Center for Integrated Primary Care Publications

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https://hdl.handle.net/20.500.14038/212

ABOUT THIS COLLECTION

The mission of the Center for Integrated Primary Care (CIPC) at UMass Chan Medical School is to develop, synthesize, and disseminate knowledge and skills for evidence-based approaches to integrated primary care and behavioral health services through work force development and practice based research. This collection showcases journal articles and other publications authored by CIPC faculty and researchers.

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Proposed Nutrition Competencies for Medical Students and Physician Trainees: A Consensus Statement
(2024-09-03) Eisenberg, David M; Cole, Alexis; Maile, Edward J; Salt, Matthew; Armstrong, Elizabeth; Broad Leib, Emily; Findley, Trevor; Massa, Jennifer; Albin, Jaclyn; Alston, Meredith; Barkoukis, Hope; Buckhold, Fred; Danoff, Robert; Delichatsios, Helen; Devries, Stephen; Dewar, Stephanie; Di Rocco, Jennifer; Duggan, Christopher P; Essel, Kofi; Frates, Beth; Hansen, Pamela; Haramati, Aviad; Harlan, Timothy S; Hauser, Michelle E; Leopold, David; Lewis, Joanna; Locke, Amy; Mann, Joshua R; McClure, Auden; McWhorter, John Wesley; Misra, Saroj; Murano, Tiffany; Oxentenko, Amy; Pierce-Talsma, Stacey; Potts, Stacy E; Reilly, Jo Marie; Ring, Melinda; Sampang, Suzanne; Shafto, Kate; Shiue, Linda; Slusser, Wendelin; Stone, Terri; Studer, Karen; Thomas, Olivia; Trilk, Jennifer; Edgar, Laura; Center for Integrated Primary Care; Family Medicine and Community Health
Importance: In 2022, the US House of Representatives passed a bipartisan resolution (House of Representatives Resolution 1118 at the 117th Congress [2021-2022]) calling for meaningful nutrition education for medical trainees. This was prompted by increasing health care spending attributed to the growing prevalence of nutrition-related diseases and the substantial federal funding via Medicare that supports graduate medical education. In March 2023, medical education professional organizations agreed to identify nutrition competencies for medical education. Objective: To recommend nutrition competencies for inclusion in medical education to improve patient and population health. Evidence review: The research team conducted a rapid literature review to identify existing nutrition-related competencies published between July 2013 and July 2023. Additional competencies were identified from learning objectives in selected nutrition, culinary medicine, and teaching kitchen curricula; dietetic core competencies; and research team-generated de novo competencies. An expert panel of 22 nutrition subject matter experts and 15 residency program directors participated in a modified Delphi process and completed 4 rounds of voting to reach consensus on recommended nutrition competencies, the level of medical education at which they should be included, and recommendations for monitoring implementation and evaluation of these competencies. Findings: A total of 15 articles met inclusion criteria for competency extraction and yielded 187 competencies. Through review of gray literature and other sources, researchers identified 167 additional competencies for a total of 354 competencies. These competencies were compiled and refined prior to voting. After 4 rounds of voting, 36 competencies were identified for recommendation: 30 at both undergraduate and graduate levels, 2 at the undergraduate level only, and 4 at the graduate level only. Competencies fell into the following nutrition-related themes: foundational nutrition knowledge, assessment and diagnosis, communication skills, public health, collaborative support and treatment for specific conditions, and indications for referral. A total of 36 panelists (97%) recommended nutrition competencies be assessed as part of licensing and board certification examinations. Conclusions and relevance: These competencies represent a US-based effort to use a modified Delphi process to establish consensus on nutrition competencies for medical students and physician trainees. These competencies will require an iterative process of institutional prioritization, refinement, and inclusion in current and future educational curricula as well as licensure and certification examinations.
Buprenorphine discontinuation in telehealth-only treatment for opioid use disorder: A longitudinal cohort analysis
(2024-09-05) Chan, Brian; Cook, Ryan; Levander, Ximena; Wiest, Katharina; Hoffman, Kim; Pertl, Kellie; Petluri, Ritwika; McCarty, Dennis; Korthuis, P Todd; Martin, Stephen A; Center for Integrated Primary Care; Family Medicine and Community Health
Introduction: At the beginning of the COVID-19 pandemic, federal agencies permitted telehealth initiation of buprenorphine treatment for opioid use disorder (OUD) without in-person assessment. It remains unclear how telehealth-only buprenorphine treatment impacts time to discontinuation and patient reported treatment outcomes. Methods: A longitudinal observational cohort study conducted September 2021 through March, 2023 enrolled participants with OUD initiating buprenorphine (≤ 45 days) with internet and phone access in Oregon and Washington. The intervention was a fully telehealth-only (THO) app versus treatment as usual (TAU) in office-based settings with some telehealth. We assessed self-reported buprenorphine discontinuation at 4-,12-, and 24-weeks. Generalized estimating equations (GEE) calculated unadjusted and adjusted relative risk ratios (RR) for discontinuation averaged over the study period. Secondary outcomes included change in the Brief Addiction Monitor (BAM) and the visual analogue craving scale. Generalized linear models estimated average within-group and between-group differences over time. Results: Participants (n = 103 THO; n = 56 TAU) had a mean age of 37 years (SD = 9.8 years) and included 52 % women, 83 % with Medicaid insurance, 80 % identified as White, 65 % unemployed/student, and 19 % unhoused. There were differences in gender (THO = 54 % women vs. TAU = 44 %, p = .04), unemployed status (60 % vs 75 %, p = .02), and stable housing (84 % vs 73 %, p = .02). Rates of buprenorphine discontinuation were low in the THO (4 %) and TAU (13 %) groups across 24 weeks. In the adjusted analysis, the risk of discontinuation was 61 % lower in the THO group (aRR = 0.39, 95 % CI [0.17, 0.89], p = .026). Decreases occurred over time on the harms subscale of the BAM (within-group difference - 0.85, p = .0004 [THO], and - 0.68, p = .04 [TAU]) and cravings (within-group difference - 13.47, p = .0001 [THO] vs -7.65, p = .01 [TAU]). Conclusions: A telehealth-only platform reduced the risk of buprenorphine discontinuation compared to office-based TAU. In-person evaluation to receive buprenorphine may not be necessary for treatment-seeking patients. Clinical trials identifier: NCT03224858.
Self-Compassion for Healthcare Communities: Exploring the Effects of a Synchronous Online Continuing Medical Education Program on Physician Burnout
(2024-09-24) Gardiner, Paula; Pérez-Aranda, Adrián; Bell, Natalie; Clark, Dawn R; Schuman-Olivier, Zev; Lin, Elizabeth H; Center for Integrated Primary Care; Family Medicine and Community Health
Introduction: Physician burnout is a common problem for which self-compassion training has shown positive effects. In this program evaluation, we explore the effects of a synchronous online continuing medical education program (Self-Compassion for Healthcare Communities, SCHC) to improve physician burnout and related outcomes. Methods: The SCHC program was delivered online via Zoom and consisted of six 1-hour weekly sessions to enhance self-compassion and well-being. The primary outcome was the "burnout" subscale of the Professional Quality of Life scale; compassion satisfaction, secondary traumatic stress, self-compassion, resilience activation and decompression, and job satisfaction were evaluated, and qualitative data were also collected. Results: A total of 116 physicians attended at least one session of the program, 48 of whom completed both the preprogram and postprogram surveys. The results showed that physicians experienced a reduction in their burnout levels (P = .001) as well as improvements in compassion satisfaction (P = .027), secondary traumatic stress (P = .001), self-compassion (P < .001), resilience decompression (P = .012), and job satisfaction (P = .038). Qualitative data, obtained from a total of 91 participants who attended at least one session, indicated that participants were satisfied with the SCHC program: they found it useful for learning to be compassionate with themselves and they highly valued having the chance to connect with other colleagues who experience similar struggles. Discussion: The live online SCHC program showed benefits on physician burnout and related outcomes such as compassion satisfaction, secondary traumatic stress, self-compassion, resilience decompression, and job satisfaction. Nonetheless, in addition to individual-focused well-being programs, systemic changes in health care delivery were also deemed necessary to decrease burnout.
Ketamine-assisted buprenorphine initiation: a pilot case series
(2024-08-29) Grande, Lucinda A; Hutch, Tom; Jack, Keira; Mironov, Wendy; Iwuoha, Jessica; Muy-Rivera, Martin; Grillo, Jacob; Martin, Stephen A; Herring, Andrew; Center for Integrated Primary Care; Family Medicine and Community Health
Background: Many people with opioid use disorder who stand to benefit from buprenorphine treatment are unwilling to initiate it due to experience with or fear of both spontaneous and buprenorphine-precipitated opioid withdrawal (BPOW). An effective means of minimizing withdrawal symptoms would reduce patient apprehensiveness, lowering the barrier to buprenorphine initiation. Ketamine, approved by the FDA as a dissociative anesthetic, completely resolved BPOW in case reports when infused at a sub-anesthetic dose range in which dissociative symptoms are common. However, most patients attempt buprenorphine initiation in the outpatient setting where altered mental status is undesirable. We explored the potential of short-term use of ketamine, self-administered sublingually at a lower, sub-dissociative dose to assist ambulatory patients undergoing transition to buprenorphine from fentanyl and methadone. Methods: Patients prescribed ketamine were either (1) seeking transition to buprenorphine from illicit fentanyl and highly apprehensive of BPOW or (2) undergoing transition to buprenorphine from illicit fentanyl or methadone and experiencing BPOW. We prescribed 4-8 doses of sublingual ketamine 16 mg (each dose bioequivalent to 3-6% of an anesthetic dose), monitored patients daily or near-daily, and adjusted buprenorphine and ketamine dosing based on patient response and prescriber experience. Results: Over a period of 14 months, 37 patients were prescribed ketamine. Buprenorphine initiation was completed by 16 patients, representing 43% of the 37 patients prescribed ketamine, and 67% of the 24 who reported trying it. Of the last 12 patients who completed buprenorphine initiation, 11 (92%) achieved 30-day retention in treatment. Most of the patients who tried ketamine reported reduction or elimination of spontaneous opioid withdrawal symptoms. Some patients reported avoidance of severe BPOW when used prophylactically or as treatment of established BPOW. We developed a ketamine protocol that allowed four of the last patients to complete buprenorphine initiation over four days reporting only mild withdrawal symptoms. Two patients described cognitive changes from ketamine at a dose that exceeded the effective dose range for the other patients. Conclusions: Ketamine at a sub-dissociative dose allowed completion of buprenorphine initiation in the outpatient setting in the majority of patients who reported trying it. Further research is warranted to confirm these results and develop reliable protocols for a range of treatment settings.
Race-Based Differences in the Response to a Mindfulness Based Integrative Medical Group Visit Intervention for Chronic Pain
(2024-05-16) Incollingo Rodriguez, Angela C; Nephew, Benjamin C; Polcari, Justin J; Melican, Veronica; King, Jean A; Gardiner, Paula; Center for Integrated Primary Care; Family Medicine and Community Health
Background: Chronic pain is one of the most common drivers of healthcare utilization and a marked domain for health disparities, as African American/Black populations experience high rates of chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence-based integrative medicine, and medical group visits. In a parent randomized controlled trial, this approach was tested as an adjunct treatment in a diverse, medically underserved population with chronic pain and depression. Objective: To determine race-based heterogeneity in the effects of a mindfulness based treatment for chronic pain. Methods: This secondary analysis of the parent trial assessed heterogeneity of treatment effects along racialized identity in terms of primary patient-reported pain outcomes in a racially diverse sample suffering from chronic pain and depression. The analytic approach examined comorbidities and sociodemographics between racialized groups. RMANOVAs examined trajectories in pain outcomes (average pain, pain severity, and pain interference) over three timepoints (baseline, 9, and 21 weeks) between participants identifying as African American/Black (n = 90) vs White (n = 29) across both intervention and control conditions. Results: At baseline, African American/Black participants had higher pain severity and had significantly different age, work status, and comorbidity profiles. RMANOVA models also identified significant race-based differences in the response to the parent IMGV intervention. There was reduced pain severity in African American/Black subjects in the IMGV condition from baseline to 9 weeks. This change was not observed in White participants over this time period. However, there was a reduction in pain severity in White participants over the subsequent interval from 9 to 21 week where IMGV had no significant effect in African American/Black subjects during this latter time period. Conclusion: Interactions between pain and racialization require further investigation to understand how race-based heterogeneity in the response to integrative medicine treatments for chronic pain contribute to the broader landscape of health inequity.
The contextual interview: a cross-cutting patient-interviewing approach for social context
(2024-02-06) Cahill, Amber; Martin, Matthew; Beachy, Bridget; Bauman, David; Howard-Young, Jordan; Center for Integrated Primary Care; Family Medicine and Community Health
Patient interviewing pedagogy in medical education has not evolved to comprehensively capture the biopsychosocial model of healthcare delivery. While gathering a patient's social history targets important aspects of social context it does not adequately capture and account for the real-time reassessment required to understand evolving factors that influence exposure to drivers of health inequities, social determinants of health, and access to supports that promote health. The authors offer a patient interviewing approach called the Contextual Interview (CI) that specifically targets dynamic and ever-changing social context information. To substantiate the use of the CI in medical education, the authors conducted a qualitative review of the Accreditation Council for Graduate Medical Education Milestones for primary care specialties (Family Medicine, Internal Medicine, and Pediatrics). Milestones were coded to the extent to which they reflected the learner's need to acknowledge, assess, synthesize and/or apply patient contextual data in real-time patient encounters. Approximately 1 in 5 milestones met the context-related and patient-facing criteria. This milestone review further highlights the need for more intentional training in eliciting meaningful social context data during patient interviewing. The CI as a cross-cutting, practical, time-conscious, and semi-structured patient interviewing approach that deliberately elicits information to improve the clinician's sense and understanding of a patient's social context. The authors reviewed future directions in researching adapted versions of the CI for undergraduate and graduate medical education.
Effects of intervention stage completion in an integrated behavioral health and primary care randomized pragmatic intervention trial [preprint]
(2024-02-08) Stephens, Kari A; van Eeghen, Constance; Zheng, Zihan; Anastas, Tracy; Ma, Kris Pui Kwan; Prado, Maria G; Clifton, Jessica; Rose, Gail; Mullin, Daniel J; Chan, Kwun C G; Kessler, Rodger; Center for Integrated Primary Care; Family Medicine and Community Health
Purpose: A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention aimed to increase behavioral health integration in primary care practices and improve patient outcomes. We examined association between the completion of intervention stages and patient outcomes across a heterogenous national sample of primary care practices. Methods: Forty-two primary care practices across the U.S. with co-located behavioral health and 2,426 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint and two year follow-up. Effects of the intervention on patient health and primary care integration outcomes were examined using multilevel mixed-effects models, while controlling for baseline outcome measurements. Results: No differences were found associated with the number of intervention stages completed in patient health outcomes were found for depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social function, patient satisfaction with care or medication adherence. The completion of each intervention stage was associated with increases in Practice Integration Profile (PIP) domain scores and were confirmed with modeling using multiple imputation for: Workflow 3.5 (95% CI: 0.9-6.1), Integration Methods 4.6 (95% CI: 1.5-7.6), Patient Identification 2.9 (95% CI: 0.9-5.0), and Total Integration 2.7 (95% CI: 0.7-4.7). Conclusion: A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogenous primary care practices treating patients with multiple chronic conditions. Interventions that allow practices to flexibly improve care have potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at a population level.
A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions
(2023-11-01) Littenberg, Benjamin; Clifton, Jessica; Crocker, Abigail M; Baldwin, Laura-Mae; Bonnell, Levi N; Breshears, Ryan E; Callas, Peter; Chakravarti, Prama; Clark/Keefe, Kelly; Cohen, Deborah J; deGruy, Frank V; Eidt-Pearson, Lauren; Elder, William; Fox, Chester; Frisbie, Sylvie; Hekman, Katie; Hitt, Juvena; Jewiss, Jennifer; Kaelber, David C; Kelley, Kairn Stetler; Kessler, Rodger; O'Rourke-Lavoie, Jennifer B; Leibowitz, George S; Macchi, C R; Martin, Matthew P; McGovern, Mark; Mollis, Brenda; Mullin, Daniel J; Nagykaldi, Zsolt; Natkin, Lisa W; Pace, Wilson; Pinckney, Richard G; Pomeroy, Douglas; Reynolds, Paula; Rose, Gail L; Scholle, Sarah Hudson; Sieber, William J; Soucie, Jeni; Stancin, Terry; Stange, Kurt C; Stephens, Kari A; Teng, Kathryn; Waddell, Elizabeth Needham; van Eeghen, Constance; Center for Integrated Primary Care; Family Medicine and Community Health
Purpose: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. Methods: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. Results: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). Conclusion: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.
Integrative medical group visits for patients with chronic pain: results of a pilot single-site hybrid implementation-effectiveness feasibility study
(2023-09-27) Roth, Isabel; Tiedt, Malik; Miller, Vanessa; Barnhill, Jessica; Chilcoat, Aisha; Gardiner, Paula; Faurot, Keturah; Karvelas, Kris; Busby, Kenneth; Gaylord, Susan; Leeman, Jennifer; Center for Integrated Primary Care; Family Medicine and Community Health
Background: Approximately 20% of adults in the United States experience chronic pain. Integrative Medical Group Visit (IMGV) offers an innovative approach to chronic pain management through training in mindfulness, nutrition, and other mind-body techniques combined with peer support. To date, there are no studies on IMGV implementation, despite its promise as a feasible non-pharmacological intervention for chronic pain management. In this study, we assessed the feasibility of implementing IMGV and assessing its effectiveness for chronic pain. Methods: Implementation Mapping was used to develop and evaluate implementation strategies for IMGV. Strategies included disseminating educational materials, conducting ongoing training, and conducting educational meetings. IMGV was delivered by three healthcare providers: an allopathic physician, registered yoga teacher, and naturopathic physician. The effectiveness of IMGV on patient health outcomes was assessed through qualitative interviews and a Patient-Reported Outcomes Scale (PROMIS-29). Provider perspectives of acceptability, appropriateness, and feasibility were assessed through periodic reflections (group interviews reflecting on the process of implementation) and field notes. Paired t-tests were used to assess changes between scores at baseline and post intervention. Qualitative data were coded by three experienced qualitative researchers using thematic content analysis. Results: Of the initial 16 patients enrolled in research, 12 completed at least two sessions of the IMGV. Other than fatigue, there was no statistically significant difference between the pre- and post-scores. Patients reported high satisfaction with IMGV, noting the development of new skills for self-care and the supportive community of peers. Themes from patient interviews and periodic reflections included the feasibility of virtual delivery, patient perspectives on acceptability, provider perspectives of feasibility and acceptability, ease of recruitment, complexity of referral and scheduling process, balancing medical check-in with group engagement, and nursing staff availability. Conclusions: IMGV was feasible, acceptable, and effective from the perspectives of patients and providers. Although statistically significant differences were not observed for most PROMIS measures, qualitative results suggested that participants experienced increased social support and increased pain coping skills. Providers found implementation strategies effective, except for engaging nurses, due to staff being overwhelmed from the pandemic. Lessons learned from this pilot study can inform future research on implementation of IMGV.
Clinician commentary on adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care
(2023-09-01) Mullin, Daniel J; Mitton, Ashley; Center for Integrated Primary Care; Family Medicine and Community Health
Comments on the original article by French, et al. (see record 2023-74550-001) regarding adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care. This article provided a potential treatment pathway for certain patients. However, it has left the question: What options are available for patients who decline to participate in this collaborative care approach? It is important to emphasize that we do not want to deny them access to treatment for their (opioid use disorder) OUD. Are there alternative interventions with a lower intensity that may still hold value for patients who opt out of this particular approach? In future research, the current authors would like to see expanded treatment pathways that match patients at all levels of engagement. By offering a more diverse range of options, we can better meet the needs of a broader spectrum of patients, ultimately improving treatment outcomes for individuals with OUD and psychiatric symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Enhancing Patient Choice: Using Self-administered Intranasal Naloxone for Novel Rapid Buprenorphine Initiation
(2022-09-22) Randall, Adam; Hull, Ilana; Martin, Stephen A; Center for Integrated Primary Care; Family Medicine and Community Health
Buprenorphine-naloxone (BUP-NX) is a lifesaving treatment for opioid use disorder. The increasing use of illicitly manufactured fentanyl, however, has made initiating BUP-NX more likely to precipitate withdrawal-an experience that deters treatment and causes return to use. If BUP-NX cannot be successfully started, it cannot work. We describe the case of a patient who was able to transition to a therapeutic dose of BUP-NX less than 3 hours after his last illicitly manufactured fentanyl use by choosing to self-administer intranasal naloxone. After the naloxone, the transition took 31 minutes, including 14 minutes of expected moderately severe withdrawal. He remains in care with BUP-NX and would recommend this transition approach to others.
Evidence on Buprenorphine Dose Limits: A Review
(2023-06-16) Grande, Lucinda A; Cundiff, Dave; Greenwald, Mark K; Murray, MaryAnne; Wright, Tricia E; Martin, Stephen A; Center for Integrated Primary Care; Family Medicine and Community Health
Objectives: As overdose deaths from fentanyl continue to increase, optimizing use of medications for opioid use disorder has become increasingly important. Buprenorphine is a highly effective medication for reducing the risk of overdose death, but only if a patient remains in treatment. Shared decision making between prescribers and patients is important to establish a dose that meets each patient's treatment needs. However, patients frequently face a dose limit of 16 or 24 mg/d based on dosing guidelines on the Food and Drug Administration's package label. Methods: This review discusses patient-centered goals and clinical criteria for determining dose adequacy, reviews the history of buprenorphine dose regulation in the United States, examines pharmacological and clinical research results with buprenorphine doses up to 32 mg/d, and evaluates whether diversion concerns justify maintaining a low buprenorphine dose limit. Results: Pharmacological and clinical research results consistently demonstrate buprenorphine's dose-dependent benefits up to at least 32 mg/d, including reductions in withdrawal symptoms, craving, opioid reward, and illicit use while improving retention in care. Diverted buprenorphine is most often used to treat withdrawal symptoms and reduce illicit opioid use when legal access to it is limited. Conclusions: In light of established research and profound harms from fentanyl, the Food and Drug Administration's current recommendations on target dose and dose limit are outdated and causing harm. An update to the buprenorphine package label with recommended dosing up to 32 mg/d and elimination of the 16 mg/d target dose would improve treatment effectiveness and save lives.
Recruitment challenges for a prospective telehealth cohort study
(2022-12-02) Pertl, Kellie; Petluri, Ritwika; Wiest, Katharina; Hoffman, Kim; McCarty, Dennis; Levander, Ximena A; Chan, Brian; Martin, Stephen A; Korthuis, P Todd; Center for Integrated Primary Care; Family Medicine and Community Health
Background: The COVID-19 pandemic presents challenges in participant recruitment strategies for clinical research involving people with opioid use disorders recently engaged in treatment. We describe challenges to participant recruitment in a trial comparing virtual buprenorphine treatment platform to office-based buprenorphine treatment. Methods: The parent study was a cohort trial of telehealth delivered buprenorphine treatment compared to office-based buprenorphine treatment, however, due to the pandemic potential participant recruitment for both arms became virtual. Between 9/27/2021 and 7/11/2022, telephone, email, flyers, and word-of-mouth were used to recruit study participants from each treatment setting. Recruitment tracking documents recorded the primary outcomes: number of outreach attempts and most effective contact methods. Results: Treatment settings provided contact information for 1485 potential study participants. Information was incorrect or disconnected for 282 (19%) individuals, 695 (47%) did not respond to outreach, and 508 (34%) responded to outreach. Of these responders, 369 were interested in study participation, 259 completed the online informed consent and screening assessment, and 148 met eligibility criteria and enrolled in the study. A total of 3804 virtual outreach attempts across 1485 potential participants were made, resulting in an average of 2.7 attempts per contact and a mean of 25.7 attempts per enrolled participant (n = 148). Conclusion: Conducting research during the COVID-19 pandemic required shifting from in-person to virtual recruitment strategies to contact and engage potential study participants. Virtual recruitment for this population during a pandemic appears to be less efficient and hindered efforts to meet recruitment goals.
Comment from the Academic Consortium for Integrative Medicine & Health on the CDC Clinical Practice Guideline for Prescribing Opioids-United States, 2022
(2022-05-17) Tick, Heather; Nielsen, Arya; Gardiner, Paula; Simmons, Samantha; Hansen, Kathryn A; Dusek, Jeffery A; Center for Integrated Primary Care; Family Medicine and Community Health
The Academic Consortium for Integrative Medicine & Health is a recognized leader in evidence-based integrative medicine (www.imconsortium.org). It is a member-supported organization with over 76 highly esteemed academic medical centers and health systems members; our vision is to transform the healthcare system by promoting access to evidence-based healthcare options for all. We whole heartily welcome the CDC’s support for evidence-based nonpharmacologic strategies as first line options for acute and chronic pain care, in alignment with the 2010 Army Surgeon General’s Pain Management Task Force Report, the American College of Physician’s Guidelines, and the Veterans Health Administration that encourage evidence-based nonpharmacologic options early in patient treatment protocols.
Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program
(2023-06-05) Tjia, Jennifer; Pugnaire, Michele; Calista, Joanne; Eisdorfer, Ethan; Hale, Janet Fraser; Terrien, Jill; Valdman, Olga; Potts, Stacy E; Garcia, Maria; Yazdani, Majid; Puerto, Geraldine; Okero, Miriam; Duodu, Vennesa; Sabin, Janice; Family Medicine and Community Health; Medicine; Population and Quantitative Health Sciences; Tan Chingfen Graduate School of Nursing
Objectives: To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods: In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results: The initial trial year enrolled n = 65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism. Conclusion: It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.
Effectiveness of an Immersive Telemedicine Platform for Delivering Diabetes Medical Group Visits for African American, Black and Hispanic, or Latina Women With Uncontrolled Diabetes: The Women in Control 2.0 Noninferiority Randomized Clinical Trial
(2023-05-10) Mitchell, Suzanne E; Bragg, Alexa; De La Cruz, Barbara A; Winter, Michael R; Reichert, Matthew J; Laird, Lance D; Moldovan, Ioana A; Parker, Kimberly N; Martin-Howard, Jessica; Gardiner, Paula; Center for Integrated Primary Care; Family Medicine and Community Health
Background: Medically underserved people with type 2 diabetes mellitus face limited access to group-based diabetes care, placing them at risk for poor disease control and complications. Immersive technology and telemedicine solutions could bridge this gap. Objective: The purpose of this study was to compare the effectiveness of diabetes medical group visits (DMGVs) delivered in an immersive telemedicine platform versus an in-person (IP) setting and establish the noninferiority of the technology-enabled approach for changes in hemoglobin A1c (HbA1c) and physical activity (measured in metabolic equivalent of task [MET]) at 6 months. Methods: This study is a noninferiority randomized controlled trial conducted from February 2017 to December 2019 at an urban safety net health system and community health center. We enrolled adult women (aged ≥18 years) who self-reported African American or Black race or Hispanic or Latina ethnicity and had type 2 diabetes mellitus and HbA1c ≥8%. Participants attended 8 weekly DMGVs, which included diabetes self-management education, peer support, and clinician counseling using a culturally adapted curriculum in English or Spanish. In-person participants convened in clinical settings, while virtual world (VW) participants met remotely via an avatar-driven, 3D VW linked to video teleconferencing. Follow-up occurred 6 months post enrollment. Primary outcomes were mean changes in HbA1c and physical activity at 6 months, with noninferiority margins of 0.7% and 12 MET-hours, respectively. Secondary outcomes included changes in diabetes distress and depressive symptoms. Results: Of 309 female participants (mean age 55, SD 10.6 years; n=195, 63% African American or Black; n=105, 34% Hispanic or Latina; n=151 IP; and n=158 in VW), 207 (67%) met per-protocol criteria. In the intention-to-treat analysis, we confirmed noninferiority for primary outcomes. We found similar improvements in mean HbA1c by group at 6 months (IP: -0.8%, SD 1.9%; VW: -0.5%, SD 1.8%; mean difference 0.3, 97.5% CI -∞ to 0.3; P<.001). However, there were no detectable improvements in physical activity (IP: -6.5, SD 43.6; VW: -9.6, SD 44.8 MET-hours; mean difference -3.1, 97.5% CI -6.9 to ∞; P=.02). The proportion of participants with significant diabetes distress and depressive symptoms at 6 months decreased in both groups. Conclusions: In this noninferiority randomized controlled trial, immersive telemedicine was a noninferior platform for delivering diabetes care, eliciting comparable glycemic control improvement, and enhancing patient engagement, compared to IP DMGVs. Trial registration: ClinicalTrials.gov NCT02726425; https://clinicaltrials.gov/ct2/show/NCT02726425.
Integrated hepatitis C treatment is associated with improved retention and success in outpatient treatment for opioid use disorder at a private clinic
(2022-09-14) Losikoff, Phyllis; Bosse, Jordon D; Martin, Stephen A; Wilson, Amanda; Chiodo, Lisa M; Family Medicine and Community Health
Background: Direct acting antiretrovirals (DAA) are effective for individuals who are infected with chronic hepatitis C virus (HCV), yet many people go without access to these lifesaving treatments. Materials and methods: We conducted a non-randomized study evaluating treatment data for patients in outpatient treatment for opioid use disorder (OUD) at a private clinic. Patients who were HCV-positive, had been in OUD treatment for at least 4 weeks, and engaged in integrated HCV treatment with DAA (co-located within their treatment for OUD) were compared to patients with HCV who only received OUD treatment. We evaluated HCV cure; OUD medication adherence, treatment utilization and retention; and illicit substance use for those engaged in treatment between 9/2016 and 1/2018. Results: Seventy-four patients completed integrated HCV-OUD treatment with DAA, with 87.8% achieving cure. Of the 66 who completed treatment and were subsequently evaluated for sustained viral response 98.5% were cured. Patients who received integrated HCV and OUD treatment in our clinic, stayed in OUD treatment longer, demonstrated higher OUD medication adherence, and used less opioids or cocaine compared to HCV-infected patients (n = 572) being treated only for OUD. Discussion: We have reported on a reproducible intervention that lends itself to outpatient OUD treatment. Analyses demonstrate the potential positive impact HCV treatment has on OUD recovery, including reduction in opioid and cocaine use and increased retention in care. Conclusion: Co-locating HCV treatment with existing OUD treatment is feasible, effective, and demonstrates positive outcomes for the treatment of both conditions.
A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain
(2023-03-02) Barceló-Soler, Alberto; Morillo-Sarto, Héctor; Fernández-Martínez, Selene; Monreal-Bartolomé, Alicia; Chambel, Maria José; Gardiner, Paula; López-Del-Hoyo, Yolanda; García-Campayo, Javier; Pérez-Aranda, Adrián; Center for Integrated Primary Care; Family Medicine and Community Health
Mindfulness-, compassion-, and acceptance-based (i.e., "third wave") psychotherapies are effective for treating chronic pain conditions. Many of these programs require that patients engage in the systematic home practice of meditation experiences so they can develop meditation skills. This systematic review aimed at evaluating the frequency, duration, and effects of home practice in patients with chronic pain undergoing a "third wave" psychotherapy. A comprehensive database search for quantitative studies was conducted in PubMed, Embase, and Web of Sciences Core Collection; 31 studies fulfilled the inclusion criteria. The reviewed studies tended to indicate a pattern of moderately frequent practice (around four days/week), with very high variability in terms of time invested; most studies observed significant associations between the amount of practice and positive health outcomes. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy were the most common interventions and presented low levels of adherence to home practice (39.6% of the recommended time). Some studies were conducted on samples of adolescents, who practiced very few minutes, and a few tested eHealth interventions with heterogeneous adherence levels. In conclusion, some adaptations may be required so that patients with chronic pain can engage more easily and, thus, effectively in home meditation practices.
Ethnically Diverse Midlife Women’s Menopausal Transition Symptom Experience and Access to Medical and Integrative Health Care: Informing the Development of an Integrative Medicine Group Visit for the Menopausal Transition [preprint]
(Cold Spring Harbor Laboratory, 2022-06-21) Taylor-Swanson, Lisa; Stoddard, Kari; Fritz, Julie; Anderson, Belinda “Beau”; Cortez, Melissa; Conboy, Lisa; Sheng, Xiaoming; Flake, Naomi; Sanchez-Birkhead, Ana; Stark, Louisa; Woods, Nancy Fugate; Gardiner, Paula; Center for Integrated Primary Care; Family Medicine and Community Health
Objective: Individuals in the menopausal transition often seek healthcare in the United States. However, many individuals who seek healthcare do not receive treatments for their symptoms. And, some lack access to providers of both medical care and evidence-based integrative health interventions such as acupuncture, acupressure, or massage. A potential solution to this problem is medical group visits. Medical group visits are when multiple patients are seen by one provider. The present study gathered the opinions of diverse midlife women about interest in and desired design elements of medical group visits for menopause-related symptoms and concerns. Methods: We conducted one focus group with ethnically diverse midlife women to learn about their experiences in the menopausal transition, specifically their symptom experience, barriers, and facilitators to accessing medical and integrative health providers, and their interest in and suggestions for the design of an integrative medical group visit. Qualitative research methods were used to summarize session results. Results: Nine women participated and were diverse in terms of race/ethnicity and religious affiliation, and were highly educated. Themes included: an interest in participating in this conversation; that medical terms were mostly unfamiliar, and that terminology was less important than having a conversation; many symptoms were experienced; social factors affected participants, stressing the need for communication on this topic; receiving both unhelpful and helpful healthcare, a desire for whole person care; a need for information about what conditions Integrative Health interventions can treat, barriers to accessing both conventional and integrative care providers and facilitators include knowledge about insurance coverage and word of mouth. The group expressed great interest in the proposed integrative medical group visit (IMGV) model but expressed barriers such as a lack of time available, and needing childcare. Women indicated that an online format may help to overcome barriers. Conclusions: These findings highlight the importance of engagement with stakeholders before the design and implementation of IMGV and the great need among midlife women for education about the menopausal transition and relevant interventions and self-care.
Lessons Learned from Clinicians in a Federally Qualified Health Center: Steps Toward Eliminating Burnout
(2022-12-12) Cauley, Andrew W; Green, Alexander R; Gardiner, Paula; Center for Integrated Primary Care; Family Medicine and Community Health; T.H. Chan School of Medicine
Background: Burnout continues to impact health care workers and its effect takes a toll on their lives and wellbeing, especially in primary care. Relatively few studies have focused specifically on the perspective of clinicians in Federally Qualified Health Centers (FQHCs), which offer crucial, preventative health care services to vulnerable and underserved patient populations. Objective: To examine the perspectives of clinicians working at an FQHC in the Northeast United States after the implementation of a year-long wellness initiative. Design: A qualitative analysis of clinician's discussion during focus groups conducted after the wellness initiative. Subjects and Setting/Location: A total of 28 clinicians (primary care physicians and nurse practitioners) in an FQHC in the Northeast United States. Interventions: A one-year wellness initiative with programs and activities designed to bolster wellness. Outcome Measures: Analyzed NVIVO-coded transcripts of focus group discussion to generate codes and used modified grounded theory to extrapolate meaningful themes. Results: Five key themes emerged from the qualitative analysis: (1) clinicians often felt burdened by their workload and personally responsible when they were not able to provide optimal care to patients; (2) burnout was exacerbated by systemic problems at the FQHC; (3) medical assistants, medical scribes, schedulers, and other support staff played a crucial role in the wellness of the entire team; (4) perceived differences in priorities between administration and health care workers may have contributed to burnout; and (5) a communicative and stable team helped clinicians effectively care for their patients. Conclusions: Clinician burnout is a complex problem at FQHCs with many root causes. Addressing burnout and improving clinician wellness at FQHCs will require a multifaceted approach encompassing systemic, team, and individual components. The perspectives from the clinicians at our FQHC may inform wellness strategies for other safety net, clinical institutions in the primary care setting.

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