New article by Gail Rose, Charlie MacLean and others

Congratulations!

J Gen Intern Med. 2016 May 20. [Epub ahead of print]

A Randomized Controlled Trial of IVR-Based Alcohol Brief Intervention to Promote Patient-Provider Communication in Primary Care.

Rose GL1, Badger GJ2, Skelly JM2, Ferraro TA3, MacLean CD4, Helzer JE5.

Author information

Abstract

BACKGROUND:

Brief interventions for unhealthy drinking in primary care settings are efficacious, but underutilized. Efforts to improve rates of brief intervention though provider education and office systems redesign have had limited impact. Our novel brief intervention uses interactive voice response (IVR) to provide information and advice directly to unhealthy drinkers before a physician office visit, with the goals of stimulating in-office dialogue about drinking and decreasing unhealthy drinking. This automated approach is potentially scalable for wide application.

OBJECTIVE:

We aimed to examine the effect of a pre-visit IVR-delivered brief alcohol intervention (IVR-BI) on patient-provider discussions of alcohol during the visit.

DESIGN:

This was a parallel group randomized controlled trial with two treatment arms: 1) IVR-BI or 2) usual care (no IVR-BI).

PARTICIPANTS:

In all, 1,567 patients were recruited from eight university medical center-affiliated internal medicine and family medicine clinics.

INTERVENTIONS:

IVR-BI is a brief alcohol intervention delivered by automated telephone. It has four components, based on the intervention steps outlined in the National Institute of Alcohol Abuse and Alcoholism guidelines for clinicians: 1) ask about alcohol use, 2) assess for alcohol use disorders, 3) advise patient to cut down or quit drinking, and 4) follow up at subsequent visits.

MAIN MEASURES:

Outcomes were patient reported: patient-provider discussion of alcohol during the visit; patient initiation of the discussion; and provider's recommendation about the patient's alcohol use.

KEY RESULTS:

Patients randomized to IVR-BI were more likely to have reported discussing alcohol with their provider (52 % vs. 44 %, p = 0.003), bringing up the topic themselves (20 % vs. 12 %, p < 0.001), and receiving a recommendation (20 % vs. 14 %, p < 0.001). Other predictors of outcome included baseline consumption, education, age, and alcohol use disorder diagnosis.

CONCLUSIONS:

Providing automated brief interventions to patients prior to a primary care visit promotes discussion about unhealthy drinking and increases specific professional advice regarding changing drinking behavior.

- Ben Littenberg

Kennedy and MacLean testify before Congress

On May 18, 2016, Charles D. MacLean, MDCM, Professor of Medicine and Amanda G. Kennedy, PharmD, BCPS, Associate Professor of Medicine, presented at the U.S. House of Representatives Congressional Briefing entitled, “Getting the Medications Right: An essential ingredient in achieving the goals of H.R. 4878 – the Medicare Better Care, Lower Cost Act". The briefing was presented by the American College of Clinical Pharmacy and the College of Psychiatric and Neurologic Pharmacists. Here is Amanda's report:

It was quite a day! Charlie and I spent most of the morning at the DC offices of ACCP, preparing for the briefing. The briefing was held in the Rayburn Building, adjacent to the Capitol building. As Congress was in session, the attendees were Congressional staff. I had the opportunity to speak informally with a few of the staff and my sense was they were very passionate about healthcare, but with a very limited understanding of what healthcare is like from the “front lines.” It was the perfect opportunity to showcase the innovative work we are doing here in Vermont. The briefing was an hour long – 20 minutes from a pharmacist-physician team from Minnesota, 20 minutes from us, and 20 minutes of questions. I think there was a great response from those who attended and it was a fabulous opportunity.

As far as H.R. 4878 – the Medicare Better Care, Lower Cost Act, we were told that the briefing was a “place holder,” as it was unlikely to be voted on in an election year. However, continuing to educate stakeholders about the value of pharmacists cannot be discussed often enough! I’m thrilled to have had the opportunity to represent Vermont in general, and specifically Vermont pharmacists.

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Connie van Eeghen accepted into prestigious AHRQ training program

Connie van Eeghen DrPH, Assistant Professor of Medicine, has been accepted into the AHRQ Certificate Program in Practice-Based Research Methods, sponsored by the eight Centers of Excellence in Practice-Based Research and Learning.  The highly-competitive  program was created to develop a new generation of independent investigators within the practice-based research network (PBRN) community. It provides training in concepts, skills, and methods for conducting practice-based research and building PBRNs.  Connie will be pursuing this certificate over the next year, mentored by Associate Professor of Family Medicine Rodger Kessler PhD and Professor of Pediatrics Mort Wasserman MD.  The program will culminate at a Convocation held prior to the North American Primary Care Research Group National PBRN Conference in Bethesda, MD during the summer of 2017.

Congratulations to Connie!

- Ben Littenberg

Nancy Gell PT MPH PhD, Assistant Professor in Rehabilitation and Movement Science is a recipient of the Armin Grams Research Award for the projec "Mobile technology to support physical therapy exercise for people aging with arthritis." Nancy is collaborating with Dr. Barbara Tschoepe in Rehabilitation and Movement Science. Justine Dee PT, MS, OCS, PhD candidate in CTS, is also a consultant on the award.

Congratulations to Nancy and company!

Quote of the day...

A change in perspective is worth 80 IQ points. 
- Alan Kay, Computer Scientist (b. 1940)

(Hat tip to Anu Garg at wordsmith.com)

Congratulations to CTS Doctoral student Katharine Cheung, MD on recent award

PhD candidate in CTS, Katharine Cheung, MD, Nephrology Unit has received the Armin Grams Research Award from the Center on Aging for $50, 000. to study trajectories of frailty and resilience in older adults with CKD. Katharine will be collaborating with Dr. Virginia Hood of Nephrology.
Go Kat, we are very proud of your work!

Clinical Research Oriented Workshop (CROW) Meeting: May 12, 2016

Present:  Marianne Burke, Abigail Crocker, Justine Dee, Nancy Gell, Juvena Hitt, Kairn Kelley, Ben Littenberg, Adam Sprouse-Blum, Connie van Eeghen

Start Up: Who’s who: welcome Abby!

1.                  Discussion: Ben on free text based data base to find missed clinical opportunities

a.       There is some anecdotal evidence that people with radiology studies may show need for services outside the primary reason for the study:

                                                  i.      Boxer fracture (esp if repeated) indicating need for anger management

                                                ii.      Nodules found on one organ when a different organ is the focus of the study

                                              iii.      Screening of smokers for lung cancern that show other fractures, calcification, growths…

b.      Three questions:

                                                  i.      Can we identify punching?

                                                ii.      Can we identify falls?

                                              iii.      Can we identify osteoporosis?

c.       Methods:

                                                  i.      Data set: 2 files of type delimited reports: 2014 and 2015 with diagnosis, text of report, year done, laterality, YOB, sex

1.      Chest CTs of all kinds

2.      All hand films

3.      All wrist films

                                                ii.      Stata process

1.      Identify the date and time fields for each record (AM vs PM)

2.      Identify key words that represent the clinical issues of interest

3.      Identify the location of those key words within the text

a.       Eliminate occurrences preceded with “no” related to those key words if >30 character positions away from key words

4.      For fall study, eliminate if <65 years or if skiing

5.      For osteoporosis study, eliminate “periarticular,” meaning a marker of inflammatory arthritis, not associated with weak bones

6.      Capture the number of times those key words occur and the phrase in which they occurred

7.      Tab by key word (gosh, that was easy)

                                              iii.      Clinical outcomes

1.      5% of hand films indicate punching, fighting, or boxer fracture

2.      2% of films indicate falls

3.      4% of films indicate osteoporosis or osteopenia (did not look for compression fractures which may increase the results)

4.      Note: wrist and hand studies showed more than chest studies

d.      Next steps

                                                  i.      Ask for reports from other film studies; check for errors

                                                ii.      Check for duplicate patients

                                              iii.      Did identified patients get follow up treatment, as identified by the problem list

2.                  Future meetings

a.       Stay with current time of Thursdays at 1:30 until end of August.  After the meeting, Connie sent out a Doodle Poll to request a change to Thursday mornings.

3.                  Next Workshop Meeting(s): Thursdays, 1:30 p.m. – 2:30 p.m., at Given Courtyard South Level 4.   

a.       May 19, 2016: Nancy?

b.      May 26, 2016:(start new time)

c.       June 2, 2016: Amanda and Connie on Rheumatology QI Project on Opioid Prescription Management

d.      June 9, 2016: Adam

Recorder: Connie van Eeghen

Kennedy and MacLean to brief US congress about pharmacists on the healthcare team

Amanda G. Kennedy, PharmD, BCPS, Associate Professor of Medicine and Charles D. MacLean, MDCM, Professor of Medicine will be briefing congress on Wednesday May 18th. The purpose of the briefing is to describe how the integration of clinical pharmacists as members of the healthcare team can improve the safety and effectiveness of medications for our complex patients. The briefing is coinciding with the introduction of HR4878, the “Better Care, Lower Cost Act” by Congressmen Erik Paulsen and Peter Welch.

Getting the Medications Right:

Essential for Effective Chronic Care Treatment

Health Care Briefing

Wednesday, May 18th

3:00 PM

B-318 Rayburn Office Building

Dear Colleague:

Please join us for a briefing on how comprehensive medication management (CMM) services, delivered under team-based care structures, can significantly improve patient outcomes and control healthcare costs.  The briefing will be held on May 18th at 3:00 PM in room B-318 of the Rayburn House Office Building. 

CMM is truly collaborative, in that it brings together highly qualified pharmacists, physicians and other members of the healthcare team to ensure that patients are getting the right medications and using them in the right way to achieve the best clinical outcomes.  CMM helps ensure that we are “getting the medications right” for seniors suffering from chronic ailments. Since prescription medicine plays such an important role in modern healthcare – especially for seniors with chronic conditions -- it is critical to build a Medicare benefit that ensures these medications are used safely, appropriately, and are aligned with the patient’s overall care plan. 

On March 23rd, we introduced H.R. 4878, “The Better Care, Lower Cost Act.”  This legislation seeks to improve care coordination for Medicare beneficiaries with multiple chronic conditions. 

Our bill will encourage and promote the kind of collaboration used in CMM, helping reduce the crippling emotional and economic costs of chronic illnesses in Medicare. 

This briefing will include some of the leading clinical pharmacists in the country, along with the physicians they work alongside, who will describe their practice within team-focused healthcare delivery systems that emphasize collaboration, cooperation, value, and patient outcomes. 

Please join us for this important health care briefing on May 18th.  If you have questions, please contact Matt Gallivan (Rep. Paulsen) or Isaac Loeb (Rep Welch). 

Sincerely

Erik Paulsen                                                Peter Welch

Member of Congress                               Member of Congress

New paper by Connie van Eeghen et al.

Integrating Behavioral Health in Primary Care Using Lean Workflow Analysis: A Case Study

Constance van Eeghen, Benjamin Littenberg, Melissa D. Holman, and Rodger Kessler

J Am Board Fam Med May-June 2016; 29:385-393; doi:10.3122/jabfm.2016.03.150186

Background: Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact.

Methods: This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method.

Results: Referrals increased from 23 to 37 per 1000 visits (P < .001). Referrals resulted in more scheduled (60% to 74%; P < .001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37–1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14–1.62). Survey responses and comments were positive.

Conclusions: This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.