Dataset Information

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

ABSTRACT: BACKGROUND:Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample. METHODS:The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (?4 drinks/day for women; ?5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs. RESULTS:A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale. CONCLUSION:The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

SUBMITTER: Bradley KA

PROVIDER: S-EPMC5436432 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

Bradley Katharine A KA Ludman Evette Joy EJ Chavez Laura J LJ Bobb Jennifer F JF Ruedebusch Susan J SJ Achtmeyer Carol E CE Merrill Joseph O JO Saxon Andrew J AJ Caldeiro Ryan M RM Greenberg Diane M DM Lee Amy K AK Richards Julie E JE Thomas Rachel M RM Matson Theresa E TE Williams Emily C EC Hawkins Eric E Lapham Gwen G Kivlahan Daniel R DR

Addiction science & clinical practice 20170517 1

<h4>Background</h4>Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consis ...[more]

PMID: 28514963

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Project description:African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations.To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups.Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland.Forty-one primary care physicians and 279 hypertension patients.Physician communication skills training and patient coaching by community health workers.Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control.Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (? = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (? = +0.22 vs. -0.17, p = 0.03) and information exchange (? = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg).Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

Project description:BackgroundFollowing implementation of the patient-centered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking.ObjectiveTo examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA.DesignCross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff).Main measuresThree outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics.Key resultsAccess was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (- 1.1% to - 1.4%, P < 0.001), primary care provider turnover during the past year (- 1.0% to - 1.6%, P < 0.001), or medical support assistant turnover in the past year (- 0.9% to - 1.4%, P < 0.001).ConclusionsPerception of access was strongly associated with identifiable organizational factors and access-related initiatives within VA primary care clinics that could be adopted by other health systems.

Project description:IntroductionThe Eastern Europe and Central Asian (EECA) region has the highest increase in HIV incidence and mortality globally, with suboptimal HIV treatment and prevention. All EECA countries (except Russia) are low and middle-income (LMIC). While LMIC are home to 80% of all older people living with HIV (OPWH), defined as ≥50 years, extant literature observed that newly diagnosed OPWH represent the lowest proportion in EECA relative to all other global regions. We examined HIV diagnoses in OPWH in Ukraine, a country emblematic of the EECA region.MethodsWe analysed incident HIV diagnoses from 2015-2018 and mortality trends from 2016-2018 for three age groups: 1) 15-24 years; 2) 25-49 years; and 3) ≥50 years. AIDS was defined as CD4<200cells/mL. Mortality was defined as deaths per 1000 patients newly diagnosed with HIV within the same calendar year. Mortality rates were calculated for 2016, 2017, and 2018, compared to age-matched general population rates, and all-cause standardized mortality ratios (SMRs) were calculated.ResultsFrom 2015-2018, the proportion of OPWH annually diagnosed with HIV increased from 11.2% to 14.9% (p<0.01). At the time of diagnosis, OPWH were also significantly (p<0.01) more likely to have AIDS (43.8%) than those aged 25-49 years (29.5%) and 15-24 years (13.3%). Newly diagnosed OPWH had the same-year mortality ranging from 3 to 8 times higher than age-matched groups in the Ukrainian general population.ConclusionsThese findings suggest a reassessment of HIV testing, prevention and treatment strategies in Ukraine is needed to bring OPWH into focus. OPWH are more likely to present with late-stage HIV and have higher mortality rates. Re-designing testing practices is especially crucial since OPWH are absent from targeted testing programs and are increasingly diagnosed as they present with AIDS-defining symptoms. New strategies for linkage and treatment programs should reflect the distinct needs of this target population.

Project description:ImportanceVideo or telephone telemedicine can offer patients access to a clinician without arranging for transportation or spending time in a waiting room, but little is known about patient characteristics associated with choosing between telemedicine or office visits.ObjectiveTo examine patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians.Design, setting, and participantsThis cross-sectional study included data from 1 131 722 patients who scheduled a primary care appointment through the Kaiser Permanente Northern California patient portal between January 1, 2016, and May 31, 2018. All completed primary care appointments booked via the patient portal were identified. Only index visits without any other clinical visits within 7 days were included to define a relatively distinct patient-initiated care-seeking episode. Visits for routine physical, which are not telemedicine-eligible, were excluded. Data were analyzed from July 1, 2018, to December 31, 2019.Main outcomes and measuresPatient choice between an office, video, or telephone visit. Relative risk ratios (RRRs) for patient sociodemographic characteristics (age, sex, race/ethnicity, neighborhood socioeconomic status, language preference), technology access (neighborhood residential internet, mobile portal use), visiting the patient's own personal primary care clinician, and in-person visit barriers (travel-time, parking, cost-sharing), associated with choice of video or telephone telemedicine (vs office visit).ResultsOf 2 178 440 patient-scheduled primary care visits scheduled by 1 131 722 patients, 86% were scheduled as office visits and 14% as telemedicine visits, with 7% of the telemedicine visits by video. Choosing telemedicine was statistically significantly associated with patient sociodemographic characteristics. For example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine (RRR, 0.24; 95% CI, 0.22-0.26 for video visit; RRR 0.55; 95% CI, 0.54-0.57 for telephone visit). Choosing telemedicine was also statistically significantly associated with technology access (patients living in a neighborhood with high rates of residential internet access were more likely to choose a video visit than patients whose neighborhoods had low internet access: RRR, 1.10; 95% CI, 1.06-1.14); as well as in-person visit barriers (patients whose clinic had a paid parking structure were more likely to choose a telemedicine visit than patients whose facility had free parking: RRR, 1.70; 95% CI, 1.41-2.05 for video visit; and RRR, 1.73, 95% CI, 1.61-1.86 for telephone visit).Conclusions and relevanceIn this cross-sectional study, patients usually chose an in-person visit when scheduling an appointment online through the portal. Telemedicine may offer the potential to reach vulnerable patient groups and improve access for patients with transportation, parking, or cost barriers to clinic visits.

Dataset Information

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

Publications

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

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