Developing and Testing Interventions to Improve Obesity‐Related Outcomes in Underserved Rural Communities: Lessons from EMPOWER

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137768/1/oby21905_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137768/2/oby21905.pd

Re‐purposing anticoagulation clinics: expanding access to opioid agonist therapy in primary care settings

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136313/1/add13531.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136313/2/add13531_am.pd

Neither Safety nor Health: How Title 42 Expulsions Harm Health and Violate Rights

Toward the beginning of the COVID-19 pandemic in March 2020, the Trump administration overrode the objections of public health experts at the U.S. Centers for Disease Control and Prevention (CDC) and compelled the CDC to issue an order under Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act that closed the border to migrants and asylum seekers. The government used public health as a pretext to summarily expel children and adults seeking refuge at the U.S. border more than 980,000 times, while at the same time allowing other types of travelers to continue to cross the border with no testing or quarantine requirements. Public health experts strenuously objected to the ban, pointing out the lack of epidemiological evidence for only banning this category of entrants to the United States while keeping the borders open to other travelers.Nevertheless, six months into the Biden administration, the U.S. government continues to expel families and adults to countries where they face severe harm and persecution, violating their rights and failing to safeguard public health. The Biden administration also continues to carry out chaotic border expulsions that perpetuate family separation and further traumatize an already vulnerable population.In May 2021, a Physicians for Human Rights (PHR) research team conducted interviews in Tijuana and Ciudad Juárez, Mexico with 28 asylum seekers who had been expelled under the Title 42 order, and with six health care workers providing services to migrants. The team sought to document people's experiences during expulsion, including family separation, the actions of U.S. and Mexican government officials during the expulsion process, and the physical and mental health impacts of expulsion and family separation.People described an impossible situation, where they were unsafe in their own country, unsafe in Mexico, and yet unable to seek safety at the U.S. border. Every day that the Title 42 order continues to expel asylum seekers is another day that the U.S. government is harming people's health and violating their human rights

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

Abstract Background Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. Methods We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers’ assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. Results 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%). Conclusions Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.http://deepblue.lib.umich.edu/bitstream/2027.42/112850/1/12913_2012_Article_2450.pd

Study protocol: The Adherence and Intensification of Medications (AIM) study - a cluster randomized controlled effectiveness study

Abstract Background Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen. Methods In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates. Discussion Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care. Trial Registration The ClinicalTrials.gov registration number is NCT00495794.http://deepblue.lib.umich.edu/bitstream/2027.42/78258/1/1745-6215-11-95.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/2/1745-6215-11-95.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/3/1745-6215-11-95-S1.DOCPeer Reviewe

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd

Personalized behavior change program for glaucoma patients with poor adherence: a pilot interventional cohort study with a pre-post design

Abstract Background About half of people with glaucoma do not adhere to their recommended medications. Interventions for other chronic conditions have successfully utilized reminder systems and motivational interviewing (MI)-based counseling. This study was designed to pilot a personalized intervention that leverages these strategies to assess their impact on medication adherence in glaucoma patients. Methods Glaucoma patients taking ≥ 1 medication will be pre-screened by telephone survey for adherence to their medication(s). Those who self-report poor adherence will be enrolled in a 3-month monitoring period to measure medication adherence using electronic medication monitors. Participants who are non-adherent (take </=80% of their medication doses) over the 3-month run in phase will be eligible for the study. We plan to enroll 57 participants who are non-adherent to their medications. Participants’ adherence will then be continuously measured with electronic medication monitors, by self-report, and via pharmacy refill data over 2 years, during which two successively more resource-intensive components of an intervention aimed to improve medication adherence will be administered. The first component is a 3-month period of reminders (audio and/or visual) and text message or automated phone call if a dose of medication is not taken within a pre-specified time frame. The second component is a 6-month MI-based counseling program with a trained glaucoma counselor. This component uses the eyeGuide, a computer-based personalized behavior change program that enables para-professional staff to provide personalized education and counseling for glaucoma. The primary outcome is change in medication adherence. The secondary outcomes include changes in clinical outcomes (intraocular pressure, IOP, and IOP fluctuation) and psychosocial mediators of adherence (e.g., competence, energy for change and satisfaction). Participants will undergo semi-structured interviews at 12 months to give feedback about the counseling program in order to improve it. Discussion This pilot study will provide insight into ways to deliver more personalized health care to non-adherent glaucoma patients in order to better support them in managing their chronic disease. Trial registration Retrospectively registered with ClinicalTrials.gov ( NCT03159247 ).https://deepblue.lib.umich.edu/bitstream/2027.42/145182/1/40814_2018_Article_320.pd

A pilot study of a Community Health Agent-led type 2 diabetes self-management program using Motivational Interviewing-based approaches in a public primary care center in São Paulo, Brazil

Abstract Background Rates of noncommunicable diseases (NCDs) such as type 2 diabetes are escalating in low and middle-income countries such as Brazil. Scalable primary care-based interventions are needed to improve self-management and clinical outcomes of adults with diabetes. This pilot study examines the feasibility, acceptability, and outcomes of training community health agents (CHAs) in Motivational Interviewing (MI)-based counseling for patients with poorly controlled diabetes in a primary care center in São Paulo, Brazil. Methods Nineteen salaried CHAs participated in 32 h of training in MI and behavioral action planning. With support from booster training sessions, they used these skills in their regular monthly home visits over a 6 month period with 57 diabetes patients with baseline HbA1cs > 7.0%. The primary outcome was patients’ reports of the quality of diabetes care as measured by the Portuguese version of the Patient Assessment of Chronic Illness Care (PACIC) scale. Secondary outcomes included changes in patients’ reported diabetes self-management behaviors and in A1c, blood pressure, cholesterol and triglycerides. We also examined CHAs’ fidelity to and experiences with the intervention. Results Patients reported improvements over the 6 month period in quality of diabetes care received (PACIC score improved 33 (+/−19) to 68 (+/−21) (p < .001)). They reported increases in physical activity (p = .001), consumption of fruits and vegetables (p < .001) and medication adherence (p = .002), but no decreases in consumption of high-fat foods (p = .402) or sweets (p = .436). Participants had mean 6-month A1c levels 0.34% points lower than at baseline (p = .08) and improved mean LDL (−16.1 mg/dL, p = .005) and triglyceride levels (−38.725 mg/dL, p = .002). Of the 16 CHAs observed in fidelity assessments, 13 were categorized as medium- or high-performing on MI skills, while 3 were low-performing. CHAs expressed enthusiasm about learning new skills, and many described a shift from advice-giving to encouraging patients to define their own goals. Conclusion In resource-scarce settings, it is essential to fully utilize existing primary care resources to stem the epidemic of diabetes and other NCDs. Our pilot results support the potential of training CHAs to incorporate effective diabetes self-management support into their routine patient encounters. Trial registration NCT02994095 12/14/2016 Registered retrospectively.http://deepblue.lib.umich.edu/bitstream/2027.42/135718/1/12913_2016_Article_1968.pd

Designing prenatal care for low-income, black patients in urban settings using human centered design

Objective: Black and low-income pregnant patients face significant inequities in health care access and outcomes in the United States. Yet, these patients’ voices have been largely absent from designing improved prenatal care models. Our objective was to use Human Centered Design to examine patients’ and health care workers’ experiences with prenatal care delivery in a largely low-income, Black population, to inform future care innovations to improve access, quality, and outcomes. Study Design: Using snowball sampling, we conducted Human Centered Design-informed interviews with low-income, Black patients and health care workers in a large, urban setting. Interview questions addressed the first two Human Centered Design phases: 1) observation: understanding the problem from the end-user’s perspective, and 2) ideation: generating novel potential solutions. We assessed these questions for the three key components of prenatal care: medical care, anticipatory guidance, and psychosocial support. Results: Nineteen patients and 19 health care workers were interviewed. All patients were Black, and the majority had public insurance (17/19, 89.5%). Health care workers included doctors, midwives, breastfeeding counselors, doulas, and social workers. Participants affirmed the three goals of prenatal care. Participants reported failures of current prenatal care delivery and potential solutions for each of the three goals (medical care, anticipatory guidance, and psychosocial support) and two overarching categories: maternity care professionals and care structure. Participants reported in an ideal model, patients would have strong relationships with their maternity care professional who would be at the center of all prenatal care services. Additionally, care would be tailored to individual patients and use care navigators, flexible models, and colocation of services, to reduce barriers. Conclusion: Current prenatal care delivery fails to meet low-income, Black patients’ needs. Ideal prenatal care delivery includes more comprehensive, integrated services tailored to patients’ medical needs and preferences