The Effect of EHR-Integrated Patient Reported Outcomes on Satisfaction with Chronic Pain Care

Objective Given its complexity, chronic noncancer pain presents an opportunity to use health information technology (IT) to improve care experiences. The objective of this study was to assess whether integrating patient-reported outcomes (PRO) data in an electronic health record (EHR) affects providers and patient satisfaction with chronic noncancer pain care. Study Design We conducted a pragmatic cluster randomized trial involving four family medicine clinics. Methods We enrolled primary care providers (PCPs) and their patients with chronic noncancer pain. In the first seven months (education phase), PCPs in intervention practices received education on how to use PROs for pain care. In the second seven months (PRO phase), patients in intervention practices reported pain-related outcomes upon arrival at their visits. PROs were immediately reported to PCPs through the EHR. Control group PCPs provided usual care. We compared intervention and control practices in terms of provider and patient satisfaction with care. Results During the education phase, patients’ mean ratings of their visits did not differ between control and intervention (9.33 vs. 9.08, p=0.20). During the PRO phase, patients’ mean ratings did not differ between control and intervention (9.28 vs 9.01, p=0.20). Similarly, there were no differences between the intervention and control groups in terms of provider satisfaction. Conclusion Delivering EHR-integrated PROs did not consistently improve patient or provider satisfaction. Positively, we found no evidence that the PRO tools negatively affected satisfaction. Future studies and technological innovations are needed to translate point-of-care health IT tools to improvements in patient and provider experiences

Distress Tolerance and Use of Antiretroviral Therapy Among HIV-Infected Individuals in Substance Abuse Treatment

Despite recent clinical guidelines recommending early initiation and widespread use of antiretroviral therapy (ART), many HIV-infected individuals are not receiving ART—in particular low-income, minority substance users. Few studies have examined psychological, as opposed to structural, factors related to not receiving ART in this population. Perceived capacity to tolerate physical and psychological distress, known as distress tolerance (DT), may be a particularly relevant yet understudied factor. The current study tested the relationship between self-reported physical and psychological DT and ART receipt among predominantly low-income, minority HIV-infected substance users (n=77). Psychiatric disorders, biological indicators of health status, ART use, structural barriers to health care, and self-reported physical and psychological DT were assessed. 61% of participants were receiving ART. The only factors that distinguished individuals not on ART were greater avoidance of physical discomfort, higher psychological DT, and higher CD4 count. Both DT measures remained associated with ART use after controlling for CD4 count and were associated with almost a two-fold decrease in likelihood of ART receipt. Current findings suggest higher perceived capacity to tolerate psychological distress and greater avoidance of physical discomfort are important factors associated with lower ART use among substance users and may be important intervention targets

Can behavioral theory inform the understanding of depression and medication nonadherence among HIV-positive substance users?

Medication adherence is highly predictive of health outcomes across chronic conditions, particularly HIV/AIDS. Depression is consistently associated with worse adherence, yet few studies have sought to understand how depression relates to adherence. This study tested three components of behavioral depression theory—goal-directed activation, positive reinforcement, and environmental punishment—as potential indirect effects in the relation between depressive symptoms and medication nonadherence among low-income, predominantly African American substance users (n = 83). Medication nonadherence was assessed as frequency of doses missed across common reasons for nonadherence. Non-parametric bootstrapping was used to evaluate the indirect effects. Of the three intermediary variables, there was only an indirect effect of environmental punishment; depressive symptoms were associated with greater nonadherence through greater environmental punishment. Goal-directed activation and positive reinforcement were unrelated to adherence. Findings suggest the importance of environmental punishment in the relation between depression and medication adherence and may inform future intervention efforts for this population

Rumination Mediates the Relationship Between Distress Tolerance and Depressive Symptoms Among Substance Users

Distress tolerance has been implicated in the emergence of internalizing symptomatology, notably depressive symptoms. However, few studies have tested potential mechanisms underlying the relationship between distress tolerance and depressive symptoms, and further, this has not been tested among substance users, who commonly experience both low distress tolerance and elevated depressive symptoms. The current study focused on the construct of rumination, which has been suggested to be a coping response to stress associated with substance use and depression. Two forms of rumination, brooding and reflection, were tested as potential mediators of the relationship between distress tolerance and self-reported depressive symptoms among 128 individuals entering substance abuse treatment. Brooding (i.e., to overly focus on symptoms of distress) mediated the relationship between distress tolerance and depressive symptoms. However, reflection (i.e., to attempt to gain insight into problems) was unrelated to distress tolerance. Findings suggest the important role of brooding as a mechanism underlying the relationship between distress tolerance and depressive symptomatology

Distress Tolerance and Use of Antiretroviral Therapy Among HIV-Infected Individuals in Substance Abuse Treatment

Despite recent clinical guidelines recommending early initiation and widespread use of antiretroviral therapy (ART), many HIV-infected individuals are not receiving ART—in particular low-income, minority substance users. Few studies have examined psychological, as opposed to structural, factors related to not receiving ART in this population. Perceived capacity to tolerate physical and psychological distress, known as distress tolerance (DT), may be a particularly relevant yet understudied factor. The current study tested the relationship between self-reported physical and psychological DT and ART receipt among predominantly low-income, minority HIV-infected substance users (n=77). Psychiatric disorders, biological indicators of health status, ART use, structural barriers to health care, and self-reported physical and psychological DT were assessed. 61% of participants were receiving ART. The only factors that distinguished individuals not on ART were greater avoidance of physical discomfort, higher psychological DT, and higher CD4 count. Both DT measures remained associated with ART use after controlling for CD4 count and were associated with almost a two-fold decrease in likelihood of ART receipt. Current findings suggest higher perceived capacity to tolerate psychological distress and greater avoidance of physical discomfort are important factors associated with lower ART use among substance users and may be important intervention targets

Rumination Mediates the Relationship Between Distress Tolerance and Depressive Symptoms Among Substance Users

Distress tolerance has been implicated in the emergence of internalizing symptomatology, notably depressive symptoms. However, few studies have tested potential mechanisms underlying the relationship between distress tolerance and depressive symptoms, and further, this has not been tested among substance users, who commonly experience both low distress tolerance and elevated depressive symptoms. The current study focused on the construct of rumination, which has been suggested to be a coping response to stress associated with substance use and depression. Two forms of rumination, brooding and reflection, were tested as potential mediators of the relationship between distress tolerance and self-reported depressive symptoms among 128 individuals entering substance abuse treatment. Brooding (i.e., to overly focus on symptoms of distress) mediated the relationship between distress tolerance and depressive symptoms. However, reflection (i.e., to attempt to gain insight into problems) was unrelated to distress tolerance. Findings suggest the important role of brooding as a mechanism underlying the relationship between distress tolerance and depressive symptomatology

Can behavioral theory inform the understanding of depression and medication nonadherence among HIV-positive substance users?

Medication adherence is highly predictive of health outcomes across chronic conditions, particularly HIV/AIDS. Depression is consistently associated with worse adherence, yet few studies have sought to understand how depression relates to adherence. This study tested three components of behavioral depression theory—goal-directed activation, positive reinforcement, and environmental punishment—as potential indirect effects in the relation between depressive symptoms and medication nonadherence among low-income, predominantly African American substance users (n = 83). Medication nonadherence was assessed as frequency of doses missed across common reasons for nonadherence. Non-parametric bootstrapping was used to evaluate the indirect effects. Of the three intermediary variables, there was only an indirect effect of environmental punishment; depressive symptoms were associated with greater nonadherence through greater environmental punishment. Goal-directed activation and positive reinforcement were unrelated to adherence. Findings suggest the importance of environmental punishment in the relation between depression and medication adherence and may inform future intervention efforts for this population