral health providers in participating practices. Instrument: Survey designed by project team to understand approaches BHPs use and range of treatments provided to patients. Outcome measures: Survey responses. Results: We received 79 BHP surveys representing 64 practices out of a total of 319 SIM practices. BHPs reported addressing health-related behaviors like diet, physical activity, and weight management with many patients who were referred to them strictly for mental health diagnoses. They expressed interest in working with patients in these areas and believe that the skills and techniques they use for traditional mental health diagnoses are effective for supporting behavior change. LCSWs are more likely to address behavior change than LMFTs and LACs. BHPs who have been in practice for longer also are more likely to address behavior change. There was no relationship between type of practice and BHPs intervention on behavior change, but BHPs in practices that had case managers or health coaches were more likely to report addressing behavior change. Health-related behavior change topics were more likely to be addressed in co-visits with providers. Conclusions: BHPs frequently address health related behavior whether that is the reason for referral or not and in general are interested in providing these services. Understanding how to formalize that in primary care may provide opportunities to better support patients with behavior change and subsequently improve health outcomes., Presenters Andrea Nederveld, MD, MPH, Jodi Summers Holtrop, PhD, [...]

Context: Primary care practices can help patients address obesity through weight loss, however, there are many barriers to doing so. Objective: This study sought to examine current weight management services provided and factors associated with higher reported provision of services. Study Design and Analysis: One time survey. We used descriptive statistics to summarize responses and linear regression with generalized estimating equations to assess the association between the clinician characteristics and the amount of weight management services provided. Setting/Population: Clinicians in 18 diverse primary care health system practices in Colorado. Instrument/Outcome measures: Survey assessing 19 weight management services (e.g. identifying obesity, educating, prescribing medications, etc.) to assess the amount and type of weight loss assistance provided and other factors that may be important. Results: The overall response rate was 65% (257/397). Of respondents, 28% were clinicians, 3% other providers, 47% clinical staff, and 21% administrative staff. On average, clinicians reported performing 70% (IQR: 60%-80%) of the services and when grouped into minimal, basic, and extensive types of services, the clinicians on average performed 87%, 78%, and 69% of them respectively. Factors associated with performing more services included perception of overall better practice culture (more team-ness, less chaos, more change culture) and perception of weight management implementation climate (support for, recognition and expectation to support weight loss) (p, Presenters Jodi Summers Holtrop, PhD, MCHES, Erik Kramer, DO, MPH, Mark Gritz, Krithika Suresh, PhD, Leigh Perreault, MD, L. Miriam Dickinson, PhD, Lauren Tolle, PhD, Johnny Williams, MPH, Peter Smith, [...]

CONTEXT: Despite the fact that obesity is both treatable and preventable, treating the comorbidities, rather than obesity per se remains the mainstay of therapy. OBJECTIVE: To evaluate the efficacy and implementation of a pragmatic approach to weight management in primary care that prioritizes treatment of weight rather than weight-related diseases (PATHWEIGH). STUDY DESIGN AND ANALYSIS: PATHWEIGH is a hybrid type 1 cluster randomized stepped wedge clinical trial. Clinics were enrolled and randomized to three sequences using covariate constrained randomization. Descriptive statistics were used to summarize clinic and patient characteristics with t-tests, Wilcoxon rank sums or Fisher's exact tests used to compare groups. SETTING: Fifty-seven primary care clinics in rural, suburban and urban Colorado in a single healthcare system were utilized. POPULATION STUDIED: Patients age >18 years and body mass index (BMI) >25 kg/m2 who had a weight-prioritized visit (WPV) in the prior year were enrolled. A WPV was defined as a chief complaint or reason for visit that included 'weight', ICD-10 codes for weight or use of an intake questionnaire for weight. INTERVENTION: None. This abstract describes the baseline (pre-intervention) characteristics of the clinics and patients treated with standard-of-care (SOC) for weight management. OUTCOME MEASURES: Baseline characteristics of the clinics and patients undergoing a WPV from March 17, 2020-March 16, 2021. RESULTS: 20,410 patients met these eligibility requirements representing 12% of patients >18 years and body mass index (BMI) >25 kg/m2 seen at the clinic during this baseline period. The three randomization sequences of 20, 18, and 19 sites were similar with an overall median age of 53 years (IQR: 39- 65), 58% women, 76% non-Hispanic whites, 64% commercial insurance, and median BMI of 36 kg/m2 (IQR: 32-41). No sequence differences were seen for vital signs, relevant laboratory values, or numbers of comorbidities or medications that cause weight loss or weight gain. Referral for anything weight-related was low (18 years and body mass index (BMI) >25 kg/m2 seen in the 57 primary care clinics, 12% had a weight prioritized visit during the baseline period. Despite most being commercially insured, referral to any weight-related service or prescription of anti-obesity medication was uncommon., Presenters Jodi Summers Holtrop, PhD, MCHES, Erik Kramer, DO, MPH, Mark Gritz, Krithika Suresh, PhD, Leigh Perreault, MD, L. Miriam Dickinson, PhD, Lauren Tolle, PhD, Johnny Williams, MPH, Peter Smith, [...]

ObjectiveReport lessons learned in an RCT of Stop My Smoking (SMS) USA, a mHealth smoking cessation program for young adult smokers.Methods164 18-24-year-olds were recruited nationally, online in 2011. Program evaluation data were provided at 12-week post-Quit Day.Results(1) Inviting participants to complete a brief text messaging survey and then asking them to complete a longer online survey resulted in the highest response rate (89%). (2) The positive tone of program messages was the most commonly noted program strength. (3) Suggested improvements included more social connectivity and additional assistance overcoming stressful situations. (4) Half of intervention participants moved through the program linearly and half went through various paths that reflected multiple relapses. Suggestions to use pharmacotherapy resulted in 22% of heavy smokers to utilize it.ConclusionParticipant feedback provided concrete ways in which this and other young adult-focused interventions can improve messaging and program features to be even more salient.Practice implicationsFuture young adult mHealth interventions could: Integrate models that are flexible to different "paths" of behavior change; address stressful life events directly and comprehensively; integrate proactive messaging that promotes pharmacotherapy options; and use text messaging as a gateway to longer online surveys.

Patients want weight management in primary care, but regular office visits tend to focus on comorbidities, leaving little time to talk about weight. In a weight-prioritized visit, both patient and clinician understand the visit will be dedicated to talking about weight and co-creating a comprehensive, personalized treatment plan. Patients want weight management in primary care, but regular office visits tend to focus on comorbidities, leaving little time to talk about weight. [ABSTRACT FROM AUTHOR]