CFHA Abstract Summaries, Vol 4, Fall 2017/Winter 2018
Compiled by: H. Jasna Haller, Brooke Palmer, and Patti Robinson
Cigrang, J.A., Rauch, S.A., Mintz, J., Brundige, A. R., Mitchell, J.A., Najera, E., Litz, B.T., … Peterson, A. L. (2017). Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military.Family, Systems, & Health, 35(4), 450-462. doi: 10.1037/fsh0000315.
OBJECTIVE: Many military service members with PTSD do not receive evidence-based specialty behavioral health treatment because of perceived barriers and stigma. The purpose of this randomized clinical trial was to determine if a brief cognitive-behavior therapy delivered in primary care using the Primary Care Behavioral Health model would be effective at reducing PTSD and co-occurring symptoms.
METHODS: A total of 67 service members (50 men, 17 women) were randomized to receive a brief, trauma-focused intervention developed for the primary care setting called Prolonged Exposure for Primary Care (PE-PC) or a delayed treatment minimal contact control condition. Assessments were completed at baseline, posttreatment/postminimal contact control, and at 8-week and 6-month posttreatment follow-up points. Primary measures were the PTSD Symptom Scale-Interview and the PTSD Checklist-Stressor-Specific.
RESULTS: PE-PC resulted in larger reduction in PTSD severity and general distress than the minimal contact control. Delayed treatment evidenced medium to large effects comparable to the immediate intervention group. Treatment benefits persisted through the 6-month follow-up of the study.
DISCUSSION: PE-PC delivered in integrated primary care is effective for the treatment of PTSD and co-occurring symptoms and may help reduce barriers and stigma found in specialty care settings.
Eaton, L.H., Langford, D.J., Meins, A.R., Rue, T., Tauben, D.J., & Doorenbos, A.Z. (2018). Use of self-management interventions for chronic pain management: A comparison between rural and nonrural residents.Pain Management Nursing, 19(1):8-13. doi: 10.1016/j.pmn.2017.09.004.
OBJECTIVE :Research has indicated that rural residents with chronic pain are more likely to receive an opioid prescription than nonrural residents. Although self-management approaches are available for chronic pain management, it is unclear to what extent rural residents use these interventions. This study compares usage of self-management interventions and opioid-based analgesics for chronic pain management between rural and nonrural residents.
METHODS: Participants, recruited from primary care clinics, were 65 rural residents and 144 nonrural residents with similar demographic characteristics. Differences in the use of self-management interventions, pain intensity, and opioid dose were evaluated between rural and nonrural residents.
RESULTS: Rural residents (n = 50, 77%) were less likely to use self-management interventions compared with nonrural residents (n = 133, 92%) (p = .019). Opioids were taken for pain relief by 76% of the rural residents compared with 52% of the nonrural residents.
DISCUSSION: A disparity exists in the use of self-management interventions for chronic pain management by rural residents compared with nonrural residents. Further study is needed to determine if this is related to the lack of access to specialists and/or pain management training of primary care providers. Nurses can play an essential role in addressing this disparity by educating patients about self-management interventions.
Wray, J. M., Funderburk, J. S., & Maisto, S. A. (2017). Willingness to engage in health behavior change interventions among primary care patients positive for tobacco use and at-risk drinking. Prim Care Companion CNS Disorders, 19(5), online edition. doi: doi: 10.4088/PCC.17m02209.
OBJECTIVE: To examine intervention preferences of primary care patients who recently screened positive for tobacco use and at-risk drinking.
METHODS: Primary care patients who screened positive for recent tobacco use and at-risk drinking were eligible to participate in a one-time telephone-based survey conducted from August 2015 to December 2015. The survey asked questions about how willingness to engage in an intervention in integrated primary care was influenced by the described format and focus of the intervention. Data from patients who smoked cigarettes and met criteria for at-risk drinking in the last 30 days (N = 53) were included in the analyses.
RESULTS: Participants reported that they would be more willing to engage in an intervention focused on helping them reduce their risk of medical problems than in services focused specifically on discussing cigarette or alcohol use (P = .00). Participants did not indicate a preference related to whether the intervention was delivered during a primary care appointment, immediately following a primary care appointment, or as a scheduled follow-up (P = .693).
CONCLUSIONS: Patients may be more willing to engage in a behavior intervention when general health is emphasized over a focus specifically on tobacco or alcohol use. Patients were equally receptive to receiving brief interventions in several different formats available within an integrated primary care setting.
Dham, P. Colman, S., Saperson, K. McAiney, C., Lourenco, L., Kates, N., Rajii, T.K. (2017). Collaborative Care for psychiatric disorders in older adults: A systematic review.Canadian Journal of Psychiatry, 62(11), 761-771. doi: https://dx.doi.org/10.1177%2F0706743717720869
OBJECTIVE: To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults.
METHODS: PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis.
RESULTS: Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation.
CONCLUSIONS: Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.
Leung, L.B., Yoon, J., Escarce, J. J., Post, E. P., Wells, K.B., Sugar, C.A., Yano, E.M., Rubenstein, L.V. (2017). Primary Care-Mental Health Integration in the VA: Shifting mental health services for common mental illnesses to primary care.Psychiatric Services, 69(4), 403-409. doi: https://doi.org/10.1176/appi.ps.201700190
OBJECTIVE: Primary care-mental health integration (PC-MHI) aims to increase access to general mental health specialty (MHS) care for primary care patients thereby decreasing referrals to non-primary care-based MHS services. It remains unclear whether new patterns of usage of MHS services reflect good mental health care. This study examined the relationship between primary care clinic engagement in PC-MHI and use of different MHS services.
METHODS: This was a retrospective longitudinal cohort study of 66,638 primary care patients with mental illnesses in 29 Southern California Veterans Affairs clinics (2008-2013). Regression models used clinic PC-MHI engagement (proportion of all primary care clinic patients who received PC-MHI services) to predict relative rates of general MHS visits and more specialized MHS visits (for example, visits for serious mental illness services), after adjustment for year and clinic fixed effects, other clinic interventions, and patient characteristics.
RESULTS: Patients were commonly diagnosed as having depression (35%), anxiety (36%), and posttraumatic stress disorder (22%). For every 1 percentage point increase in a clinic's PC-MHI engagement rate, patients at the clinic had 1.2% fewer general MHS visits per year (p<.001) but no difference in more specialized MHS visits. The reduction in MHS visits occurred among patients with depression (-1.1%, p=.01) but not among patients with psychosis; however, the difference between the subsets was not statistically significant.
CONCLUSIONS: Primary care clinics with greater engagement in PC-MHI showed reduced general MHS use rates, particularly for patients with depression, without accompanying reductions in use of more specialized MHS services.
Longpré, C., & Dubois, C.A. (2017). Fostering development of nursing practices to support integrated care when implementing integrated care pathways: what levers to use?BMC Health Services Research, 17(1), 790. doi: 10.1186/s12913-017-2687-0.
OBJECTIVE: The aim of this study was to identify levers and strategies that organizations can use to support the development of a nursing practice aligned with the requirements of care integration in a health and social services centre (HSSC) in Quebec.
METHODS: The research design was a cross-sectional descriptive qualitative study based on a single case study with nested levels of analysis. The case was a public, multi-disciplinary HSSC in a semi-urban region of Quebec. Semi-structured interviews with 37 persons (nurses, professionals, managers, administrators) allowed for data saturation and ensured theoretical representation by covering four care pathways constituting different care integration contexts. Analysis involved four steps: preparing a predetermined list of codes based on the reference framework developed by Minkman (2011); coding transcript content; developing general and summary matrices to group observations for each care pathway; and creating a general model showing the overall results for the four pathways.
RESULTS: The organization's capacity for response with regard to developing an integrated system of services resulted in two types of complementary interventions. The first involved investing in key resources and renewing organizational structures; the second involved deploying a series of organizational and clinical-administrative processes. In resource terms, integration efforts resulted in setting up new strategic services, re-arranging physical infrastructures, and deploying new technological resources. Organizational and clinical-administrative processes to promote integration involved renewing governance, improving the flow of care pathways, fostering continuous quality improvement, developing new roles, promoting clinician collaboration, and strengthening care providers' capacities. However, progress in these areas was offset by persistent constraints.
CONCLUSIONS: The results highlight key levers organizations can use to foster the implementation and institutionalization of integrative nursing practices. They show that progress in this area requires a combination of strategies using multiple complementary levers. They also suggest that such progress calls for rethinking not only the deployment of certain organizational resources and structures, but also a series of organizational and clinical processes.
Hunter, R., Wallace, P., Struzzo, P., Della Vedova, R., Scafuri, F., Tersar, C., ... & Freemantle, N. (2017). Randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website: cost-effectiveness analysis.BMJ Open, 7(11), e014577.
OBJECTIVE: To evaluate the 12-month costs and quality-adjusted life years (QALYs) gained to the Italian National Health Service of facilitated access to a website for hazardous drinkers compared with a standard face-to-face brief intervention (BI).
METHOD: This was a randomised 1:1 non-inferiority trial in practices of 58 general practitioners (GPs) in Italy. Of 9080 patients (>18 years old) approached to take part in the trial, 4529 (49·9%) logged on to the website and 3841 (84.8%) undertook online screening for hazardous drinking. 822 (21.4%) screened positive and 763 (19.9%) were recruited to the trial. Patients were randomised to receive either a face-to-face BI or access via a brochure from their GP to an alcohol reduction website (facilitated access). The primary outcome is the cost per QALY gained of facilitated access compared with face-to-face. A secondary analysis includes total costs and benefits per 100 patients, including number of hazardous drinkers prevented at 12 months.
RESULTS: The average time required for the face-to-face BI was 8 min (95% CI 7.5 min to 8.6 min). Given the maximum time taken for facilitated access of 5 min, face-to-face is an additional 3 min: equivalent to having time for another GP appointment for every three patients referred to the website. Complete case analysis adjusting for baseline the difference in QALYs for facilitated access is 0.002 QALYs per patient (95% CI -0.007 to 0.011).
CONCLUSIONS: Facilitated access to a website to reduce hazardous drinking costs less than a face-to-face BI given by a GP with no worse outcomes. The lower cost of facilitated access, particularly in regards to investment of time, may facilitate the increase in provision of BIs for hazardous drinking.
Painter, J. T., Fortney, J. C., Austen, M. A., & Pyne, J. M. (2017). Cost-Effectiveness of Telemedicine-Based Collaborative Care for Posttraumatic Stress Disorder. Psychiatric Services, 68(11), 1157-1163.
OBJECTIVE: The study examined the cost-effectiveness of a telemedicine-based collaborative care model designed to increase rural veterans' engagement in evidence-based treatments for posttraumatic stress disorder (PTSD).
METHODS: The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial to examine effects of PTSD care teams located at Veterans Affairs medical centers and supporting primary care providers in satellite clinics. Teams included a nurse care manager, pharmacist, psychologist, and psychiatrist. Effectiveness was estimated with quality-adjusted life years (QALYs) derived from the Short Form Health Survey for Veterans and Quality of Well-Being (QWB) scale. Intervention and health care costs were collected to evaluate the cost-effectiveness of the intervention.
RESULTS: The sample (N=265) included mostly rural, unemployed, middle-aged men with a military service-connected disability for PTSD randomly assigned to TOP or usual care. Only minor improvements in QWB QALYs were found. The TOP intervention was relatively expensive, with costs totaling $2,029 per patient per year. Intervention costs were not offset by reductions in health care utilization costs, resulting in an incremental cost-effectiveness ratio of $185,565 per QALY (interquartile range $57,675 to $395,743).
CONCLUSIONS: Because of the upfront training costs and the resource-intensive nature of this intervention, associated expenses were high. Although PTSD-specific effectiveness measures were significantly improved, these changes did not translate to QALYs in the main analysis. However, analyses focusing on patient subgroups with comorbid mental disorders indicated greater QALY improvement for TOP at lower cost.
Basu, S., Landon, B. E., Williams, J. W., Bitton, A., Song, Z., & Phillips, R. S. (2017). Behavioral health integration into primary care: a microsimulation of financial implications for practices.Journal of General Internal Medicine, 32(12), 1330-1341.
OBJECTIVE: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities. To evaluate the financial impact for primary care practices of integrating behavioral health services.
METHODS: This was a microsimulation model. We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey. A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist. Net revenue change per full-time physician was the main outcome.
RESULTS: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD inyear 1 and $28,548/year in subsequent years) than PCBM (- $7052 in year 1 and-$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types.
CONCLUSIONS: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.
Wilkins, K. M., Fenick, A. M., Goldenberg, M. N., Ellis, P. J., Barkil-Oteo, A., & Rohrbaugh, R. M. (2018). Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships. Journal of General Internal Medicine, 33(1), 120-124.
OBJECTIVE: Public health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems. The aim of this examination was to implement an integrated primary care-psychiatry clerkship for third-year medical students.
METHOD: This was a program evaluation. SETTING: Undergraduate medical education, amid institutional curriculum reform. PARTICIPANTS: Two hundred thirty-seven medical students participated in the clerkship in academic years 2015-2017. PROGRAM DESCRIPTION: Educators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care-Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.
RESULTS: Students reported satisfaction with the clerkship overall, rating it 3.9-4.3 on a 1-5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.
CONCLUSIONS: While preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.
Martin, M. P. (2017). Integrated behavioral health training for primary care clinicians: Five lessons learned from a negative study. Families, Systems, & Health, 35(3), 352.
OBJECTIVE: There are very few studies examining the effectiveness of integrated behavioral health training for primary care clinicians. The purpose of this article is to review the findings of a negative study examining the effectiveness of medical resident training in integrated behavioral health and offer specific ideas for future research in workforce development.
METHODS: Twenty-three family medicine residents from a community-based residency program in the mid-Atlantic region completed a required rotation in which they consulted with behavioral health in primary care, observed psychotherapy, read behavioral medicine books, and received individual instruction. Fourteen residents completed a survey pre- and postrotation, and all 23 residents completed a semistructured interview postrotation.
RESULTS: Survey findings demonstrate that resident attitudes about collaboration and behavioral health consultants did not significantly change as a result of the rotation. Findings also show that internal referral orders for behavioral health services dropped sharply after the rotation. Qualitative data suggest that residents value integrated behavioral health.
DISCUSSION: There are five lessons to learn from this negative study: learning outcomes should match learning activities, residents benefit from direct observation, longitudinal data help measure change over time, collaborative care curriculum evaluation deserves collaborative partnership with other training sites, and evaluating the resident and the behavioral health provider offers a systems viewpoint and new insights. Future research should identify core knowledge and skills for primary care clinicians working in settings with integrated behavioral health and evaluate the long-term effectiveness of a curriculum based on those competencies.
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