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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Recently Published

  • Effects of intervention stage completion in an integrated behavioral health and primary care randomized pragmatic intervention trial [preprint]

    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; et al. (2024-02-08)
    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.
  • The contextual interview: a cross-cutting patient-interviewing approach for social context

    Cahill, Amber; Martin, Matthew; Beachy, Bridget; Bauman, David; Howard-Young, Jordan (2024-02-06)
    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.
  • A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions

    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; et al. (2023-11-01)
    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

    Roth, Isabel; Tiedt, Malik; Miller, Vanessa; Barnhill, Jessica; Chilcoat, Aisha; Gardiner, Paula; Faurot, Keturah; Karvelas, Kris; Busby, Kenneth; Gaylord, Susan; et al. (2023-09-27)
    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

    Mullin, Daniel J; Mitton, Ashley (2023-09-01)
    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).
  • Evidence on Buprenorphine Dose Limits: A Review

    Grande, Lucinda A; Cundiff, Dave; Greenwald, Mark K; Murray, MaryAnne; Wright, Tricia E; Martin, Stephen A (2023-06-16)
    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.
  • Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program

    Tjia, Jennifer; Pugnaire, Michele; Calista, Joanne; Eisdorfer, Ethan; Hale, Janet Fraser; Terrien, Jill; Valdman, Olga; Potts, Stacy E; Garcia, Maria; Yazdani, Majid; et al. (2023-06-05)
    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

    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 (2023-05-10)
    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.
  • A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain

    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 (2023-03-02)
    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.
  • Lessons Learned from Clinicians in a Federally Qualified Health Center: Steps Toward Eliminating Burnout

    Cauley, Andrew W; Green, Alexander R; Gardiner, Paula (2022-12-12)
    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.
  • Recruitment challenges for a prospective telehealth cohort study

    Pertl, Kellie; Petluri, Ritwika; Wiest, Katharina; Hoffman, Kim; McCarty, Dennis; Levander, Ximena A; Chan, Brian; Martin, Stephen A; Korthuis, P Todd (2022-12-02)
    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.
  • Enhancing Patient Choice: Using Self-administered Intranasal Naloxone for Novel Rapid Buprenorphine Initiation

    Randall, Adam; Hull, Ilana; Martin, Stephen A (2022-09-22)
    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.
  • Integrated hepatitis C treatment is associated with improved retention and success in outpatient treatment for opioid use disorder at a private clinic

    Losikoff, Phyllis; Bosse, Jordon D; Martin, Stephen A; Wilson, Amanda; Chiodo, Lisa M (2022-09-14)
    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.
  • Practice integration profile revised: Improving item readability and completion

    Rose, Gail L; Weldon, Tara L; McEntee, Mindy L; Hitt, Juvena R; Kessler, Rodger; Littenberg, Benjamin; Macchi, C R; Martin, Matthew P; Mullin, Daniel J; van Eeghen, Constance (2022-09-01)
    Introduction: The Practice Integration Profile (PIP) is a reliable, valid, and broadly used measure of the integration of behavioral health (BH) into primary care. The PIP assesses operational and procedural elements that are grounded in the AHRQ Lexicon for Behavioral Health and Primary Care Integration. Prior analyses of PIP data and feedback from users suggested the measure was in need of revisions. This article describes the process used to improve readability, clarity, and pragmatic utility of the instrument. Method: Two rounds of structured cognitive interviews were conducted with clinicians in primary care settings. After each round, interview transcripts were coded by an analytic team using an iterative and consensus-driven process. Themes were identified based on codes. Themes and recommendations for revisions were reviewed and modified by committee. Results: Based on feedback and a prior factor analysis of the PIP, revisions were undertaken to: (a) eliminate redundant or overlapping items; (b) clarify the meaning of items; (c) standardize the response categories, and (d) place items in the most appropriate domains. The resulting measure has 28 items in five domains. Discussion: PIP 2.0 will need further examination to confirm its continuing use as a foundational tool for evaluating integrated care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
  • 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]

    Taylor-Swanson, Lisa; Stoddard, Kari; Fritz, Julie; Anderson, Belinda “Beau”; Cortez, Melissa; Conboy, Lisa; Sheng, Xiaoming; Flake, Naomi; Sanchez-Birkhead, Ana; Stark, Louisa; et al. (2022-06-21)
    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.
  • Patient screening for integrated behavioral health in adult primary care: A rapid review of effective procedures

    Martin, Matthew P.; McEntee, Mindy L.; Mullin, Daniel J; Suri, Yash; van Eeghen, Constance (2022-06-02)
    PURPOSE: Although many primary care clinics screen for behavioral health (BH) conditions using validated tools, it is not clear whether adult BH screening leads to better patient outcomes. Our objective was to determine the evidence base by reviewing effectiveness research for multiple strategies of BH screening in adult primary care identified in the Practice Integration Profile. METHOD: We conducted five rapid reviews of effectiveness research supporting BH screening strategies cited in the Practice Integration Profile. Each rapid review was conducted using an adapted REAL (Rapid Evidence Assessment of the Literature) methodology and a standardized search tailored for each screening strategy to identify evidence related to BH screening in primary care. RESULTS: The database search yielded 931 references. Following eligibility review and extraction, we evaluated data from 20 references examining five screening strategies. Results demonstrated limited support for all five strategies and high risk of bias within most studies. Outcomes associated with various BH screening strategies were rarely the focus of study. CONCLUSIONS: There is an absence of robust, well-structured evidence supporting many of the BH screening strategies advocated for in primary care. Stakeholders may wish to understand how to ensure value when developing a robust screening program that will improve patient health outcomes. Future research should advance the science of BH screen selection, timing, and implementation by answering new questions about screening strategies.
  • Comment from the Academic Consortium for Integrative Medicine & Health on the CDC Clinical Practice Guideline for Prescribing Opioids-United States, 2022

    Tick, Heather; Nielsen, Arya; Gardiner, Paula; Simmons, Samantha; Hansen, Kathryn A; Dusek, Jeffery A (2022-05-17)
    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.
  • Our Whole Lives for Hypertension and Cardiac Risk Factors-Combining a Teaching Kitchen Group Visit With a Web-Based Platform: Feasibility Trial

    Gardiner, Paula; McGonigal, Lisa; Villa, Ariel; Kovell, Lara C.; Rohela, Pallavi; Cauley, Andrew; Rinker, Diana; Olendzki, Barbara C. (2022-05-16)
    BACKGROUND: Hypertension (HTN) affects millions of Americans. Our Whole Lives: an eHealth toolkit for Hypertension and Cardiac Risk Factors (OWL-H) is an eHealth platform that teaches evidence-based lifestyle strategies, such mindfulness and cooking skills, to improve self-management of HTN. OBJECTIVE: The primary goal of this pilot study was to evaluate the feasibility of OWL-H combined with teaching kitchen medical group visits (TKMGVs) in a low-income population of participants with HTN. METHODS: We conducted a pre-post 8-week study to assess the feasibility of a hybrid program (a web-based 9-module self-management program, which includes mindfulness and Mediterranean and Dietary Approaches to Stop Hypertension diet) accompanied by 3 in-person TKMGVs among patients with HTN. Data including demographics, platform use, and satisfaction after using OWL-H were examined. Outcome data collected at baseline and 8 weeks included the Mediterranean Diet Questionnaire, Hypertension Self-Care Profile Self-Efficacy Instrument, Blood Pressure Knowledge Questionnaire, and the number of self-reported blood pressure readings. For the statistical analysis, we used descriptive statistics, paired sample t tests (1-tailed), and qualitative methods. RESULTS: Of the 25 enrolled participants, 22 (88%) participants completed the study. Participants' average age was 57 (SD 12.1) years, and 46% (11/24) of them reported a household income < US $30,000 per year. Among the 22 participants who logged in to OWL-H, the average number of mindfulness practices completed was 7 and the average number of module sessions accessed was 4. In all, 73% (16/22) of participants reported that they were "very satisfied" with using OWL-H to help manage their HTN. Participants' blood pressure knowledge significantly increased from baseline (mean 5.58, SD 1.44) to follow-up (mean 6.13, SD 1.23; P=.03). Participants significantly increased their adherence to a Mediterranean diet from baseline (mean 7.65, SD 2.19) to follow-up (mean 9, SD 1.68; P=.004). Participants' self-efficacy in applying heart-healthy habits, as measured by the Hypertension Self-Care Profile Self-Efficacy Instrument, increased from baseline (mean 63.67, SD 9.06) to follow-up (mean 65.54, SD 7.56; P=.14). At the 8-week follow-up, 82% (18/22) of the participants had self-reported their blood pressure on the OWL-H platform at least once during the 8 weeks. CONCLUSIONS: The eHealth platform for HTN self-management, OWL-H, and accompanying in-person TKMGVs have the potential to effectively improve lifestyle management of HTN. TRIAL REGISTRATION: ClinicalTrials.gov NCT03974334; https://clinicaltrials.gov/ct2/show/NCT03974334.
  • Depression predicts chronic pain interference in racially diverse, income-disadvantaged patients

    Nephew, Benjamin C.; Incollingo Rodriguez, Angela C.; Melican, Veronica; Polcari, Justin J.; Nippert, Kathryn E.; Rashkovskii, Mikhail; Linnell, Lilly-Beth; Hu, Ruofan; Ruiz, Carolina; King, Jean A.; et al. (2021-12-15)
    BACKGROUND: Chronic pain is one of the most common reasons adults seek medical care in the US, with prevalence estimates ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses, including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies. OBJECTIVE AND DESIGN: The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in diverse, income disadvantaged patients suffering from chronic pain and depression. METHODS: The analytical approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference. RESULTS: Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes. CONCLUSIONS: In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racialized, income disadvantaged populations, demographics often neglected in studies of chronic pain. TRIAL REGISTRATION: NCT from clinicaltrials.gov: 02262377. American Academy of Pain Medicine.
  • A Teaching Kitchen Medical Groups Visit with an eHealth Platform for Hypertension and Cardiac Risk Factors: A Qualitative Feasibility Study

    Rohela, Pallavi; Olendzki, Barbara C.; McGonigal, Lisa J.; Villa, Ariel; Gardiner, Paula (2021-11-01)
    Introduction: Our Whole Lives-Hypertension (OWL-H) is an eHealth toolkit for hypertension and cardiac risks factors. It is a hybrid online self-management platform that teaches blood pressure (BP) self-monitoring and evidence-based lifestyle modifications combined with in-person teaching kitchen medical group visit. Qualitative feedback from participants regarding the facilitators and barriers of using OWL-H has been discussed in this article. Methods: The OWL-H platform was pilot tested in a pre-post trial with two cohorts of participants with hypertension (N = 24). The online intervention utilized OWL-H for teaching mindfulness meditation, the Dietary Approaches to Stop Hypertension nutrition plan, and evidence-based strategies for lifestyle modifications. Three in-person teaching kitchen medical group visits were held to demonstrate cooking skills to reinforce the online platform. Semi-structured focus group discussions (FGDs) were held after the intervention. Results: Fourteen of the 24 participants in the trial participated in the FGDs, and 1 participant provided feedback in a solo interview. Major themes that emerged included: (1) participants' request to tailor OWL-H's recipes and meal planning to suit their own dietary needs or preferences, to personalize the Home Practices (e.g., meditation) according to individual preferences (e.g., addition of nature sounds or guided visual imagery); (2) the strengths and weaknesses of OWL-H as a BP self-monitoring tool; (3) the need for community support in managing BP; and (4) participants noted lack of time, work and commute, Internet connectivity, stress, and sickness as obstacles in using OWL-H. Participants described feeling outpaced by the growth of technology and raised concerns of poor Internet connectivity hampering their use of OWL-H. Conclusion: OWL-H and the accompanying teaching kitchen medical group visit are potential tools to help reduce hypertension and cardiac risk factors. The intervention was found to have acceptability among people with lower income. Clinical Trials Registration#: NCT03974334.

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